Peptic ulcers, characterized by acid-induced lesions in the stomach and duodenum, are a significant medical concern with a global impact. In the United States, the prevalence of physician-diagnosed peptic ulcer disease (PUD) was 10 percent in 1990, with approximately 500,000 new cases reported annually. However, a positive trend has emerged, showing a decline in the risk of mortality and the need for hospitalizations related to PUD worldwide. Several factors contribute to this decline, notably the successful treatment of Helicobacter pylori (H. pylori) infections and improved hygiene practices.
Two primary risk factors for PUD are H. pylori infection and the use of non-steroidal anti-inflammatory drugs (NSAIDs). Although nearly half of the world's population is colonized by H. pylori, not all infected individuals or NSAID users develop PUD. Acquisition of H. pylori often occurs during childhood and persists without treatment. Factors such as lower socioeconomic status and unsanitary conditions contribute to a higher prevalence of infection, particularly in developing countries and specific ethnic groups.
H. pylori infection triggers an inflammatory response within the mucosal layer, leading to epithelial cell damage and degeneration. Gastritis tends to be more severe in the antrum, with minimal inflammation in the corpus. Testing for H. pylori is recommended for all patients with peptic ulcers, with noninvasive methods like the urea breath test and stool antigen tests being preferred over serologic testing. Endoscopy, though invasive, allows for biopsy and various testing methods like histology, culture, or rapid urease tests, although these can be affected by acid-suppressing medications.
While the clinical burden of PUD has decreased due to declining H. pylori infections and improved access to antisecretory therapy, it remains a prevalent condition with diverse clinical presentations. Proper recognition and management are essential to prevent complications. Key strategies include testing and treating H. pylori infections and minimizing mucosal injury caused by NSAIDs (e.g., concurrent proton pump inhibitor use or choosing COX-2 selective NSAIDs if available). For PUD-related bleeding, the most common complication, management involves resuscitation, antisecretory therapy, endoscopy, and addressing antithrombotic agent use.
Peptic ulcer disease has seen a decline in clinical burden but continues to impact global healthcare. Understanding risk factors, testing and treating H. pylori infections, and minimizing NSAID-related mucosal injury are essential components of effective PUD management. With modern approaches and greater awareness, we can reduce the impact of this condition on individuals' health and well-being.
