Peptic Ulcer Disease

Peptic ulcer disease is the formation of a defect that breaches the mucosa of the stomach or duodenum, exposing deeper tissue to acid and pepsin. It arises chiefly from an imbalance between mucosal defence and aggressive luminal factors, and is dominated by two causes: Helicobacter pylori infection and the use of non-steroidal anti-inflammatory drugs.

Definition

Peptic ulcer disease is a break in the mucosa of the stomach or duodenum that extends through the muscularis mucosae, resulting from an imbalance between mucosal protective factors and the aggressive action of gastric acid and pepsin.

Scope

This topic covers the pathophysiology, the principal causes, and the place of peptic ulcer disease among upper gastrointestinal disorders. It is a reference and educational entry that explains how ulcers form and why their epidemiology has shifted; it does not provide eradication regimens, dosing, or individualised treatment advice.

Core questions

• What disrupts the balance between mucosal defence and acid-peptic injury?
• How do Helicobacter pylori and NSAIDs cause peptic ulcers?
• Why has the epidemiology of peptic ulcer disease changed over recent decades?

Key concepts

• Mucosal defence versus acid-peptic aggression
• Helicobacter pylori infection
• NSAID-induced mucosal injury
• Gastric versus duodenal ulcer
• Acid and pepsin
• Ulcer complications (bleeding, perforation)

Mechanisms

Peptic ulcers form when the mucosal barrier of the stomach or duodenum is overwhelmed by acid and pepsin. The two dominant insults act on this balance: Helicobacter pylori colonises the gastric mucosa and provokes chronic inflammation that alters acid secretion and weakens defence, while non-steroidal anti-inflammatory drugs inhibit cyclooxygenase and deplete the prostaglandins that maintain mucosal blood flow, mucus, and bicarbonate. The exposed mucosa is then digested, producing a defect that may bleed or perforate. The recognition of H. pylori as a primary cause reframed peptic ulcer disease from a chronic acid-driven, relapsing condition into one that is frequently curable by eradicating the infection.

Clinical relevance

Peptic ulcer disease is a major cause of upper gastrointestinal symptoms and of acute complications such as bleeding and perforation, and its two principal causes — H. pylori and NSAIDs — are central to how it is understood. This entry describes the disease and its mechanisms for reference and education; it is not a basis for diagnosing or treating any individual and contains no medication guidance.

Epidemiology

The incidence of uncomplicated peptic ulcer disease has declined in many regions alongside falling Helicobacter pylori prevalence and more judicious acid suppression, even as NSAID-related ulcers remain important, particularly in older adults. The condition is still a significant source of upper gastrointestinal bleeding worldwide, and its burden tracks closely with H. pylori prevalence and patterns of anti-inflammatory drug use.

History

Once attributed mainly to stress and excess acid and managed as a chronic relapsing disorder, peptic ulcer disease was transformed by the demonstration that Helicobacter pylori infection causes most non-NSAID ulcers, work recognised with a Nobel Prize. Subsequent international consensus reports, in the Maastricht series, codified the approach to H. pylori as a manageable and often curable cause, shifting the disease's natural history.

Debates

How should rising Helicobacter pylori antibiotic resistance shape management strategy?

Eradication of H. pylori is central to managing peptic ulcer disease attributable to the infection, but increasing antimicrobial resistance complicates regimen selection; consensus reports increasingly emphasise susceptibility-guided and locally tailored approaches.

Key figures

• Peter Malfertheiner
• Francis K. L. Chan
• Kenneth E. L. McColl

Seminal works

• malfertheiner-2009-lancet
• malfertheiner-2022-maastricht6

Frequently asked questions

What causes most peptic ulcers?

The two leading causes are Helicobacter pylori infection and the use of non-steroidal anti-inflammatory drugs; both tip the balance between mucosal defence and acid-peptic injury toward ulceration.

What is the difference between a gastric and a duodenal ulcer?

Both are peptic ulcers, distinguished by location: a gastric ulcer breaches the lining of the stomach, while a duodenal ulcer occurs in the first part of the small intestine; they share mechanisms but differ in some associations.