Overview of the natural history and treatment of peptic ulcer disease
- Andrew H Soll, MD
Andrew H Soll, MD
- Emeritus Professor of Medicine
- University of California Los Angeles Center for Health Sciences
- Nimish B Vakil, MD, AGAF, FACP, FACG, FASGE
Nimish B Vakil, MD, AGAF, FACP, FACG, FASGE
- Clinical Professor of Medicine
- University of Wisconsin School of Medicine and Public Health
Peptic ulcer disease (PUD) is a common problem. The natural history and an overview of the treatment of peptic ulcer disease will be reviewed here. Issues related to the treatment of Helicobacter pylori infection, treatment of complications of peptic ulcer disease, and the role of surgery are discussed separately. (See "Management of duodenal ulcers in patients infected with Helicobacter pylori" and "Treatment regimens for Helicobacter pylori" and "Overview of the complications of peptic ulcer disease" and "Surgical management of peptic ulcer disease".)
Data from the pre-H. pylori, pre-proton pump inhibitor (PPI) era provide important to insights into the natural history of PUD. Untreated, peptic ulcers have a widely variable natural history [1-7]. Some heal spontaneously, but recur within months or sometimes within a year or two. An illustrative report described patients who were followed for 12 months after documented healing of duodenal ulcers. Relapse occurred in 74 percent of cases; 33 percent had one recurrence, 24 percent two recurrences, and 17 percent experienced three or more recurrences . Other reports have confirmed a 50 to 80 percent recurrence rate during the 6 to 12 months following initial ulcer healing, although relapses are not always symptomatic [2,3].
Other ulcers cause complications or remain refractory despite antisecretory therapy. The patient's prior ulcer history tends to predict future behavior; those with a history of complications have an increased risk of future complications. Ulcers that take longer to heal initially are more likely to recur rapidly and ulcers that have recurred frequently are likely to continue to do so, unless the underlying cause (eg, H. pylori or nonsteroidal anti-inflammatory drugs [NSAIDs]) is removed. A long duration of symptoms prior to presentation is more likely to be associated with a poor response to medical therapy. (See "Refractory or recurrent peptic ulcer disease".)
Distal antral ulcers, especially prepyloric ulcers (within 2 to 3 cm of the pylorus), may have a different pattern of healing than ulcers at or proximal to the incisura because of different levels of acid secretion and the distribution of gastritis . Many studies did not analyze gastric ulcers by location, and available data are conflicting. Nevertheless, prepyloric ulcers appear to heal more slowly and may be more likely to recur [9,10].
Treatment of H. pylori in infected individuals dramatically alters the incidence of ulcer relapse [11,12]. In a meta-analysis that included 14 studies, duodenal ulcers recurred in fewer than 10 percent of patients successfully treated for H. pylori compared with 65 to 95 percent of those who remained infected . However, newer data from the United States suggest that recurrences after successful H. pylori antibiotic treatment may be more frequent . By contrast, relapse is the rule in the absence of successful anti-H. pylori therapy. (See "Management of duodenal ulcers in patients infected with Helicobacter pylori".)
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- NATURAL HISTORY
- General approach
- Eradication of H. pylori
- - Treatment of H. pylori in patients on NSAIDs
- - Antisecretory therapy after H. pylori eradication
- Initial approach to ulcers not due to H. pylori
- - Confirm H. pylori negativity
- - Antisecretory therapy
- - Giant ulcers
- FOLLOW-UP AFTER INITIAL THERAPY FOR PEPTIC ULCER
- Duodenal ulcers
- Gastric ulcers
- MAINTENANCE THERAPY
- Duodenal ulcers
- Gastric ulcers
- DISCONTINUING PPIs
- TREATMENT DURING PREGNANCY AND LACTATION
- REFRACTORY ULCERS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS