Peptic Ulcer Disease - Causes, H. pylori, Treatment & More

Peptic Ulcer Disease (PUD) refers to breaks in the mucosal lining of the stomach or duodenum due to gastric acid and pepsin, often worsened by Helicobacter pylori infection or NSAID use.

Causes of PUD: More Than Just Spicy Food

Common Causes:

• H. pylori infection – most common (especially in duodenal ulcers)
• NSAIDs – disrupt mucosal barrier
• Alcohol and smoking
• Acid hypersecretion states (Zollinger-Ellison syndrome, G-cell hyperplasia)
• Stress ulcers – severe illness or trauma

Role of H. pylori in Ulcer Formation

Helicobacter pylori is a gram-negative bacterium that:

• Resides in gastric crypts
• Releases cytotoxic cytokines
• Damages delta cells, reducing somatostatin
• Increases acid production
• Weakens mucosal defense

Result:

• Formation of both duodenal and gastric ulcers

Types of Peptic Ulcers: Gastric vs Duodenal

Duodenal Ulcers (DU)

• Pre- and post-pyloric locations
• Peak age: 25–50 years
• Pain relieved by food
• More commonly linked to H. pylori

Gastric Ulcers (GU)

• Body of stomach (type I) or antrum (type II)
• Peak age: >50 years
• Pain worsened by food
• Higher malignancy risk

Symptoms and Clinical Features

General Symptoms:

• Epigastric pain (burning/hunger-type)
• Boring back pain (posterior DU)
• Nausea, vomiting
• Weight loss
• GI bleeding (haematemesis or melaena)

Classic Sign:

• Pain periodicity – recurs at intervals

Complications of Peptic Ulcers

From the diagram and notes:

• Bleeding – GI haemorrhage
• Perforation – peritonitis
• Gastric outlet obstruction (pre-/post-pyloric stenosis)
• Malignant transformation (mainly gastric ulcers)

Diagnosis and Tests for PUD

Initial Investigations:

• FOB (faecal occult blood)
• U+E – assess for dehydration or electrolyte imbalance

Specific Tests:

• OGD (endoscopy) – gold standard
• Biopsy – rule out malignancy
• CLO test or rapid urease – for H. pylori
• Urea breath test / H. pylori serology
• Barium meal – if endoscopy contraindicated

Medical Management: Triple Therapy Explained

Eradication Therapy:

Triple Therapy (7–14 days):

• Amoxicillin 500 mg
• Clarithromycin 500 mg
• PPI (omeprazole 20 mg BID or lansoprazole)

Quadruple Therapy:

• PPI + metronidazole + tetracycline + bismuth

NSAID-Induced Ulcers:

• PPI (e.g., omeprazole) for 4 weeks (DU), 8 weeks (GU)

Other Recommendations:

• Avoid NSAIDs, smoking, spicy food
• Re-endoscopy for GU after 6 weeks

When Is Surgery Required for PUD?

Surgical Indications:

• Perforation
• Bleeding not controlled endoscopically
• Obstruction (e.g., pyloric stenosis)
• Suspicion of malignancy (esp. in gastric ulcers)

Surgical Options:

• Highly selective vagotomy
• Billroth I gastrectomy
• Simple closure + biopsy for perforated ulcers
• Gastroenterostomy + truncal vagotomy (for stenosis)
• Endoscopic or surgical control of bleeding: adrenaline, thermal coagulation, fibrin sealants

Frequently Asked Questions (FAQs)

Q1. What’s the most common cause of duodenal ulcers?

H. pylori infection is the most common cause of DU worldwide.

Q2. Can peptic ulcers lead to cancer?

Yes – especially gastric ulcers. Biopsy is essential to rule out malignancy.

Q3. What is the role of PPIs in PUD?

PPIs reduce acid secretion and are key to both symptom control and ulcer healing.

Q4. Is surgery still common in PUD?

Only for complications like bleeding, obstruction, or non-healing gastric ulcers with suspicion of cancer.