36. Gastric and duodenal ulcers; Zollinger-Ellison syndrome

Gastric and duodenal ulcers; Zollinger–Ellison syndrome

Peptic ulcer disease (PUD) is a mucosal defect extending through the muscularis mucosae in the stomach or proximal duodenum, caused by imbalance between mucosal defence and acid-peptic injury.
Major causes are Helicobacter pylori infection and NSAID/aspirin use. Other contributors include smoking, severe physiological stress in critically ill patients and rare hypersecretory states.
Duodenal ulcers are commonly associated with H. pylori and increased acid load; gastric ulcers may be associated with H. pylori, NSAIDs or malignancy.

H. pylori causes chronic gastritis and alters acid regulation and mucosal defence. NSAIDs inhibit cyclo-oxygenase and reduce protective prostaglandins, impairing mucus, bicarbonate and mucosal blood flow.
Epigastric burning or gnawing pain is common. Duodenal ulcer pain may improve temporarily with food and recur later/night; gastric ulcer pain may worsen with meals, but symptoms are not reliable for localisation.
Other symptoms include nausea, bloating, early satiety and dyspepsia. Alarm features include GI bleeding, persistent vomiting, weight loss, anaemia, dysphagia or palpable mass.

Upper GI endoscopy is indicated for alarm features, suspected complications, older-onset symptoms according to local guidance, or persistent symptoms despite treatment. Gastric ulcers require biopsy to exclude malignancy and often repeat endoscopy to document healing.
Test for H. pylori using urea breath test, stool antigen or biopsy-based testing. Proton-pump inhibitors, antibiotics and bismuth can cause false-negative tests; follow recommended washout periods.
Check full blood count and iron studies if bleeding/anaemia is suspected. CT is used when perforation or other acute complication is suspected.

Stop NSAIDs where possible; if they must continue, assess gastroprotection. Treat H. pylori with a locally recommended eradication regimen based on resistance patterns and prior antibiotic exposure.
Use a proton-pump inhibitor to promote healing. Confirm H. pylori eradication with breath or stool antigen testing after appropriate medication washout.
Endoscopic haemostasis is used for bleeding ulcers. Surgery is considered for perforation, uncontrolled/recurrent bleeding despite endoscopic/radiological therapy, obstruction or suspicion of malignancy.
Complications include haemorrhage, perforation, penetration into pancreas, gastric outlet obstruction and recurrent ulceration.

Zollinger–Ellison syndrome is caused by a gastrin-secreting neuroendocrine tumour (gastrinoma), usually in the duodenum or pancreas, producing marked gastric acid hypersecretion.
Features include recurrent, multiple or refractory ulcers, ulcers distal to the duodenal bulb, severe reflux and diarrhoea/steatorrhoea.