Peptic Ulcer

Definition/diagnostic criteria Peptic ulcers are defined as ulceration developing on the inside lining of the stomach (gastric ulcer) or the upper portion of the small intestine (duodenal ulcer). The primary diagnostic criterion is the presence of a mucosal break of at least 5 mm in diameter with apparent depth. Endoscopic verification is the gold standard for diagnosis. Helicobacter pylori infection and the use of NSAIDs are recognised as the primary causative factors.

Epidemiology Peptic ulcers are a common condition, affecting around 10% of the population at some point in their lives. In the UK, the prevalence has been declining, attributed to reduced H. pylori infection rates and improved management strategies. However, the increasing use of NSAIDs and low-dose aspirin has been linked to a steady number of cases, especially in older populations.

Diagnosis
Clinical features:

Typical symptoms include epigastric pain, which may be relieved by eating or antacids (in duodenal ulcers) or worsened (in gastric ulcers), bloating, early satiety and, in some cases, nausea or vomiting.

Alarm features indicating potential complications or alternative diagnoses include weight loss, anaemia, haematemesis or melaena.

Investigations:

• Endoscopy: Gold standard for diagnosis, allowing direct visualisation and biopsy – crucial for excluding malignancy, especially in gastric ulcers.
• H. pylori testing: Urea breath test, stool antigen test, or biopsy-based tests during endoscopy.
• Blood tests: Full blood count may show anaemia; urea can be elevated if there is bleeding.
• Imaging: Not routinely used for diagnosis but may be indicated in complicated cases (e.g., perforation).

Treatment Treatment aims to relieve symptoms, heal the ulcer, prevent complications, and prevent recurrence.

• H. pylori eradication: If present, eradication therapy is recommended, usually a one-week triple therapy combining two antibiotics with a proton pump inhibitor (PPI).
• Acid suppression therapy: PPIs are the first-line treatment for NSAID-associated and idiopathic ulcers.
• NSAID management: If NSAIDs are implicated, they should be discontinued if possible. If continuation is necessary, co-prescription of a PPI or misoprostol is recommended.
• Antisecretory therapy: H2-receptor antagonists may be used where PPIs are not tolerated.
• Surgery: Rarely required, but may be necessary for complications such as perforation or uncontrolled bleeding.

Prognosis With appropriate treatment, the prognosis for peptic ulcer disease is generally good. Healing rates for uncomplicated ulcers are high with appropriate eradication of H. pylori and/or withdrawal of NSAIDs, combined with acid suppression therapy. However, the recurrence rate is significant, especially if risk factors such as H. pylori infection are not adequately addressed.

Complications, although less common due to advances in diagnosis and management, can include bleeding, perforation, and gastric outlet obstruction, and they significantly worsen the prognosis.