A chronic ulcer in the lining of the gastrointestinal tract.

• Duodenal ulcer (DU): Most are located in the duodenal bulb. Multiple ulcers, and ulcers distal to the bulb, raise the possibility of Zollinger–Ellison syndrome.
• Gastric ulcer (GU): Much less common than DU (in the absence of NSAIDs). Most commonly located along the lesser curvature of the antrum near the incisura and in the pre-pyloric area.
• Esophageal ulcers: A peptic ulcer in the distal esophagus may be part of Barrett’s epithelial change due to chronic reflux of gastroduodenal contents.
• Ectopic gastric mucosal ulceration: May develop in patients with Meckel’s diverticula or other sites of ectopic gastric mucosa.
• System(s) affected: Gastrointestinal
• Genetics: Higher incidence with HLA-B12, B5, Bw35 phenotypes, identical twins
• Incidence/Prevalence in USA:
  • DU: 4 times more common than GU. Lifetime prevalence = 10% for men; 5% for women (gender gap is closing). 200,000–400,000 new DU cases annually.
  • GU: 87,500 new cases annually. Incidence of new GU in adults: 50 per 100,000.
• Predominant age:
  • DU: 25–75 years (rare before age 15)
  • GU: peak incidence age 55–65; rare under age 40
• Predominant sex:
  • DU: Male > Female (slightly)
  • GU: Male = Female (female predominance among NSAID users)

• In adults (DU)
  • Gnawing or burning epigastric pain 1–3 hours after meals, relieved by food, antacids, or antisecretory agents
  • Nocturnal pain causing early morning awakening
  • Epigastric pain in 60–90% (often vague discomfort, cramping, hunger pangs). Non-specific dyspeptic complaints (belching, bloating, abdominal distention, food intolerance) in 40–70%.
  • Symptomatic periods occur in clusters lasting a few weeks followed by symptom-free periods for weeks to months. Some seasonal occurrence (spring and fall).
  • Early satiety, anorexia, weight loss, abnormal saline load test, succussion splash, gastric retention of barium, nausea, vomiting suggest pyloric obstruction
  • Heartburn (suggesting reflux disease)
  • Sudden, severe mid-epigastric pain radiating to right shoulder, peritoneal signs, and free peritoneal air may indicate perforation
  • Dizziness, syncope, hematemesis, or melena suggest hemorrhage
• In adults (GU)
  • Symptom complex similar to DU
  • NSAID-induced ulcers often silent; perforation or bleeding may be initial presentation
  • Epigastric pain following a meal is uncommon; early satiety, nausea, vomiting suggest gastric outlet obstruction
  • Weight loss can occur with either benign or malignant gastric ulcers
• In children (DU)
  • Positive family history in 50% of early-onset DU patients (under age 20)
  • May account for chronic abdominal pain syndrome in young children
  • Gastric outlet obstruction from ulcer must be distinguished from congenital infantile hypertrophic pyloric stenosis (seen within the first month after birth along with visible peristalses and a palpable pyloric mass)

Etiology of DU and GU is multifactorial. H. pylori gastritis is present in >80% of DU and >60% of GU.

• Imbalance between aggressive factors (e.g., gastric acid, pepsin, bile salts, pancreatic enzymes) and defensive factors maintaining mucosal integrity (e.g., mucus, bicarbonate, blood flow, prostaglandins, growth factors, cell turnover), which may relate to H. pylori infection
• Ulcerogenic drugs (e.g., NSAIDs)
• Zollinger–Ellison syndrome
• Other hypersecretory syndromes

• Strongly associated:
  • Drugs (e.g., NSAID use)
  • Family history of ulcer
  • Zollinger–Ellison syndrome (gastrinoma)
  • Cigarettes (> 1/2 pack/day)
• Possibly associated:
  • Corticosteroids (high dose and/or prolonged therapy)
  • Blood group O
  • HLA-B12, B5, Bw35 phenotypes
  • Stress
  • Lower socioeconomic status
  • Manual labor
• Poorly or not associated:
  • Dietary spices
  • Alcohol
  • Caffeine
  • Acetaminophen
• Annual risk of DU developing in H. pylori–positive individuals < 1%