Peptic ulcer

Abstract

Peptic ulcer disease is defined as a breakage greater than 3-5 mm in the gastrointestinal mucosa. It is mostly seen in the stomach and proximal duodenum. The lifetime prevalence of peptic ulcer disease is approximately 10%. Peptic ulcer disease occurs secondary to an imbalance between protective and damaging factors of the mucosa. The use of nonsteroidal anti-inflammatory drugs (NSAIDs) and Helicobacter pylori infection are the main causes of peptic ulcer disease. Some comorbidities and other infections are related with an increased risk of peptic ulcer disease, and smoking, alcohol intake and stress slow the healing process and increase the risk of ulcer recurrence. Family physicians often encounter patients with undifferentiated symptoms rather than documented peptic ulcer disease. The anamnesis and physical examination are critical to identify patients at risk of peptic ulcer disease. If peptic ulcer is the most likely diagnosis after evaluation, patients should be evaluated for alarm symptoms. Endoscopy is required to confirm an ulcer diagnosis for patients who have alarm symptoms and are older than 55 years. Further laboratory and radiologic tests might be needed for the diagnosis of complications of peptic ulcer disease. Current guidelines for primary care suggest a "test and treat" strategy in patients with peptic ulcer disease for H. pylori. With this approach, patients undergo a noninvasive test include a stool antigen test, urea breath test or serology for H. pylori infection. If the test results are positive for H. pylori, primary line therapy for eradication with antibiotics and proton pump inhibitors is necessary. If first line therapy fails, second line therapy should be applied. If symptoms persist despite successful eradication or there is no response on second line therapy, referral to a specialist and endoscopic evaluation would be needed. Primary complications of peptic ulcer disease are bleeding, gastric outlet obstruction and perforation. The most common complication is bleeding. The Glasgow-Blatchford score and Rockall scores have been used for risk classification. Gastric outlet obstruction is rare but an underlying malignancy should be considered in those patients. Complications of peptic ulcer disease remain life threatening and a proper evaluation of patients at risk for peptic ulcer disease and treatment of subsequent sequela remain critical. Prevention of peptic ulcer disease is the best course of action. Every primary care visit is crucial in assessing and eliminating risk factors for peptic ulcer disease with its biopsychosocial and patient centered approach of primary care.