Peptic Ulcer Diseases

Definition

Peptic ulcer disease (PUD) refers to mucosal erosions ≥5 mm in the stomach (gastric ulcer) or duodenum (duodenal ulcer) caused by an imbalance between aggressive factors (acid, pepsin, NSAIDs, H. pylori) and defensive mechanisms (mucus, bicarbonate, prostaglandins, mucosal blood flow).

Etiology / Risk Factors

  • Helicobacter pylori infection (most common worldwide)
  • NSAID/ASA use (dose- and duration-dependent)
  • Stress-related mucosal injury (critical illness, burns, trauma)
  • Smoking and alcohol
  • Zollinger-Ellison syndrome (gastrinoma, rare)
  • Genetic predisposition

Pathophysiology

  • Acid and pepsin disrupt mucosal integrity
  • H. pylori infection:
    • Damages epithelial cells
    • Induces inflammation
    • Increases acid secretion (duodenal ulcers)
  • NSAIDs inhibit COX-1 → reduced prostaglandins → impaired mucosal defense

Clinical Presentation

  • Symptoms
    • Epigastric pain (burning or gnawing)
      • Duodenal: pain relieved by food
      • Gastric: pain worse with food
    • Nausea, bloating, early satiety
    • Occult or overt GI bleeding
  • Complications
    • Hemorrhage
    • Perforation → acute abdomen
    • Gastric outlet obstruction

Diagnosis

  • Endoscopy (gold standard)
  • H. pylori testing: Urea breath test, stool antigen, biopsy
  • Laboratory: CBC for anemia if bleeding suspected
  • Imaging: Only if perforation suspected

Pharmacist’s Role & Clinical Pearls

Acid Suppression Therapy

  • Proton Pump Inhibitors (PPIs):
    • Omeprazole, pantoprazole, esomeprazole
    • High efficacy for ulcer healing
  • H2 Receptor Antagonists:
    • Ranitidine (less used), famotidine
    • Alternative in mild cases or PPI intolerance

H. pylori Eradication (Triple or Quadruple Therapy)

  • Triple therapy: PPI + clarithromycin + amoxicillin (or metronidazole)
  • Quadruple therapy: PPI + bismuth + tetracycline + metronidazole
  • Clinical pearls:
    • Assess for antibiotic allergies
    • Monitor for drug–drug interactions (e.g., clarithromycin with statins)
    • Counsel on adherence for 10–14 days
  • Discontinue offending NSAID if possible
  • Co-therapy with PPI for gastroprotection if continued NSAID required
  • Avoid concomitant anticoagulants unless necessary; monitor closely

Lifestyle & Counseling

  • Avoid smoking and excess alcohol
  • Limit NSAID use
  • Educate about warning signs of bleeding or perforation (hematemesis, melena, severe abdominal pain)
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