Introduction 

Peptic ulcer disease (PUD) is characterised by ulcers (open sores) in the inner lining of the gastrointestinal (GI) tract. It derives its name from pepsin, a digestive enzyme produced in the stomach. Pepsin and gastric acid are the active ingredients in the stomach juices that help in the chemical breakdown of the food, thereby aiding in digestion. Some of these gastric juices may pass into the duodenum, the first part of the small intestine. The inside wall of the stomach and duodenum has a protective mucous lining or mucosa which protects it from the gastric acids and enzymes. In PUD, an imbalance occurs between the digestive juices produced in the stomach and the factors protecting the lining of the stomach. As a result of the imbalance, the stomach lining is corroded causing an ulcer. The ulcers in PUD are mostly found in the stomach and duodenum.

PUD is characterised by stomach pain that usually occurs within 15-30 minutes following a meal; duodenal ulcer pain on the other hand tends to occur 2-3 hours after a meal. The most common cause of PUD is an infection in the stomach by a bacteria known as Helicobacter Pylori (H. Pylori). Therefore, testing for Helicobacter pylori is recommended in all patients with peptic ulcer disease. Endoscopy may be required in some patients for confirmation of diagnosis. Management includes treatment with a proton pump inhibitor (PPI). Timely diagnosis and treatment are essential in high-risk patients  in order to minimise complications such as gastrointestinal bleeding and cancer in patients.¹

Understanding peptic ulcer disease

Causes and risk factors

The two major causes of PUD are H.pylori and Non-steroidal anti-inflammatory drugs (NSAIDs).² 

H. Pylori infection: H. Pylori is a common bacterial infection in almost half of the world’s population. The bacteria is transferred from person to person as a result of direct contact with the saliva, blood, or stool of an infected person. In most cases, the bacteria doesn’t seem to cause any trouble. Bacterial overgrowth may upset the natural balance of microbes, causing an inflammatory response. Chronic inflammation in the gastrointestinal lining can wear it out and diminish its tendency for self-repair. The bacteria might attack the gastrointestinal lining leading to damage in the gastrointestinal mucosa. This can allow the acids in the stomach to create ulcers.²

Overuse of NSAIDs: Nonsteroidal anti-inflammatory drugs use is the second most common cause of PUD after H. pylori infection.

NSAIDs including aspirin and ibuprofen are common over-the-counter (OTC) medications used to relieve pain. They can be taken without a prescription and without proper medical supervision, which makes it easier for people to overuse them too often. Prostaglandins are hormone-like substances, which protect the gastric mucosa against agents that cause mucosal damage and repair the damage in the gastrointestinal lining.³ Overuse of NSAIDs blocks the synthesis of prostaglandins, leading to decreased gastric mucus and bicarbonate production and a decrease in mucosal blood flow, thereby increasing the susceptibility to mucosal injury and ulcers.⁴

Other cases include smoking, alcohol use, chemotherapy or radiation therapy, medical conditions like Zollinger-Ellison syndrome, Crohn's disease, and stomach cancer, and mental health conditions like stress.⁵

Common symptoms

Small ulcers may be asymptomatic and may heal on their own. The most common symptom is stomach pain. Stomach pain may occur in the upper abdomen, at night upon waking up, and on an empty stomach 1 to 3 hours after a meal. It is difficult to distinguish a stomach ulcer from a duodenal ulcer. A stomach ulcer feels worse within 30 minutes after a meal. This is when the gastric juices are at their peak. Duodenal ulcers on the other hand may feel better after a meal. Pain from duodenal ulcers gets better after a meal. The effect is usually felt after 2 or 3 hours when the gastric juices enter the duodenum. 

Other symptoms include nausea, vomiting, blood in stools, fatigue, weight loss, heartburn, and loss of appetite. 

Complications

Some people may not experience any symptoms until the PUD causes complications. Untreated ulcers start bleeding and wear through the gastrointestinal mucosa leading to a hole. 

Symptoms of gastrointestinal bleeding include blood in stools, black stools, dizziness, coffee coloured vomit. Symptoms of stomach hole (gastrointestinal perforation) include sudden and sharp pain in the abdomen, fever, abdominal swelling and tenderness upon touching. 

Diagnosis

Peptic ulcer disease (PUD) can be diagnosed by a healthcare professional by taking a detailed history, physical examination, and invasive/non-invasive medical tests. A patient presenting with abdominal pain, decreased appetite, and pain 2 to 3 hours after a meal should be examined for PUD. Healthcare professionals may look for signs and symptoms of PUD such as abdominal pain, or tenderness in the abdomen, and signs of anaemia during physical examination. Individuals presenting with these symptoms will be tested for H.Pylori infection during an endoscopy examination or separately.

Investigations:

1. Esophagogastroduodenoscopy (EGD): This test is the gold standard and is considered the most accurate diagnostic test with an accuracy of up to 90% in the diagnosis of gastric and duodenal ulcers. The examiner uses a scope with a tiny lighted camera that goes inside the upper gastrointestinal tract. A stomach biopsy can be done during endoscopy to test for H. pylori. Endoscopy shows images of the organs and also allows healthcare providers access to those organs by passing long instruments through the tube. This procedure can be helpful in immediately stopping bleeding in the ulcers.
2. Helicobacter pylori testing: Serologic testing,⁶ stool antigen tests, urea breath test, urine-based test.
3. Computerized tomography scan (CT scan): Detailed imaging tests like CT scans can be used to detect large ulcers. It can be helpful in the detection of complications like perforation.
4. Barium swallow: In patients where EGD is contraindicated barium swallow can be done to diagnose PUD.
5. Complete blood work.

Treatment

The treatment of PUD depends on the cause. The first line of treatment involves antibiotics and medications to relieve pain, decrease gastric acid production, and repair or protect the gastric lining. PUD caused by H. Pylori bacteria is treated with antibiotics. It is important to address the underlying cause of ulcers for effective treatment. Additional interventions may be necessary in case of complications such as bleeding or perforation. These complications can be managed by surgical procedures, such as endoscopy. NSAID alternatives such as acetaminophen can be prescribed to the patients for pain relief.

Medications

• Antibiotics: If the patient tests positive for H. pylori infection in the digestive tract, a combination of antibiotics may be prescribed by the doctor to kill the bacteria. Antibiotics such as amoxicillin, clarithromycin, metronidazole, tinidazole, tetracycline and levofloxacin are commonly prescribed for treatment. Antibiotics may be prescribed for a duration of two weeks, along with a combination of medications to reduce stomach acid like a proton pump inhibitor and possibly bismuth subsalicylate (Pepto-Bismol).
• Medications to block gastric acid production and promote healing. Proton pump inhibitors (PPIs) act by blocking gastric acid secretion from the cells in the lining of the stomach. They also coat and protect the mucous lining to promote healing. These drugs include prescription and over-the-counter medications like omeprazole, lansoprazole, rabeprazole, esomeprazole and pantoprazole. Long-term use of PPIs, particularly at high doses, may increase the risk of joint fractures. 
• Medications to reduce gastric acid production: Histamine receptor blockers (H2 blockers) relieve ulcer pain and promote healing of gastric lining by decreasing gastric acid production. Available by prescription or over the counter, acid blockers include famotidine, cimetidine and nizatidine.
• Antacids: Antacids can provide symptomatic relief from pain by neutralising the acid in the stomach. 
• Medications to protect the gastrointestinal lining: In some cases, medications known as cytoprotective agents may be prescribed to coat and protect the tissues that line the stomach and small intestine. These medications include sucralfate and misoprostol.

Surgical treatment

In patients who are unresponsive, non-compliant or at high risk of complications, surgical treatment might be indicated. Bleeding ulcers can be addressed during an endoscopy exam. Doctors may treat bleeding by using techniques like cauterising or injecting medication into the wound. A perforation can be repaired with stitches. Surgical options include vagotomy or partial gastrectomy. When ulcers cause complications such as intestinal obstruction ⁷, suctioning of the stomach for decompression or surgical intervention in rare cases may be required to reopen the channels.

Summary

A peptic ulcer disease is characterised by sores in the lining of the stomach or duodenum. If left untreated, peptic ulcers can lead to complications such as bleeding, perforation, or blockage in the gastrointestinal tract (stomach and duodenum). Symptoms include pain or tenderness in the abdomen, feeling full too soon during or too full after a meal, nausea, bloating, and belching. Peptic ulcers can be attributed to a Helicobacter pylori (H. pylori) infection or chronic use of nonsteroidal anti-inflammatory drugs (NSAIDs). Diagnosis of PUD can be done by a healthcare professional after performing a physical exam and ordering other tests such as blood tests, endoscopy, CT scan, and barium swallow to confirm the diagnosis and check for complications. Treatments include antibiotics for bacterial infection, along with other medications such as PPIs to reduce gastric acid production and to protect the lining of the stomach and small intestine. Seeking prompt medical assistance for PUD and its symptoms can prevent the development of complications and reduce the probability of recurrence of peptic ulcers.