Peptic ulcer disease (PUD) is defined as disruption of the mucosal membrane of the esophagus, stomach and/or duodenum.

Types :

Peptic ulcers include:

1) Esophageal ulcers that occur inside the esophagus, a narrow lumen for the food passage from mouth to stomach.

2) Gastric ulcers that occur within the stomach characterized by a burning sensation and pain in the upper abdomen immediately below the ribs that is exacerbated by fasting and improved with meals.

3) Duodenal ulcers occur in the upper portion of the small intestine, duodenum.

Causes :

Common causes include:

1. Helicobacter pylori infection:
An infection with Helicobacter pylori bacteria commonly causes inflammation of the inner mucosal layer of the stomach. The bacteria usually transmitted through close contact with an infected person, food and water.
2. Anti-inflammatory drugs :
Regular use of certain NSAIDs' (anti-inflammatory drugs) causes peptic ulcer. These medications erodes the mucosal lining of the gut, if not ingested along with food or an ulcer protective drug. These medications include like aspirin, ibuprofen, naproxen etc.

3. Other medications :
Certain other medications are also found to cause peptic ulcers. These include medications used to treat osteoporosis called bisphosphonates and potassium supplements.

4. Certain disease:
Peptic ulcers occurs in association with certain diseases. Eg: Gastronimas -  tumors of cells of stomach that produce excess acid, cysticfibrosis etc.

Risk factors :

Certain risk factors for the development of peptic ulcers include:

1) Family history
2) Stress
3) Traumatic head injury
4) Burns
5) Persons having 'O' Blood group
6) Consumption of pickles, high spicy foods
7) Sedentary lifestyle
8) Smoking and alcoholism
9) Irregular meal pattern

Signs and symptoms :

Most common symptoms of peptic ulcer include

1) Abdominal pain and cramps, especially over the epigastric region.
2) Heartburn
3) Bloating sensation
4) Nausea and vomiting
5) Hematemesis (vomiting of blood)
6) Malena (occult blood in stool)
7) Dyspepsia (indigestion)

Complications :

1) Bleeding, which can be fatal
2) Perforation of the stomach wall, causing acute peritonitis
3) Gastric outlet obstruction from swelling of the pyloric part of the stomach.

Diagnosis :

History and physical examination of the patient to reveal the signs and symptoms.
Specific diagnostic measures include

1) Endoscopy
Usually an upper gastrointestinal tract endoscopy is performed to identify the peptic ulcers.

2) Biopsy
A sample of the inner gastric mucosa is collected during endoscopy and is sent for histopathological evaluation. Inherited diseases such as cystic-fibrosis can be revealed through a biopsy.

3) Esophagogastroduodenoscopy
It permits the direct visualization of the stomach and is useful in identifying the exact location and severity of the ulcer.

4) Routine blood examination to evaluate the signs of infection.

5) Stool sample for presence of occult blood.


Treatment :

The medications used for the treatment of peptic ulcers include the following.

1) Antibiotics to treat infection. Eg:Clarithromycin, Amoxicillin, Tetracycline, Metronidazole

2) Antacids are those medications used to protect the mucosa layer of the gut from the acidic erosion. Eg: aluminium hydroxide, magnesium hydroxide.

3) Proton Pump Inhibitors Eg: Pantorazole, Raniprazole. PPIs are a group of drugs reduce the production of acid.

4) H2 receptor antagonists Eg: Ranitidine, Famotidine

5) Ulcer protective drugs Eg: Sucralfate

Surgery:

The surgical options for peptic ulcer are,

Vagotomy
It involves cutting one ore more branches of vagus nerve that innervates the stomach and thereby reducing gastric acid secretion. It can be trunkal vagotomy or selective vagotomy.

Pyloroplasty
It is usually performed in  with gastric outlet obstruction. The pyloric part of the stomach is widened in this surgery.

Gastrectomy:
Removing the part of the stomach. It can be either complete or total gastrectomy, or partial gastrectomy.
Based on the parts of stomach removed, it is termed as Billroth I and Billroth II.

Billroth I is an operation in which the pylorus is removed and the proximal stomach is anastomosed directly to the duodenum. This operation is otherwise known as gastroduodenostomy.

Billroth II is an operation in which the greater curvature of the stomach is connected to the first part of the jejunum in a side-to-side manner, preserving the duodenum. The surgical procedure is called gastrojejunostomy. The Billroth II is often indicated in refractory peptic ulcer disease