A peptic ulcer is a sore or lesion that develops on the lining of the stomach, upper small intestine (duodenum), or esophagus due to the erosion of the mucosal barrier by acidic gastric juices. The term encompasses gastric ulcers (in the stomach) and duodenal ulcers (in the duodenum). Rarely, ulcers can occur in the esophagus, known as esophageal ulcers.

Types of Peptic Ulcer

1. Gastric Ulcers: Develop on the inner lining of the stomach. Often associated with pain exacerbated by eating.

2. Duodenal Ulcers: Occur on the upper part of the small intestine (duodenum). Pain usually improves after eating but worsens several hours later.

3. Esophageal Ulcers: Occur in the esophagus. Commonly associated with gastroesophageal reflux disease (GERD).

4. Stress Ulcers: Result from severe physiological stress, such as major surgeries or critical illness. Common in ICU patients.

Causes of Peptic Ulcer

Peptic ulcers occur when there is an imbalance between the protective factors of the gastrointestinal mucosa and aggressive factors such as acid and pepsin.

1. Helicobacter pylori (H. pylori) Infection: A bacterium that weakens the mucosal layer, making it susceptible to acid damage. Found in approximately 70-90% of duodenal ulcers and 60% of gastric ulcers.

2. NSAIDs (Non-Steroidal Anti-Inflammatory Drugs): Long-term use of NSAIDs such as aspirin, ibuprofen, or naproxen can inhibit prostaglandin synthesis, reducing mucosal protection.

3. Lifestyle Factors

Smoking: Increases gastric acid secretion.

Alcohol: Irritates the gastric lining.

Dietary habits: Spicy foods and caffeine may aggravate symptoms.

 4. Zollinger-Ellison Syndrome (ZES): A rare condition characterized by tumors (gastrinomas) that excessively secrete gastrin, leading to increased acid production.

5. Stress: Emotional and physical stress can exacerbate the condition but is not a primary cause.

6. Other Factors Genetic predisposition. Chronic diseases like chronic obstructive pulmonary disease (COPD) or chronic renal failure.

Pathophysiology of Peptic Ulcer

1. Mucosal Barrier Disruption: The gastric mucosa is protected by a barrier composed of mucus and bicarbonate. When this barrier is compromised (e.g., by H. pylori, NSAIDs, or stress), gastric acid and pepsin penetrate the mucosa.

2. Inflammatory Response: Damage to the epithelial cells triggers inflammation, leading to further mucosal injury.

3. Acid and Pepsin Activity: Acid secretion increases, and pepsinogen converts to pepsin, which accelerates mucosal erosion and ulceration.

4. Ulceration and Healing Imbalance: A failure in the repair mechanisms due to ongoing injury leads to chronic ulcers.

Symptoms of Peptic Ulcer

Burning Pain: Localized to the epigastric region, often described as gnawing or burning.

Timing of Pain:

Gastric ulcer: Pain worsens immediately after eating.

Duodenal ulcer: Pain improves after eating and recurs 2-3 hours later or at night.

Nausea and Vomiting

Bloating and Early Satiety

Melena (Black, Tarry Stools): Indicates gastrointestinal bleeding.

Hematemesis (Vomiting Blood): A sign of severe bleeding.

Unexplained Weight Loss: Due to avoidance of food from pain.

Fatigue: Caused by chronic blood loss leading to anemia.

Treatment of Peptic Ulcer

1. Medical Management :

1. Proton Pump Inhibitors (PPIs): Reduce gastric acid secretion by inhibiting the H+/K+ ATPase pump.

Examples: Omeprazole, Pantoprazole, Esomeprazole.

2. H2 Receptor Antagonists: Block histamine-mediated acid production.

Examples: Ranitidine, Famotidine.

3. Antacids: Neutralize existing gastric acid.

Examples: Aluminum hydroxide, Magnesium hydroxide.

4. Mucosal Protectants

Examples: Sucralfate (forms a protective barrier), Misoprostol (prostaglandin analog that enhances mucosal defenses).

5. Antibiotics (for H. pylori eradication)

Common regimen: Clarithromycin, Amoxicillin (or Metronidazole), and a PPI for 7-14 days (Triple Therapy).

Quadruple therapy includes bismuth subsalicylate.

6. Prokinetics: Used if gastric emptying is delayed.

Examples: Metoclopramide, Domperidone.

2. Surgical Management: Reserved for complications such as perforation, obstruction, or severe bleeding.

Procedures include:

Vagotomy: Reduces acid secretion by severing vagus nerve branches.

Partial Gastrectomy: Removal of the ulcerated portion of the stomach.

Pyloroplasty: Enlarges the pyloric outlet to improve gastric emptying.

3. Lifestyle Modifications

Avoid smoking, alcohol, and NSAIDs.

Eat small, frequent meals and avoid irritating foods.

Manage stress through relaxation techniques or counseling.