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Symptoms
Abdominal pain that is often epigastric and described as burning, but may
present as vague discomfort, abdominal fullness, or cramping.
A typical nocturnal pain that awakens the patient from sleep (especially
between 12 AM and 3 AM).
The severity of ulcer pain varies from patient to patient, and may be seasonal,
occurring more frequently in the spring or fall; episodes of discomfort usually
occur in clusters, lasting up to a few weeks and followed by a pain-free period
or remission lasting from weeks to years.
Changes in the character of the pain may suggest the presence of
complications.
Heartburn, belching, and bloating often accompany the pain.
Nausea, vomiting, and anorexia, are more common in patients with gastric
ulcer than with duodenal ulcer, but may also be signs of an ulcer-related
complication
Signs
Weight loss associated with nausea, vomiting, and anorexia
Complications, including ulcer bleeding, perforation, penetration, or obstruction
Signs and Symptoms
Ulcer-related pain in duodenal ulcer often occurs 1 to 3 hours
after meals and is usually relieved by food, but this is variable
In gastric ulcer, food may precipitate or accentuate ulcer
pain.
Patients taking NSAIDs often report dyspepsia, but dyspeptic
symptoms do not directly correlate with an ulcer.
If an ulcer is not confirmed in a patient with ulcer-like
symptoms at the time of endoscopy, the disorder is referred to
as nonulcer dyspepsia.
Ulcer-like symptoms may occur in the absence of peptic
ulceration in association with H. pylori gastritis or duodenitis.
There is no one sign or symptom that differentiates between
H. pylori-associated and NSAID-induced ulcer.
Potential Causes of PUD
Common causes
Helicobacter pylori infection
Nonsteroidal antiinflammatory drugs
Critical illness (stress-related mucosal damage)
Uncommon causes
Hypersecretion of gastric acid (e.g., Zollinger-Ellisons
syndrome)
Viral infections (e.g., cytomegalovirus)
Vascular insufficiency (crack cocaine associated)
Radiation
Chemotherapy (e.g., hepatic artery infusions)
Rare genetic subtypes
Idiopathic
Etiology and Risk Factors
Most peptic ulcers
occur in the presence
of acid and pepsin
when H. pylori,
NSAIDs, or other
factors disrupt normal
mucosal defense and
healing mechanisms.
Benign gastric ulcers
can occur anywhere
in the stomach,
although most are
located on the lesser
curvature.
Most duodenal ulcers
occur in the first part
of the duodenum
(duodenal bulb).
Risk Factors for NSAID-Induced Ulcers
and Upper GI Complications
Established risk factors Possible risk factors
Older than 60 years of age NSAID-related dyspepsia
Previous peptic ulcer Helicobacter pylori infection
Previous ulcer-related upper GI
complication
Rheumatoid arthritis (extent of
Concomitant use of corticosteroid disability)
High-dose NSAIDs Alcohol consumption
Multiple NSAID use or NSAID plus
aspirin use
Choice of NSAID
Aspirin (including cardioprotective dosages)
Concomitant use of anticoagulant or
coagulopathy
Concomitant use of antiplatelet drug such
as clopidogrel
Concomitant use of oral bisphosphonates
Concomitant use of selective serotonin
reuptake inhibitor
Chronic illness (e.g., cardiovascular disease)
GI Risk Factor Stratification for Chronic
NSAID Use
Category Risk Factors
Moderate
Age>65 years
Risk (1-2
High dose NSAID therapy
risk
Previous history of uncomplicated ulcer
factors)
Concurrent use of aspirin (including low
dose), corticosteroids, or anticoagulants
Low Risk No risk factors
Prevention of NSAID-induced PUD
If low CV risk and:
Low GI risk - NSAID (lowest dose of the least
ulcerogenic agent)
Moderate GI risk - NSAID + PPI or misoprostol
High GI risk - COX-2 inhibitor + PPI or
misoprostol