What is Peptic Ulcer Disease?
Peptic ulcer disease (PUD) refers to open sores (ulcers) that develop in the lining of the stomach (gastric ulcer) or the first part of the small intestine (duodenal ulcer). The most common cause is infection with Helicobacter pylori (H. pylori) bacteria. These ulcers develop when the protective mucus layer is disrupted, allowing gastric acid to damage the underlying tissue.
Classic symptoms include a burning or gnawing pain in the upper abdomen (epigastrium), often relieved by eating in duodenal ulcers or worsened by eating in gastric ulcers. Duodenal ulcers often cause pain at night that wakes the patient.
Causes of Peptic Ulcer
| Cause | Frequency | Key Test |
|---|---|---|
| H. pylori infection | 80–90% of duodenal ulcers; 70% of gastric ulcers | Urea breath test, stool antigen, endoscopy biopsy |
| NSAIDs (aspirin, ibuprofen, diclofenac) | Second most common cause | Medication history |
| Stress ulcers | ICU patients on mechanical ventilation | Endoscopy in appropriate context |
| Zollinger-Ellison Syndrome (rare) | Rare gastrin-secreting tumour (gastrinoma) | Fasting serum gastrin level |
Diagnostic Tests
| Test | How it Works | Accuracy |
|---|---|---|
| Urea Breath Test (UBT) | Patient drinks labelled urea; H. pylori breaks it down releasing labelled CO2 detected in breath | Sensitivity 95%, Specificity 96% — gold standard non-invasive test. Stop PPIs 2 weeks before, antibiotics 4 weeks before testing. |
| H. pylori Stool Antigen Test | Detects H. pylori proteins in stool | Good alternative when breath test not available; sensitivity ~94% |
| H. pylori Serology (IgG) | Blood test detecting antibodies to H. pylori | Cannot distinguish active from past infection; not used to confirm eradication |
| Endoscopy + Biopsy (OGD) | Direct visualisation of ulcer; biopsy tests for H. pylori (RUT — rapid urease test, histology) and rules out cancer in gastric ulcers | Definitive test; mandatory for gastric ulcers to exclude cancer |
| Haemoglobin / CBC | Blood count checks for iron deficiency anaemia from chronic GI bleeding | Important to detect occult blood loss |
Treatment
Triple Therapy (H. pylori Eradication)
Standard first-line treatment: Proton Pump Inhibitor (omeprazole or pantoprazole) + Amoxicillin + Clarithromycin, taken twice daily for 14 days. Eradication rates: approximately 85–90%. All three must be taken together and completed fully — partial courses promote antibiotic resistance.
Quadruple Therapy (if Clarithromycin Resistance Suspected)
PPI + Bismuth + Tetracycline + Metronidazole for 14 days. Used in areas with high clarithromycin resistance (increasingly common in India) or if first-line therapy fails. Bismuth quadruple therapy may also be used as first-line in some guidelines.
NSAID-Induced Ulcers
Stop the offending NSAID if possible. If NSAID must continue (e.g. for cardiac protection), co-prescribe a PPI (omeprazole 20mg daily) for the duration. Ulcers heal with PPI therapy over 4–8 weeks.
Confirm Eradication
A urea breath test or stool antigen test should be done at least 4 weeks after completing H. pylori treatment to confirm eradication. Do not use serology to confirm — it remains positive for months after successful treatment.
Questions to Ask Your Doctor
- Do I have H. pylori — and which test will you use?
- Do I need an endoscopy, or is the breath test sufficient?
- Which H. pylori treatment regimen is best given local resistance patterns?
- Should I avoid NSAIDs and aspirin until the ulcer heals?
- When should I return to confirm H. pylori has been eradicated?