Understanding Stomach Ulcers: Causes, Risk Factors, and Prevention

Peptic ulcer disease (PUD) refers to mucosal breaks >3 mm in the stomach (gastric ulcer) or duodenum (duodenal ulcer) extending through the muscularis mucosae. Helicobacter pylori and NSAIDs cause >90% of cases.

Major Etiologies

1. Helicobacter pylori Infection

• Gram-negative, spiral, urease-producing bacterium colonizing gastric antrum.
• Causes chronic active gastritis → disrupts mucosal defense (mucus, bicarbonate, blood flow, prostaglandins).
• Present in 70–90% of duodenal ulcers, 60–80% of gastric ulcers.
• Eradication cures ulcer and prevents recurrence.

2. NSAIDs (Nonsteroidal Anti-Inflammatory Drugs)

• Aspirin, ibuprofen, naproxen, diclofenac, celecoxib (COX-2 selective, lower GI risk).
• Inhibit COX-1 → ↓ prostaglandins (PGE₂, PGI₂) → ↓ mucus/bicarbonate, ↓ mucosal blood flow, ↓ epithelial restitution.
• Risk factors: age >60, prior ulcer, high dose, multiple NSAIDs, anticoagulants, steroids, H. pylori co-infection (synergistic).

3. Other Contributors

• Stress ulcers: Severe physiologic stress (burns, trauma, sepsis, ICU) → mucosal ischemia → Curling's (burn) / Cushing's (CNS) ulcers. Prophylaxis with PPI/H2RA in ICU.
• Zollinger-Ellison syndrome: Gastrinoma → massive acid hypersecretion → refractory ulcers.
• Crohn's disease: Granulomatous inflammation can involve stomach/duodenum.
• Malignancy: Gastric adenocarcinoma can ulcerate (must biopsy gastric ulcers).
• Infections: CMV, HSV, TB, syphilis (rare).
• Radiation, chemotherapy.

Risk Factor Modification

• H. pylori: Test-and-treat (urea breath test, stool antigen, biopsy). Eradication: PPI + 2 antibiotics (clarithromycin + amoxicillin/metronidazole) × 14 days (preferred) or bismuth quadruple × 14 days.
• NSAIDs: Avoid if possible; use lowest effective dose; substitute acetaminophen; if required, co-prescribe PPI (omeprazole 20–40 mg daily) or misoprostol; consider COX-2 selective.
• Lifestyle: Smoking cessation (impairs healing, ↑ recurrence). Alcohol moderation (↑ acid, mucosal injury). Stress management.

Alarm Features – Urgent Endoscopy

• Age >60 with new-onset dyspepsia.
• Unintentional weight loss.
• GI bleeding (hematemesis, melena, hematochezia).
• Iron deficiency anemia.
• Dysphagia, odynophagia.
• Family history of gastric cancer.

Most ulcers heal with acid suppression + cause eradication. Maintenance PPI may be needed for high-risk patients on continued NSAIDs.