Gastroduodenal ulcers: causes, diagnosis, prevention, and treatment

The precise diagnosis and duration of peptic ulcer disease can now be made endoscopically. Numerous effective medical therapies are available to treat these disorders. While the vast majority of patients respond to medical therapy with complete healing of ulcers within 4 to 6 weeks, a small percentage require longer and probably more intense treatment. A total assessment of the patient's lifestyle is important in order to achieve the best therapeutic response. Cigarette smoking is a potent negative factor for both healing and ulcer recurrence. The question of who should continue on maintenance therapy and for how long has not been answered. Certainly, the first-time ulcer patient who smokes and becomes asymptomatic on treatment requires nothing more than standard 4- to 6-week therapy and discontinuation of smoking. Patients with recurrent disease and those who have sustained complications such as bleeding or perforation probably warrant 6 to 12 months of maintenance therapy, with close follow-up thereafter. Some patients will require continuous maintenance therapy in order to remain asymptomatic. In such patients it is important to determine that the problem is, in fact, "routine" peptic ulcer disease. Ulcers associated with NSAIDs are unique in that their cause is known and, at present, their treatment is specific. Studies to date indicate that the only appropriate therapy to prevent NSAID ulcers is misoprostol, and that this drug is also effective in healing such ulcers while NSAID treatment is continued. Except for complications, few patients now need to be referred for surgical intervention. Those who are should receive the least destructive procedure possible. The efficacy of medical therapy is generally enhanced following selective and highly selective vagotomy. No patient should be referred electively to surgery without the Zollinger-Ellison syndrome being ruled out.