Peptic ulcer disease !
A peptic ulcer is a sore in the lining of the stomach or duodenum, mostly caused by Helicobacter pylori or anti-inflammatory drugs; it can bleed or perforate.
Updated 2026-10-29
Structures involved
Tap one to see what it is and open it in 3D.
In biochemistry
- Prostaglandin and thromboxane synthesis: Step 2 · Cyclooxygenase activity of COX-1/COX-2 (PTGS1/PTGS2)
- Eicosanoids: prostaglandins, thromboxanes and leukotrienes
- Cyclooxygenase (COX-1 and COX-2)
- H⁺/K⁺-ATPase (gastric proton pump)
Microorganisms that cause it
In histology
In embryology
In the clinical exam
In physiology
Why it happens
- Arachidonic acid metabolites in inflammation, and the drugs that block them
- Patterns of acute inflammation: serous, fibrinous, purulent, abscess, ulcer
- Injury by therapeutic drugs: the classic examples
- Special stains in diagnosis: Congo red, Prussian blue, PAS, Ziehl–Neelsen, Gram
What it is
A break in the lining of the stomach or duodenum that reaches through the muscularis mucosae, caused by an imbalance between acid and mucosal defences.
Who gets it
Common worldwide. Helicobacter pylori infection is very frequent in Colombia and Latin America, and the region has a high rate of gastric cancer, so gastric ulcers are investigated carefully.
Causes
- Helicobacter pylori infection
- Non-steroidal anti-inflammatory drugs and aspirin
- Less often: acid hypersecretion (Zollinger–Ellison syndrome), stress ulcers in critical illness, Crohn disease, cancer
Risk factors
- Helicobacter pylori infection
- Regular use of NSAIDs or aspirin, especially with anticoagulants, antiplatelets or corticosteroids
- Older age
- Smoking
- Heavy alcohol use
- Previous ulcer
Pathophysiology
Helicobacter pylori causes chronic gastritis and alters acid secretion, while NSAIDs block prostaglandins that protect the mucosa. Acid and pepsin then erode the weakened lining. Deep ulcers can erode an artery (bleeding), go through the wall (perforation) or scar the pylorus (obstruction).
Classification
- By site: gastric or duodenal
- By cause: Helicobacter pylori, NSAID-related, other
- Forrest classification for bleeding ulcers at endoscopy
Symptoms and signs
- Burning or gnawing epigastric pain
- Duodenal ulcers: pain often eased by food and worse hours later or at night
- Gastric ulcers: pain often worse with eating
- Bloating, early satiety, nausea
- Many ulcers, especially NSAID-related, cause no pain until a complication occurs
Diagnosis
- Clinical
- History of dyspepsia, NSAID use and alarm features. Upper endoscopy is indicated with alarm features and, given the higher gastric cancer risk in Colombia, at a lower age threshold than in low-risk countries; criteria vary.
- Tests
- Helicobacter pylori testing: urea breath test, stool antigen, or biopsy at endoscopy; confirm eradication after treatment. Blood count for anaemia; gastrin if Zollinger–Ellison syndrome is suspected.
- Imaging
- Upper endoscopy is the test of choice; gastric ulcers are biopsied to exclude cancer and re-checked until healed. Erect chest X-ray or CT shows free air if perforation is suspected.
Differential diagnosis
- Functional dyspepsia
- Gastro-oesophageal reflux disease
- Gastric cancer
- Biliary colic
- Chronic pancreatitis
- Inferior myocardial infarction
Goal of treatment
Heal the ulcer, remove the cause (Helicobacter pylori, NSAIDs) and prevent recurrence and complications.
Treatment
- Medical
- Proton pump inhibitors to suppress acid and heal the ulcer; histamine H2 receptor antagonists are an alternative.
- Medical
- Helicobacter pylori eradication with combination therapy (a proton pump inhibitor plus two or more antibiotics, sometimes with bismuth), chosen according to local resistance.
- Lifestyle
- Stopping NSAIDs where possible, plus stopping smoking and limiting alcohol.
- Procedure
- Endoscopic therapy for bleeding ulcers (injection, thermal coagulation, clips).
- Surgical
- Surgery for perforation (closure, often with an omental patch), refractory bleeding or obstruction not relieved by endoscopic dilatation.
- Follow-up
- Follow-up endoscopy with biopsies for gastric ulcers; confirm Helicobacter pylori eradication.
Drugs for this condition
- Glycopyrronium
- Famotidine
- Cimetidine
- Pantoprazole
- Sucralfate
- Aluminium hydroxide
- Esomeprazole
- Lansoprazole
- Omeprazole
- Misoprostol
Complications
- Upper gastrointestinal bleeding
- Perforation and peritonitis
- Penetration into the pancreas
- Gastric outlet obstruction
- Missed gastric cancer presenting as an ulcer
Prognosis
Most ulcers heal with acid suppression, and recurrence falls sharply once Helicobacter pylori is eradicated and NSAIDs stopped. Bleeding and perforation still cause significant mortality, mostly in older adults.
Prevention
- Proton pump inhibitor protection for high-risk patients who need NSAIDs or aspirin
- Testing and treating Helicobacter pylori
- Avoiding unnecessary NSAIDs
Test yourself
Think of the answer, then tap the question to see it.
What are the two main causes of peptic ulcer disease?
Helicobacter pylori infection and non-steroidal anti-inflammatory drugs (including aspirin).
How does the timing of pain classically differ between duodenal and gastric ulcers?
Duodenal ulcer pain is often eased by eating and returns hours later or at night; gastric ulcer pain often worsens with food.
Why are gastric ulcers biopsied and followed up until healed?
To exclude gastric cancer, which can look like a benign ulcer; this matters in regions with high gastric cancer rates such as Colombia.
Which tests detect active Helicobacter pylori infection without endoscopy?
Urea breath test and stool antigen test.
Which artery is classically eroded by a bleeding posterior duodenal ulcer?
The gastroduodenal artery.
Related conditions
- Upper gastrointestinal bleeding
- Acute pancreatitis
- Gastric cancer
- Gastro-oesophageal reflux disease (GERD)
- Chronic pancreatitis
- Acute cholecystitis
- Gallstones (cholelithiasis)
- Helicobacter pylori gastritis
Educational information, not medical advice. For any symptom, see a health professional.
Sources: Peptic Ulcer Disease (StatPearls (NCBI Bookshelf), 2023).
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Representative model, for educational purposes only.
