Peptic Ulcer Disease (PUD)

Primary causes:**

• Helicobacter pylori infection (disrupts mucosal defence).
• Nonsteroidal anti-inflammatory drug (NSAID) use (inhibits prostaglandin synthesis).

Other factors:**

• Hypersecretory states (e.g., Zollinger-Ellison syndrome).
• Severe physiological stress (e.g., critical illness, burns → “stress ulcers”).
• Smoking, alcohol, and genetic predisposition.

Pathophysiology:** Impaired mucosal defence and/or increased acid-pepsin aggression lead to ulcer formation.

Common symptoms:**

• Epigastric burning or gnawing pain (may improve or worsen with food: gastric ulcers often worsen, duodenal ulcers may improve).
• Bloating, nausea, and early satiety.

Atypical presentations:** Asymptomatic (especially in NSAID users).

Red-flag symptoms/complications:**

• Hematemesis, melena, or hematochezia (indicating bleeding).
• Severe, penetrating pain radiating to the back (suggesting penetration/perforation).
• Unintended weight loss, vomiting (suggesting obstruction or malignancy).

• Clinical assessment:* History (NSAID use, *H. pylori risk factors), physical exam (epigastric tenderness).
• Endoscopy (gold standard):* Direct visualisation, biopsy (for *H. pylori, malignancy).
• H. pylori testing: Urea breath test, stool antigen test, or histology (if endoscopy performed).
• Testing for hypersecretory states:** Serum gastrin (if Zollinger-Ellison syndrome suspected).
• Imaging:** Abdominal X-ray or CT if perforation suspected (free air under diaphragm).

Eradicate H. pylori:** Triple or quadruple therapy (PPI plus antibiotics).

Discontinue NSAIDs:** If possible, use COX-2 inhibitors or alternative analgesics with PPI cover if necessary.

Acid suppression:**

• Proton pump inhibitors (PPIs) are first-line for healing and symptom relief.
• H2-receptor antagonists (alternative).

Cytoprotective agents:** Sucralfate, misoprostol (for NSAID-induced ulcers).

Treatment of complications:**

• Endoscopic therapy for bleeding ulcers (e.g., coagulation, clipping).
• Surgery for perforation, obstruction, or refractory bleeding.

• Haemorrhage:** Most common complication.
• Perforation:** Surgical emergency.
• Gastric outlet obstruction:** Due to scarring and oedema.
• Penetration:** Into adjacent organs (e.g., pancreas).
• Malignant transformation:** Rare, but gastric ulcers require biopsy to rule out malignancy.

Prevention:**

• H. pylori screening/treatment in high-risk groups.
• Avoid unnecessary NSAIDs; use the lowest effective dose with PPI cover if needed.
• Smoking cessation, moderation of alcohol.

Follow-up:**

• Confirm H. pylori eradication (e.g., urea breath test).
• Repeat endoscopy in 6-8 weeks for gastric ulcers to confirm healing and exclude malignancy.
• Long-term PPI use only if indicated (e.g., recurrent ulcers, continued NSAID use).