Browse > Article
http://dx.doi.org/10.3904/kjim.2015.30.5.559

A systematic approach for the diagnosis and treatment of idiopathic peptic ulcers  

Chung, Chen-Shuan (Department of Internal Medicine, Far Eastern Memorial Hospital)
Chiang, Tsung-Hsien (Department of Internal Medicine, National Taiwan University Hospital)
Lee, Yi-Chia (Department of Internal Medicine, National Taiwan University Hospital)
Publication Information
The Korean journal of internal medicine / v.30, no.5, 2015 , pp. 559-570 More about this Journal
Abstract
An idiopathic peptic ulcer is defined as an ulcer with unknown cause or an ulcer that appears to arise spontaneously. The first step in treatment is to exclude common possible causes, including Helicobacter pylori infection, infection with other pathogens, ulcerogenic drugs, and uncommon diseases with upper gastrointestinal manifestations. When all known causes are excluded, a diagnosis of idiopathic peptic ulcer can be made. A patient whose peptic ulcer is idiopathic may have a higher risk for complicated ulcer disease, a poorer response to gastric acid suppressants, and a higher recurrence rate after treatment. Risk factors associated with this disease may include genetic predisposition, older age, chronic mesenteric ischemia, smoking, concomitant diseases, a higher American Society of Anesthesiologists score, and higher stress. Therefore, the diagnosis and management of emerging disease should systematically explore all known causes and treat underlying disease, while including regular endoscopic surveillance to confirm ulcer healing and the use of proton-pump inhibitors on a case-by-case basis.
Keywords
Idiopathic peptic ulcer; Helicobacter pylori infection; Endoscopy;
Citations & Related Records
Times Cited By KSCI : 2  (Citation Analysis)
연도 인용수 순위
1 Gisbert JP, Blanco M, Mateos JM, et al. H. pylori-negative duodenal ulcer prevalence and causes in 774 patients. Dig Dis Sci 1999;44:2295-2302.   DOI
2 Meucci G, Di Battista R, Abbiati C, et al. Prevalence and risk factors of Helicobacter pylori-negative peptic ulcer: a multicenter study. J Clin Gastroenterol 2000;31:42-47.   DOI
3 Arents NL, Thijs JC, van Zwet AA, Kleibeuker JH. Does the declining prevalence of Helicobacter pylori unmask patients with idiopathic peptic ulcer disease? Trends over an 8 year period. Eur J Gastroenterol Hepatol 2004;16:779-783.   DOI
4 Sbrozzi-Vanni A, Zullo A, Di Giulio E, et al. Low prevalence of idiopathic peptic ulcer disease: an Italian endoscopic survey. Dig Liver Dis 2010;42:773-776.   DOI
5 Vu C, Ng YY. Prevalence of Helicobacter pylori in peptic ulcer disease in a Singapore hospital. Singapore Med J 2000;41:478-481.
6 Yakoob J, Jafri W, Jafri N, et al. Prevalence of non-Helicobacter pylori duodenal ulcer in Karachi, Pakistan. World J Gastroenterol 2005;11:3562-3565.   DOI
7 Ootani H, Iwakiri R, Shimoda R, et al. Role of Helicobacter pylori infection and nonsteroidal anti-inflammatory drug use in bleeding peptic ulcers in Japan. J Gastroenterol 2006;41:41-46.   DOI
8 Goenka MK, Majumder S, Sethy PK, Chakraborty M. Helicobacter pylori negative, non-steroidal anti-inflammatory drug-negative peptic ulcers in India. Indian J Gastroenterol 2011;30:33-37.   DOI
9 Kang JM, Seo PJ, Kim N, et al. Analysis of direct medical care costs of peptic ulcer disease in a Korean tertiary medical center. Scand J Gastroenterol 2012;47:36-42.   DOI
10 Uyanikoglu A, Danalioglu A, Akyuz F, et al. Etiological factors of duodenal and gastric ulcers. Turk J Gastroenterol 2012;23:99-103.   DOI
11 Yoon H, Kim SG, Jung HC, Song IS. High recurrence rate of idiopathic peptic ulcers in long-term follow-up. Gut Liver 2013;7:175-181.   DOI
12 Chow DK, Sung JJ. Non-NSAID non-H. pylori ulcer disease. Best Pract Res Clin Gastroenterol 2009;23:3-9.
13 Quan C, Talley NJ. Management of peptic ulcer disease not related to Helicobacter pylori or NSAIDs. Am J Gastroenterol 2002;97:2950-2961.   DOI
14 Gisbert JP, Abraira V. Accuracy of Helicobacter pylori diagnostic tests in patients with bleeding peptic ulcer: a systematic review and meta-analysis. Am J Gastroenterol 2006;101:848-863.   DOI
15 Raj SM, Yap K, Haq JA, Singh S, Hamid A. Further evidence for an exceptionally low prevalence of Helicobacter pylori infection among peptic ulcer patients in north-eastern peninsular Malaysia. Trans R Soc Trop Med Hyg 2001;95:24-27.   DOI
16 Laine L, Estrada R, Trujillo M, Knigge K, Fennerty MB. Effect of proton-pump inhibitor therapy on diagnostic testing for Helicobacter pylori. Ann Intern Med 1998;129:547-550.   DOI
17 Chey WD, Woods M, Scheiman JM, Nostrant TT, DelValle J. Lansoprazole and ranitidine affect the accuracy of the 14C-urea breath test by a pH-dependent mechanism. Am J Gastroenterol 1997;92:446-450.
18 Lee JM, Breslin NP, Fallon C, O'Morain CA. Rapid urease tests lack sensitivity in Helicobacter pylori diagnosis when peptic ulcer disease presents with bleeding. Am J Gastroenterol 2000;95:1166-1170.   DOI
19 Leung WK, Sung JJ, Siu KL, Chan FK, Ling TK, Cheng AF. False-negative biopsy urease test in bleeding ulcers caused by the buffering effects of blood. Am J Gastroenterol 1998;93:1914-1918.   DOI
20 Lee TH, Lin CC, Chung CS, Lin CK, Liang CC, Tsai KC. Increasing biopsy number and sampling from gastric body improve the sensitivity of rapid urease test in patients with peptic ulcer bleeding. Dig Dis Sci 2015;60:454-457.   DOI
21 Bayerdorffer E, Oertel H, Lehn N, et al. Topographic association between active gastritis and Campylobacter pylori colonisation. J Clin Pathol 1989;42:834-839.   DOI
22 Genta RM, Graham DY. Comparison of biopsy sites for the histopathologic diagnosis of Helicobacter pylori: a topographic study of H. pylori density and distribution. Gastrointest Endosc 1994;40:342-345.   DOI
23 Craanen ME, Dekker W, Blok P, Ferwerda J, Tytgat GN. Intestinal metaplasia and Helicobacter pylori: an endoscopic bioptic study of the gastric antrum. Gut 1992;33:16-20.   DOI
24 Hirschowitz BI, Lanas A. Intractable upper gastrointestinal ulceration due to aspirin in patients who have undergone surgery for peptic ulcer. Gastroenterology 1998;114:883-892.   DOI
25 Lanas A, Serrano P, Bajador E, Esteva F, Benito R, Sainz R. Evidence of aspirin use in both upper and lower gastrointestinal perforation. Gastroenterology 1997;112:683-689.   DOI
26 Blank MA, Ems BL, Gibson GW, et al. Nonclinical model for assessing gastric effects of bisphosphonates. Dig Dis Sci 1997;42:281-288.   DOI
27 Graham DY, Malaty HM. Alendronate gastric ulcers. Aliment Pharmacol Ther 1999;13:515-519.   DOI
28 Saini SD, Eisen G, Mattek N, Schoenfeld P. Utilization of upper endoscopy for surveillance of gastric ulcers in the United States. Am J Gastroenterol 2008;103:1920-1925.   DOI
29 Pruitt RE, Truss CD. Endoscopy, gastric ulcer, and gastric cancer: follow-up endoscopy for all gastric ulcers? Dig Dis Sci 1993;38:284-288.   DOI
30 Podolsky I, Storms PR, Richardson CT, Peterson WL, Fordtran JS. Gastric adenocarcinoma masquerading endoscopically as benign gastric ulcer: a five-year experience. Dig Dis Sci 1988;33:1057-1063.   DOI
31 Breslin NP, Sutherland LR. Survey of current practices among members of CAG in the follow-up of patients diagnosed with gastric ulcer. Can J Gastroenterol 1999;13:489-493.   DOI
32 Kaltenbach T, Sano Y, Friedland S, Soetikno R; American Gastroenterological Association. American Gastroenterological Association (AGA) Institute technology assessment on image-enhanced endoscopy. Gastroenterology 2008;134:327-340.   DOI
33 Goh KL. Prevalence of and risk factors for Helicobacter pylori infection in a multi-racial dyspeptic Malaysian population undergoing endoscopy. J Gastroenterol Hepatol 1997;12:S29-S35.   DOI
34 Niv Y, Boltin D, Halpern M, et al. Membrane-bound mucins and mucin terminal glycans expression in idiopathic or Helicobacter pylori, NSAID associated peptic ulcers. World J Gastroenterol 2014;20:14913-14920.   DOI
35 Niv Y, Boltin D. Secreted and membrane-bound mucins and idiopathic peptic ulcer disease. Digestion 2012;86:258-263.   DOI
36 Lee YC, Yen AM, Tai JJ, et al. The effect of metabolic risk factors on the natural course of gastro-oesophageal reflux disease. Gut 2009;58:174-181.   DOI
37 Azuma T, Konishi J, Ito Y, et al. Genetic differences between duodenal ulcer patients who were positive or negative for Helicobacter pylori. J Clin Gastroenterol 1995;21 Suppl 1:S151-S154.
38 Xia HH, Wong BC, Wong KW, et al. Clinical and endoscopic characteristics of non-Helicobacter pylori, non-NSAID duodenal ulcers: a long-term prospective study. Aliment Pharmacol Ther 2001;15:1875-1882.   DOI
39 Cryer B, Redfern JS, Goldschmiedt M, Lee E, Feldman M. Effect of aging on gastric and duodenal mucosal prostaglandin concentrations in humans. Gastroenterology 1992;102(4 Pt 1):1118-1123.   DOI
40 Ma L, Chow JY, Cho CH. Effects of cigarette smoking on gastric ulcer formation and healing: possible mechanisms of action. J Clin Gastroenterol 1998;27 Suppl 1:S80-S86.   DOI
41 Luo JC, Leu HB, Hou MC, et al. Cirrhotic patients at increased risk of peptic ulcer bleeding: a nationwide population-based cohort study. Aliment Pharmacol Ther 2012;36:542-550.   DOI
42 Kanno T, Iijima K, Abe Y, et al. Hemorrhagic ulcers after Great East Japan Earthquake and Tsunami: features of post-disaster hemorrhagic ulcers. Digestion 2013;87:40-46.   DOI
43 Kanno T, Iijima K, Abe Y, et al. Peptic ulcers after the Great East Japan earthquake and tsunami: possible existence of psychosocial stress ulcers in humans. J Gastroenterol 2013;48:483-490.   DOI
44 Howden CW, Leontiadis GI. Current indications for acid suppressants in Helicobacter pylori-negative ulcer disease. Best Pract Res Clin Gastroenterol 2001;15:401-412.
45 Levenstein S, Rosenstock S, Jacobsen RK, Jorgensen T. Psychological stress increases risk for peptic ulcer, regardless of Helicobacter pylori infection or use of nonsteroidal anti-inflammatory drugs. Clin Gastroenterol Hepatol 2015;13:498.e1-506.e1.
46 Freston JW. Review article: role of proton pump inhibitors in non-H. pylori-related ulcers. Aliment Pharmacol Ther 2001;15 Suppl 2:2-5.
47 Freston JW. Helicobacter pylori-negative peptic ulcers: frequency and implications for management. J Gastroenterol 2000;35 Suppl 12:29-32.
48 McColl KE. Helicobacter pylori-negative ulcer disease. J Gastroenterol 2000;35 Suppl 12:47-50.   DOI
49 Bytzer P, Teglbjaerg PS; Danish Ulcer Study Group. Helicobacter pylori-negative duodenal ulcers: prevalence, clinical characteristics, and prognosis: results from a randomized trial with 2-year follow-up. Am J Gastroenterol 2001;96:1409-1416.
50 Hyvarinen H, Salmenkyla S, Sipponen P. Helicobacter pylori-negative duodenal and pyloric ulcer: role of NSAIDs. Digestion 1996;57:305-309.   DOI
51 McColl KE, el-Nujumi AM, Chittajallu RS, et al. A study of the pathogenesis of Helicobacter pylori negative chronic duodenal ulceration. Gut 1993;34:762-768.   DOI
52 Wong GL, Wong VW, Chan Y, et al. High incidence of mortality and recurrent bleeding in patients with Helicobacter pylori-negative idiopathic bleeding ulcers. Gastroenterology 2009;137:525-531.   DOI
53 IARC Helicobacter pylori Working Group. Helicobacter pylori eradication as a strategy for gastric cancer prevention (IARC Working Group Reports, No. 8) [Internet]. Lyon (FR): International Agency for Research on Cancer, c2015 [cited 2015 Jun 22]. Available from: http://www.iarc.fr/en/publications/pdfs-online/wrk/wrk8/index.php.
54 Gillen D, Wirz AA, Neithercut WD, Ardill JE, McColl KE. Helicobacter pylori infection potentiates the inhibition of gastric acid secretion by omeprazole. Gut 1999;44:468-475.   DOI
55 Infection with Helicobacter pylori. IARC Monogr Eval Carcinog Risks Hum 1994;61:177-240.
56 Torres J, Lopez L, Lazcano E, Camorlinga M, Flores L, Munoz O. Trends in Helicobacter pylori infection and gastric cancer in Mexico. Cancer Epidemiol Biomarkers Prev 2005;14:1874-1877.   DOI
57 Kuipers EJ, Thijs JC, Festen HP. The prevalence of Helicobacter pylori in peptic ulcer disease. Aliment Pharmacol Ther 1995;9 Suppl 2:59-69.
58 Lee YC, Chen TH, Chiu HM, et al. The benefit of mass eradication of Helicobacter pylori infection: a community-based study of gastric cancer prevention. Gut 2013;62:676-682.   DOI
59 Xia B, Xia HH, Ma CW, et al. Trends in the prevalence of peptic ulcer disease and Helicobacter pylori infection in family physician-referred uninvestigated dyspeptic patients in Hong Kong. Aliment Pharmacol Ther 2005;22:243-249.   DOI
60 Uyub AM, Raj SM, Visvanathan R, et al. Helicobacter pylori infection in north-eastern peninsular Malaysia: evidence for an unusually low prevalence. Scand J Gastroenterol 1994;29:209-213.   DOI
61 Musumba C, Jorgensen A, Sutton L, et al. The relative contribution of NSAIDs and Helicobacter pylori to the aetiology of endoscopically-diagnosed peptic ulcer disease: observations from a tertiary referral hospital in the UK between 2005 and 2010. Aliment Pharmacol Ther 2012;36:48-56.   DOI
62 Sugiyama T, Nishikawa K, Komatsu Y, et al. Attributable risk of H. pylori in peptic ulcer disease: does declining prevalence of infection in general population explain increasing frequency of non-H. pylori ulcers? Dig Dis Sci 2001;46:307-310.   DOI
63 Singh V, Trikha B, Nain CK, Singh K, Vaiphei K. Epidemiology of Helicobacter pylori and peptic ulcer in India. J Gastroenterol Hepatol 2002;17:659-665.   DOI
64 Asaka M, Kimura T, Kudo M, et al. Relationship of Helicobacter pylori to serum pepsinogens in an asymptomatic Japanese population. Gastroenterology 1992;102:760-766.   DOI
65 Graham DY. Large U.S. clinical trials report a high proportion of H. pylori negative duodenal ulcers at study entry as well as a high recurrence rate after cure of the infection: have we all been wrong? Gastroenterology 1998;114(Suppl 1):A17.
66 Nensey YM, Schubert TT, Bologna SD, Ma CK. Helicobacter pylori-negative duodenal ulcer. Am J Med 1991;91:15-18.   DOI
67 Sprung DJ, Apter MN. What is the role of Helicobacter pylori in peptic ulcer and gastric cancer outside the big cities? J Clin Gastroenterol 1998;26:60-63.   DOI
68 Jyotheeswaran S, Shah AN, Jin HO, Potter GD, Ona FV, Chey WY. Prevalence of Helicobacter pylori in peptic ulcer patients in greater Rochester, NY: is empirical triple therapy justified? Am J Gastroenterol 1998;93:574-578.   DOI
69 Borody TJ, George LL, Brandl S, et al. Helicobacter pylori-negative duodenal ulcer. Am J Gastroenterol 1991;86:1154-1157.
70 Charpignon C, Lesgourgues B, Pariente A, et al. Peptic ulcer disease: one in five is related to neither Helicobacter pylori nor aspirin/NSAID intake. Aliment Pharmacol Ther 2013;38:946-954.   DOI
71 Higuchi K, Arakawa T, Fujiwara Y, et al. Is Helicobacter pylori-negative duodenal ulcer masked by the high prevalence of H. pylori infection in the general population? Am J Gastroenterol 1999;94:3083-3084.
72 Tsuji H, Kohli Y, Fukumitsu S, et al. Helicobacter pylori-negative gastric and duodenal ulcers. J Gastroenterol 1999;34:455-460.   DOI
73 Arakawa T1, Higuchi K, Fujiwara Y, et al. Helicobacter pylori: criminal or innocent bystander? J Gastroenterol 2000;35 Suppl 12:42-46.
74 Aoyama N, Shinoda Y, Matsushima Y, et al. Helicobacter pylori-negative peptic ulcer in Japan: which contributes most to peptic ulcer development, Helicobacter pylori, NSAIDS or stress? J Gastroenterol 2000;35 Suppl 12:33-37.
75 Nishikawa K, Sugiyama T, Kato M, et al. Non-Helicobacter pylori and non-NSAID peptic ulcer disease in the Japanese population. Eur J Gastroenterol Hepatol 2000;12:635-640.   DOI
76 Chan HL, Wu JC, Chan FK, et al. Is non-Helicobacter pylori, non-NSAID peptic ulcer a common cause of upper GI bleeding? A prospective study of 977 patients. Gastrointest Endosc 2001;53:438-442.   DOI
77 Kamada T, Haruma K, Kusunoki H, et al. Significance of an exaggerated meal-stimulated gastrin response in pathogenesis of Helicobacter pylori-negative duodenal ulcer. Dig Dis Sci 2003;48:644-651.   DOI
78 Ong TZ, Hawkey CJ, Ho KY. Nonsteroidal anti-inflammatory drug use is a significant cause of peptic ulcer disease in a tertiary hospital in Singapore: a prospective study. J Clin Gastroenterol 2006;40:795-800.   DOI
79 Chu KM, Kwok KF, Law S, Wong KH. Patients with Helicobacter pylori positive and negative duodenal ulcers have distinct clinical characteristics. World J Gastroenterol 2005;11:3518-3522.   DOI
80 Hung LC, Ching JY, Sung JJ, et al. Long-term outcome of Helicobacter pylori-negative idiopathic bleeding ulcers: a prospective cohort study. Gastroenterology 2005;128:1845-1850.   DOI
81 Jang HJ, Choi MH, Shin WG, et al. Has peptic ulcer disease changed during the past ten years in Korea? A prospective multi-center study. Dig Dis Sci 2008;53:1527-1531.   DOI
82 Chen TS, Luo JC, Chang FY. Prevalence of Helicobacter pylori infection in duodenal ulcer and gastro-duodenal ulcer diseases in Taiwan. J Gastroenterol Hepatol 2010;25:919-922.   DOI
83 Wong GL, Au KW, Lo AO, et al. Gastroprotective therapy does not improve outcomes of patients with Helicobacter pylori-negative idiopathic bleeding ulcers. Clin Gastroenterol Hepatol 2012;10:1124-1129.   DOI
84 Kim JJ, Kim N, Park HK, et al. Clinical characteristics of patients diagnosed as peptic ulcer disease in the third referral center in 2007. Korean J Gastroenterol 2012;59:338-346.   DOI
85 Ciociola AA, McSorley DJ, Turner K, Sykes D, Palmer JB. Helicobacter pylori infection rates in duodenal ulcer patients in the United States may be lower than previously estimated. Am J Gastroenterol 1999;94:1834-1840.   DOI