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Peptic ulcer disease
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<h2 id="signs-and-symptoms">Signs and symptoms</h2> <p>Signs and symptoms of a peptic ulcer can include one or more of the following:<a class="footnote-ref" id="fnref:30" href="#fn:30"><sup>30</sup></a> </p> <ul><li><a href="/facts/Abdominal_pain/aF6gPB0G">abdominal pain</a>, classically <a href="/facts/Epigastric/USauNfqu">epigastric</a>, strongly correlated with mealtimes. In case of duodenal ulcers, the pain appears about three hours after taking a meal and wakes the person from sleep;</li> <li><a href="/facts/Bloating/GnjG2Mdz">bloating</a> and abdominal fullness;</li> <li><a href="/facts/Hypersalivation/fjDlJ6tj">waterbrash</a> (a rush of saliva after an episode of regurgitation to dilute the acid in esophagus, although this is more associated with <a href="/facts/Gastroesophageal_reflux_disease/8YhncnDz">gastroesophageal reflux disease</a>);</li> <li>nausea and copious vomiting;</li> <li><a href="/facts/Anorexia_(symptom)/G7RsaXp9">loss of appetite</a> and weight loss, in gastric ulcer;</li> <li>weight gain, in duodenal ulcer, as the pain is relieved by eating;</li> <li><a href="/facts/Hematemesis/YAAh4Clp">hematemesis</a> (vomiting of blood); this can occur due to bleeding directly from a gastric ulcer or from damage to the esophagus from severe/continuing vomiting.</li> <li><a href="/facts/Melena/YRBQrkGY">melena</a> (tarry, foul-smelling feces due to presence of <a href="/facts/Oxidation/Pyd5RVcj">oxidized</a> iron from <a href="/facts/Hemoglobin/RsD1MzYA">hemoglobin</a>);</li> <li>rarely, an ulcer can lead to a gastric or <a href="/facts/Gastrointestinal_perforation/TjuCNtyk">duodenal perforation</a>, which leads to <a href="/facts/Acute_peritonitis/pWjYb4MB">acute peritonitis</a> and extreme, stabbing pain,<a class="footnote-ref" id="fnref:31" href="#fn:31"><sup>31</sup></a> and requires immediate surgery.</li></ul> <p>A history of <a href="/facts/Heartburn/MkNPKoxS">heartburn</a> or <a href="/facts/Gastroesophageal_reflux_disease/8YhncnDz">gastroesophageal reflux disease</a> (GERD) and use of certain medications can raise the suspicion for peptic ulcer. Medicines associated with peptic ulcer include <a href="/facts/NSAID/coIkzl4s">NSAIDs</a> (non-steroidal anti-inflammatory drugs) that inhibit <a href="/facts/Cyclooxygenase/L2HFqExc">cyclooxygenase</a> and most <a href="/facts/Glucocorticoid/2P91Aj3S">glucocorticoids</a> (e.g., <a href="/facts/Dexamethasone/rwAhDqls">dexamethasone</a> and <a href="/facts/Prednisolone/aAB8cAPv">prednisolone</a>).<a class="footnote-ref" id="fnref:32" href="#fn:32"><sup>32</sup></a> </p><p>In people over the age of 45 with more than two weeks of the above symptoms, the odds for peptic ulceration are high enough to warrant rapid investigation by <a href="/facts/Esophagogastroduodenoscopy/5mDpBzLA">esophagogastroduodenoscopy</a>. </p><p>The timing of symptoms in relation to the meal may differentiate between gastric and duodenal ulcers. A gastric ulcer would give <a href="/facts/Epigastrium/USauNfqu">epigastric</a> pain during the meal, associated with nausea and vomiting, as <a href="/facts/Gastric_acid/btVCyhYH">gastric acid</a> production is increased as food enters the stomach. Pain in duodenal ulcers would be aggravated by hunger and relieved by a meal and is associated with night pain.<a class="footnote-ref" id="fnref:33" href="#fn:33"><sup>33</sup></a> </p><p>Also, the symptoms of peptic ulcers may vary with the location of the ulcer and the person's age. Furthermore, typical ulcers tend to heal and recur, and as a result the pain may occur for few days and weeks and then wane or disappear.<a class="footnote-ref" id="fnref:34" href="#fn:34"><sup>34</sup></a> Usually, children and the <a href="/facts/Elderly/nEpQmo9g">elderly</a> do not develop any symptoms unless complications have arisen. </p><p>A burning or gnawing feeling in the stomach area lasting between 30 minutes and 3 hours commonly accompanies ulcers. This pain can be misinterpreted as <a href="/facts/Hunger/7EJxmrXn">hunger</a>, <a href="/facts/Indigestion/axnCu0gn">indigestion</a>, or <a href="/facts/Heartburn/MkNPKoxS">heartburn</a>. Pain is usually caused by the ulcer, but it may be aggravated by the <a href="/facts/Stomach_acid/btVCyhYH">stomach acid</a> when it comes into contact with the ulcerated area. The pain caused by peptic ulcers can be felt anywhere from the navel up to the <a href="/facts/Human_sternum/qIPMpyIz">sternum</a>, it may last from few minutes to several hours, and it may be worse when the stomach is empty. Also, sometimes the pain may flare at night, and it can commonly be temporarily relieved by eating foods that buffer stomach acid or by taking anti-acid medication.<a class="footnote-ref" id="fnref:35" href="#fn:35"><sup>35</sup></a> However, peptic ulcer disease symptoms may be different for everyone.<a class="footnote-ref" id="fnref:36" href="#fn:36"><sup>36</sup></a> </p> <h3>Complications</h3> <ul><li><a href="/facts/Upper_gastrointestinal_bleeding/KaVppKHV">Gastrointestinal bleeding</a> is the most common complication. Sudden large bleeding can be life-threatening.<a class="footnote-ref" id="fnref:37" href="#fn:37"><sup>37</sup></a><a class="footnote-ref" id="fnref:38" href="#fn:38"><sup>38</sup></a> It is associated with 5% to 10% death rate.<a class="footnote-ref" id="fnref:39" href="#fn:39"><sup>39</sup></a></li> <li><a href="/facts/Gastrointestinal_perforation/TjuCNtyk">Perforation</a> (a hole in the <a href="/facts/Gastrointestinal_wall/lKhz0AUT">wall of the gastrointestinal tract</a>) following a gastric ulcer often leads to catastrophic consequences if left untreated. Erosion of the gastrointestinal wall by the ulcer leads to spillage of the stomach or intestinal contents into the abdominal cavity, leading to an acute chemical <a href="/facts/Peritonitis/pWjYb4MB">peritonitis</a>.<a class="footnote-ref" id="fnref:40" href="#fn:40"><sup>40</sup></a> The first sign is often sudden intense abdominal pain,<a class="footnote-ref" id="fnref:41" href="#fn:41"><sup>41</sup></a> as seen in <a href="/facts/Valentino%2527s_syndrome/hdEPH8Cf">Valentino's syndrome</a>. Posterior gastric wall perforation may lead to bleeding due to the involvement of gastroduodenal artery that lies posterior to the first part of the duodenum.<a class="footnote-ref" id="fnref:42" href="#fn:42"><sup>42</sup></a> The death rate in this case is 20%.<a class="footnote-ref" id="fnref:43" href="#fn:43"><sup>43</sup></a></li> <li>Penetration is a form of perforation in which the hole leads to and the ulcer continues into adjacent organs such as the <a href="/facts/Liver/Rtp4Fk2b">liver</a> and <a href="/facts/Pancreas/r0WPGjAq">pancreas</a>.<a class="footnote-ref" id="fnref:44" href="#fn:44"><sup>44</sup></a></li> <li><a href="/facts/Gastric_outlet_obstruction/47eaSbPt">Gastric outlet obstruction</a> (stenosis) is a narrowing of the pyloric canal by scarring and swelling of the gastric antrum and duodenum due to peptic ulcers. The person often presents with severe vomiting.<a class="footnote-ref" id="fnref:45" href="#fn:45"><sup>45</sup></a></li> <li>Cancer is included in the differential diagnosis (elucidated by <a href="/facts/Biopsy/A0TdRRlr">biopsy</a>), <i><a href="/facts/Helicobacter_pylori/9q4H68LP">Helicobacter pylori</a></i> as the etiological factor making it 3 to 6 times more likely to develop stomach cancer from the ulcer.<a class="footnote-ref" id="fnref:46" href="#fn:46"><sup>46</sup></a> The risk for developing gastrointestinal cancer also appears to be slightly higher with gastric ulcers.<a class="footnote-ref" id="fnref:47" href="#fn:47"><sup>47</sup></a></li></ul> <h2 id="cause">Cause</h2> <h3><i>H. pylori</i></h3> <p><i><a href="/facts/Helicobacter_pylori/9q4H68LP">Helicobacter pylori</a></i> is one of the major causative factors of peptic ulcer disease. It secretes <a href="/facts/Urease/qh6XKw4w">urease</a> to create an alkaline environment, which is suitable for its survival. It expresses blood group antigen-binding adhesin (BabA) and outer inflammatory protein adhesin (OipA), which enables it to attach to the gastric epithelium. The bacterium also expresses virulence factors such as <i>CagA</i> and <i>PicB</i>, which cause stomach mucosal inflammation. The VacA gene encodes for vacuolating cytotoxin, but its mechanism of causing peptic ulcers is unclear. Such stomach mucosal inflammation can be associated with <a href="/facts/Hyperchlorhydria/oeI67hq4">hyperchlorhydria</a> (increased stomach acid secretion) or <a href="/facts/Hypochlorhydria/s34xesR6">hypochlorhydria</a> (reduced stomach acid secretion). Inflammatory <a href="/facts/Cytokine/SdWpWABH">cytokines</a> inhibit the <a href="/facts/Parietal_cell/jS1nXJnw">parietal cell</a> acid secretion. <i>H. pylori</i> also secretes certain products that inhibit <a href="/facts/Hydrogen_potassium_ATPase/8fbvtrRP">hydrogen potassium ATPase</a>; activate <a href="/facts/Calcitonin_gene-related_peptide/wyo5dlEM">calcitonin gene-related peptide</a> sensory neurons, which increases <a href="/facts/Somatostatin/GAD2utoz">somatostatin</a> secretion to inhibit acid production by parietal cells; and inhibit <a href="/facts/Gastrin/C4a4VSbz">gastrin</a> secretion. This reduction in acid production causes gastric ulcers.<a class="footnote-ref" id="fnref:48" href="#fn:48"><sup>48</sup></a> On the other hand, increased acid production at the <a href="/facts/Pyloric_antrum/920mWuBz">pyloric antrum</a> is associated with duodenal ulcers in 10% to 15% of <i>H. pylori</i> infection cases. In this case, somatostatin production is reduced and gastrin production is increased, leading to increased <a href="/facts/Histamine/Vfjda665">histamine</a> secretion from the <a href="/facts/Enterochromaffin/Wzno95rP">enterochromaffin</a> cells, thus increasing acid production. An acidic environment at the antrum causes <a href="/facts/Metaplasia/k3S1XCrA">metaplasia</a> of the duodenal cells, causing duodenal ulcers.<a class="footnote-ref" id="fnref:49" href="#fn:49"><sup>49</sup></a> </p><p>Human immune response toward the bacteria also determines the emergence of peptic ulcer disease. The human IL1B gene encodes for <a href="/facts/Interleukin_1_beta/tJhf3nRu">Interleukin 1 beta</a>, and other genes that encode for <a href="/facts/Tumour_necrosis_factor/5G0MA0dG">tumour necrosis factor</a> (TNF) and <a href="/facts/Lymphotoxin_alpha/d4o1CFRn">Lymphotoxin alpha</a> also play a role in gastric inflammation.<a class="footnote-ref" id="fnref:50" href="#fn:50"><sup>50</sup></a> </p> <h3>NSAIDs</h3> <p>Taking <a href="/facts/Nonsteroidal_anti-inflammatory_drug/coIkzl4s">nonsteroidal anti-inflammatory drugs</a> (NSAIDs) such as <a href="/facts/Aspirin/opMK4qLk">aspirin</a><a class="footnote-ref" id="fnref:51" href="#fn:51"><sup>51</sup></a> can increase the risk of peptic ulcer disease by four times compared to non-users. The risk of getting a peptic ulcer is two times for aspirin users. Risk of bleeding increases if NSAIDs are combined with <a href="/facts/Selective_serotonin_reuptake_inhibitor/L6jjcmEH">selective serotonin reuptake inhibitor</a> (SSRI), <a href="/facts/Corticosteroid/jeL2QeIL">corticosteroids</a>, <a href="/facts/Antimineralocorticoid/zbHHR8sT">antimineralocorticoids</a>, and <a href="/facts/Anticoagulants/cARpjm0G">anticoagulants</a>. The gastric mucosa protects itself from <a href="/facts/Gastric_acid/btVCyhYH">gastric acid</a> with a layer of mucus, the secretion of which is stimulated by certain <a href="/facts/Prostaglandin/kIKw0gDj">prostaglandins</a>. NSAIDs block the function of <a href="/facts/Cyclooxygenase/L2HFqExc">cyclooxygenase</a> 1 (<i>COX-1</i>), which is essential for the production of these prostaglandins. Besides this, NSAIDs also inhibit stomach mucosa cells proliferation and mucosal blood flow, reducing <a href="/facts/Bicarbonate/zzSVVAl1">bicarbonate</a> and mucus secretion, which reduces the integrity of the mucosa. Another type of NSAIDs, called COX-2 selective anti-inflammatory drugs (such as <a href="/facts/Celecoxib/DqbVQYSs">celecoxib</a>), preferentially inhibit <i>COX-2</i>, which is less essential in the gastric mucosa. This reduces the probability of getting peptic ulcers; however, it can still delay ulcer healing for those who already have a peptic ulcer.<a class="footnote-ref" id="fnref:52" href="#fn:52"><sup>52</sup></a> Peptic ulcers caused by NSAIDs differ from those caused by <i>H. pylori</i> as the latter's appear as a consequence of inflammation of the mucosa (presence of neutrophil and submucosal edema), the former instead as a consequence of a direct damage of the NSAID molecule against COX enzymes, altering the hydrophobic state of the mucus, the permeability of the lining epithelium and mitochondrial machinery of the cell itself. In this way NSAID's ulcers tend to complicate faster and dig deeper in the tissue causing more complications, often asymptomatically until a great portion of the tissue is involved.<a class="footnote-ref" id="fnref:53" href="#fn:53"><sup>53</sup></a><a class="footnote-ref" id="fnref:54" href="#fn:54"><sup>54</sup></a> </p> <h3>Stress</h3> <p>Physiological (not psychological) <a href="/facts/Stress_(biology)/H29jPp2B">stress</a> due to serious health problems, such as those requiring treatment in an intensive care unit, is well described as a cause of peptic ulcers, which are also known as <a href="/facts/Stress_ulcer/aFwq7usU">stress ulcers</a>.<a class="footnote-ref" id="fnref:55" href="#fn:55"><sup>55</sup></a> </p><p>While chronic life stress was once believed to be the main cause of ulcers, this is no longer the case.<a class="footnote-ref" id="fnref:56" href="#fn:56"><sup>56</sup></a> It is, however, still occasionally believed to play a role.<a class="footnote-ref" id="fnref:57" href="#fn:57"><sup>57</sup></a> This may be due to the well-documented effects of stress on gastric physiology, increasing the risk in those with other causes, such as <i>H. pylori</i> or NSAID use.<a class="footnote-ref" id="fnref:58" href="#fn:58"><sup>58</sup></a> </p> <h3>Diet</h3> <p><a href="/facts/Diet_(nutrition)/7qzDHpop">Dietary</a> factors, such as <a href="/facts/Spice/n6K7m0nq">spice</a> consumption, were hypothesized to cause ulcers until the late 20th century, but have been shown to be of relatively minor importance.<a class="footnote-ref" id="fnref:59" href="#fn:59"><sup>59</sup></a> <a href="/facts/Caffeine/Hx6E2QC5">Caffeine</a> and <a href="/facts/Coffee/Q4Ko2C7I">coffee</a>, also commonly thought to cause or exacerbate ulcers, appear to have little effect.<a class="footnote-ref" id="fnref:60" href="#fn:60"><sup>60</sup></a><a class="footnote-ref" id="fnref:61" href="#fn:61"><sup>61</sup></a> Similarly, while studies have found that alcohol consumption increases risk when associated with <i>H. pylori</i> infection, it does not seem to independently increase risk. Even when coupled with <i>H. pylori</i> infection, the increase is modest in comparison to the primary risk factor.<a class="footnote-ref" id="fnref:62" href="#fn:62"><sup>62</sup></a><a class="footnote-ref" id="fnref:63" href="#fn:63"><sup>63</sup></a><a class="footnote-ref" id="fnref:64" href="#fn:64"><sup>64</sup></a> </p> <h3>Other</h3> <p>Other causes of peptic ulcer disease include gastric <a href="/facts/Ischaemia/ySL9xbCl">ischaemia</a>, drugs, metabolic disturbances, <a href="/facts/Cytomegalovirus/gtxdYP8S">cytomegalovirus</a> (CMV), upper abdominal radiotherapy, <a href="/facts/Crohn%2527s_disease/zm55cBtd">Crohn's disease</a>, and <a href="/facts/Vasculitis/rS2rP61A">vasculitis</a>.<a class="footnote-ref" id="fnref:65" href="#fn:65"><sup>65</sup></a> <a href="/facts/Gastrinoma/rbTJS9tI">Gastrinomas</a> (<a href="/facts/Zollinger%25E2%2580%2593Ellison_syndrome/qrI4NkPa">Zollinger–Ellison syndrome</a>), or rare gastrin-secreting tumors, also cause multiple and difficult-to-heal ulcers.<a class="footnote-ref" id="fnref:66" href="#fn:66"><sup>66</sup></a> </p><p>It is still unclear whether smoking increases the risk of getting peptic ulcers.<a class="footnote-ref" id="fnref:67" href="#fn:67"><sup>67</sup></a> </p> <h2 id="diagnosis">Diagnosis</h2> <p>The diagnosis is mainly established based on the characteristic symptoms. Stomach pain is the most common sign of a peptic ulcer.<a class="footnote-ref" id="fnref:68" href="#fn:68"><sup>68</sup></a> </p><p>More specifically, peptic ulcers erode the <a href="/facts/Muscularis_mucosae/I7NRmALL">muscularis mucosae</a>, at minimum reaching to the level of the submucosa (contrast with erosions, which do not involve the muscularis mucosae).<a class="footnote-ref" id="fnref:69" href="#fn:69"><sup>69</sup></a> </p><p>Confirmation of the diagnosis is made with the help of tests such as endoscopies or barium contrast <a href="/facts/X-ray/wseP79cN">x-rays</a>. The tests are typically ordered if the symptoms do not resolve after a few weeks of treatment, or when they first appear in a person who is over age 45 or who has other symptoms such as <a href="/facts/Weight_loss/DQE4cXw0">weight loss</a>, because <a href="/facts/Stomach_cancer/HJjYtkqS">stomach cancer</a> can cause similar symptoms. Also, when severe ulcers resist treatment, particularly if a person has several ulcers or the ulcers are in unusual places, a doctor may suspect an underlying condition that causes the stomach to overproduce <a href="/facts/Acid/FySU18n1">acid</a>.<a class="footnote-ref" id="fnref:70" href="#fn:70"><sup>70</sup></a> </p><p>An <a href="/facts/Esophagogastroduodenoscopy/5mDpBzLA">esophagogastroduodenoscopy</a> (EGD), a form of <a href="/facts/Endoscopy/L4V1fGPN">endoscopy</a>, also known as a <a href="/facts/Gastroscopy/5mDpBzLA">gastroscopy</a>, is carried out on people in whom a peptic ulcer is suspected. It is also the gold standard of diagnosis for peptic ulcer disease.<a class="footnote-ref" id="fnref:71" href="#fn:71"><sup>71</sup></a> By direct visual identification, the location and severity of an ulcer can be described. Moreover, if no ulcer is present, EGD can often provide an alternative diagnosis. </p><p>One of the reasons that <a href="/facts/Blood_test/zevsf3rC">blood tests</a> are not reliable for accurate peptic ulcer diagnosis on their own is their inability to differentiate between past exposure to the bacteria and current infection. Additionally, a false negative result is possible with a blood test if the person has recently been taking certain drugs, such as <a href="/facts/Antibiotics/sF1kIfxg">antibiotics</a> or <a href="/facts/Proton-pump_inhibitor/JIpwabbk">proton-pump inhibitors</a>.<a class="footnote-ref" id="fnref:72" href="#fn:72"><sup>72</sup></a> </p><p>The diagnosis of <i><a href="/facts/Helicobacter_pylori/9q4H68LP">Helicobacter pylori</a></i> can be made by: </p> <ul><li><a href="/facts/Urea_breath_test/KeAnw8Qx">Urea breath test</a> (noninvasive and does not require EGD);</li> <li>Direct culture from an EGD biopsy specimen; this is difficult and can be expensive. Most labs are not set up to perform <i>H. pylori</i> cultures;</li> <li>Direct detection of <a href="/facts/Urease/qh6XKw4w">urease</a> activity in a biopsy specimen by <a href="/facts/Rapid_urease_test/hsdQbl6c">rapid urease test</a>;<a class="footnote-ref" id="fnref:73" href="#fn:73"><sup>73</sup></a></li> <li>Measurement of <a href="/facts/Antibody/MX8pdTdP">antibody</a> levels in the blood (does not require EGD). It is still somewhat controversial whether a positive antibody without EGD is enough to warrant eradication therapy;</li> <li>Stool <a href="/facts/Antigen/9JlAernG">antigen</a> test;<a class="footnote-ref" id="fnref:74" href="#fn:74"><sup>74</sup></a></li> <li>Histological examination and staining of an EGD biopsy.</li></ul> <p>The breath test uses radioactive <a href="/facts/Carbon/ukrgQexo">carbon</a> to detect H. pylori.<a class="footnote-ref" id="fnref:75" href="#fn:75"><sup>75</sup></a> To perform this exam, the person is asked to drink a tasteless liquid that contains the carbon as part of the substance that the bacteria breaks down. After an hour, the person is asked to blow into a sealed bag. If the person is infected with <i>H. pylori</i>, the breath sample will contain radioactive <a href="/facts/Carbon_dioxide/xGzpppEp">carbon dioxide</a>. This test provides the advantage of being able to monitor the response to treatment used to kill the bacteria. </p><p>The possibility of other causes of ulcers, notably <a href="/facts/Malignancy/L03QLSbE">malignancy</a> (<a href="/facts/Gastric_cancer/HJjYtkqS">gastric cancer</a>), needs to be kept in mind. This is especially true in ulcers of the <a href="/facts/Greater_curvature_of_the_stomach/6YsMmDwr">greater curvature of the stomach</a>; most are also a consequence of chronic <i>H. pylori</i> infection. </p><p>If a peptic ulcer perforates, air will leak from inside the gastrointestinal tract (which always contains some air) to the peritoneal cavity (which normally never contains air). This leads to "free gas" within the peritoneal cavity. If the person stands, as when having a chest X-ray, the gas will float to a position underneath the diaphragm. Therefore, gas in the peritoneal cavity, shown on an erect chest X-ray or supine lateral abdominal X-ray, is an omen of perforated peptic ulcer disease. </p> <h3>Classification</h3> <p>Peptic ulcers are a form of <a href="/facts/Acid_peptic_diseases/DoDsBA5T">acid–peptic disorder</a>. Peptic ulcers can be classified according to their location and other factors. </p> <h4>By location</h4> <ul><li><a href="/facts/Duodenum/IAIgHBmq">Duodenum</a> (called duodenal ulcer)</li> <li><a href="/facts/Esophagus/XWa7WoWn">Esophagus</a> (called esophageal ulcer)</li> <li><a href="/facts/Stomach/Q4PPDGT6">Stomach</a> (called gastric ulcer)</li> <li><a href="/facts/Meckel%2527s_diverticulum/pvHLIf1E">Meckel's diverticulum</a> (called Meckel's diverticulum ulcer; is very tender with palpation)</li></ul> <h4>Modified Johnson</h4> <ul><li>Type I: Ulcer along the body of the stomach, most often along the lesser curve at incisura angularis along the locus minoris resistantiae. Not associated with acid hypersecretion.</li> <li>Type II: Ulcer in the body in combination with duodenal ulcers. Associated with acid oversecretion.</li> <li>Type III: In the pyloric channel within 3 cm of pylorus. Associated with acid oversecretion.</li> <li>Type IV: Proximal gastroesophageal ulcer.</li> <li>Type V: Can occur throughout the stomach. Associated with the chronic use of NSAIDs (such as <a href="/facts/Ibuprofen/vsKBTfVl">ibuprofen</a>).</li></ul> <h3>Macroscopic appearance</h3> <p>Gastric ulcers are most often localized on the lesser curvature of the stomach. The ulcer is a round to oval parietal defect ("hole"), 2–4 cm diameter, with a smooth base and perpendicular borders. These borders are not elevated or irregular in the acute form of peptic ulcer, and regular but with elevated borders and inflammatory surrounding in the chronic form. In the ulcerative form of gastric cancer, the borders are irregular. Surrounding mucosa may present radial folds, as a consequence of the parietal scarring. </p> <h3>Microscopic appearance</h3> <p>A gastric peptic ulcer is a mucosal perforation that penetrates the <a href="/facts/Muscularis_mucosae/I7NRmALL">muscularis mucosae</a> and lamina propria, usually produced by acid-pepsin aggression. Ulcer margins are perpendicular and present chronic gastritis. During the active phase, the base of the ulcer shows four zones: fibrinoid necrosis, inflammatory exudate, granulation tissue and fibrous tissue. The fibrous base of the ulcer may contain vessels with thickened wall or with thrombosis.<a class="footnote-ref" id="fnref:76" href="#fn:76"><sup>76</sup></a> </p> <h3>Differential diagnosis</h3> <p>Conditions that may appear similar include: </p> <ul><li><a href="/facts/Gastritis/YxIqy1MP">Gastritis</a></li> <li><a href="/facts/Stomach_cancer/HJjYtkqS">Stomach cancer</a></li> <li><a href="/facts/Gastroesophageal_reflux_disease/8YhncnDz">Gastroesophageal reflux disease</a></li> <li><a href="/facts/Pancreatitis/gmbNTcCG">Pancreatitis</a></li> <li><a href="/facts/Congestive_hepatopathy/vqp0ngcc">Hepatic congestion</a></li> <li><a href="/facts/Cholecystitis/7XK7kF9S">Cholecystitis</a></li> <li><a href="/facts/Biliary_colic/vVIlzhBl">Biliary colic</a></li> <li><a href="/facts/Myocardial_infarction/xoGw0qcG">Inferior myocardial infarction</a></li> <li><a href="/facts/Referred_pain/JcxtqdvX">Referred pain</a> (<a href="/facts/Pleurisy/JEHqK0wu">pleurisy</a>, <a href="/facts/Pericarditis/Exq9hrxK">pericarditis</a>)</li> <li><a href="/facts/Superior_mesenteric_artery_syndrome/ycxrEu0s">Superior mesenteric artery syndrome</a></li></ul> <h2 id="prevention">Prevention</h2> <p>Prevention of peptic ulcer disease for those who are taking NSAIDs (with low cardiovascular risk) can be achieved by adding a <a href="/facts/Proton_pump_inhibitor/JIpwabbk">proton pump inhibitor</a> (PPI), an <a href="/facts/H2_antagonist/Ra6UHBGy">H2 antagonist</a>, or <a href="/facts/Misoprostol/cxPh0XJr">misoprostol</a>.<a class="footnote-ref" id="fnref:77" href="#fn:77"><sup>77</sup></a> NSAIDs of the COX-2 inhibitors type may reduce the rate of ulcers when compared to non-selective NSAIDs.<a class="footnote-ref" id="fnref:78" href="#fn:78"><sup>78</sup></a> PPI is the most popular agent in peptic ulcer prevention.<a class="footnote-ref" id="fnref:79" href="#fn:79"><sup>79</sup></a> However, there is no evidence that H2 antagonists can prevent stomach bleeding for those taking NSAIDs.<a class="footnote-ref" id="fnref:80" href="#fn:80"><sup>80</sup></a> Although misoprostol is effective in preventing peptic ulcer, its properties of promoting abortion and causing gastrointestinal distress limit its use.<a class="footnote-ref" id="fnref:81" href="#fn:81"><sup>81</sup></a> For those with high cardiovascular risk, naproxen with PPI can be a useful choice.<a class="footnote-ref" id="fnref:82" href="#fn:82"><sup>82</sup></a> Otherwise, low-dose aspirin, celecoxib, and PPI can also be used.<a class="footnote-ref" id="fnref:83" href="#fn:83"><sup>83</sup></a> </p> <h2 id="management">Management</h2> <h3>Eradication therapy</h3> <p>Once the diagnosis of <i>H. pylori</i> is confirmed, the first-line treatment would be a triple regimen in which <a href="/facts/Pantoprazole/HJ2cVrvF">pantoprazole</a> and <a href="/facts/Clarithromycin/LoeUP4Ih">clarithromycin</a> are combined with either <a href="/facts/Amoxicillin/ny596nAN">amoxicillin</a> or <a href="/facts/Metronidazole/pY5K5twk">metronidazole</a>. This treatment regimen can be given for 7–14 days. However, its effectiveness in eradicating <i>H. pylori</i> has been reducing from 90% to 70%. However, the rate of eradication can be increased by doubling the dosage of pantoprazole or increasing the duration of treatment to 14 days. Quadruple therapy (pantoprazole, clarithromycin, amoxicillin, and metronidazole) can also be used. The quadruple therapy can achieve an eradication rate of 90%. If the clarithromycin resistance rate is higher than 15% in an area, the usage of clarithromycin should be abandoned. Instead, <a href="/facts/Bismuth/75FLjkoX">bismuth</a>-containing quadruple therapy can be used (pantoprazole, bismuth citrate, <a href="/facts/Tetracycline/DQ0exP62">tetracycline</a>, and metronidazole) for 14 days. The bismuth therapy can also achieve an eradication rate of 90% and can be used as second-line therapy when the first-line triple-regimen therapy has failed. </p> <h3>NSAIDs-induced ulcers</h3> <p>NSAID-associated ulcers heal in six to eight weeks provided the NSAIDs are withdrawn with the introduction of <a href="/facts/Proton_pump_inhibitor/JIpwabbk">proton pump inhibitors</a> (PPI).<a class="footnote-ref" id="fnref:84" href="#fn:84"><sup>84</sup></a> </p> <h3>Bleeding</h3> <p>For those with bleeding peptic ulcers, <a href="/facts/Fluid_replacement/hQ1mMS6W">fluid replacement</a> with <a href="/facts/Crystalloid_solution/aV90zqjo">crystalloids</a> is sometimes given to maintain volume in the blood vessels. Maintaining haemoglobin at greater than 7 g/dL (70 g/L) through restrictive blood transfusion has been associated with reduced rate of death. <a href="/facts/Glasgow-Blatchford_score/CLljN98P">Glasgow-Blatchford score</a> is used to determine whether a person should be treated inside a hospital or as an outpatient. <a href="/facts/Intravenous/AwwuD3Nu">Intravenous</a> PPIs can suppress stomach bleeding more quickly than oral ones. A neutral stomach pH is required to keep platelets in place and prevent clot lysis. <a href="/facts/Tranexamic_acid/gzN6y7mK">Tranexamic acid</a> and <a href="/facts/Antifibrinolytic/DedPE0gs">antifibrinolytic</a> agents are not useful in treating peptic ulcer disease.<a class="footnote-ref" id="fnref:85" href="#fn:85"><sup>85</sup></a> </p><p>Early endoscopic therapy can help to stop bleeding by using <a href="/facts/Cautery/cMtoR6I8">cautery</a>, <a href="/facts/Endoclip/bJcp1dxa">endoclip</a>, or <a href="/facts/Epinephrine/k7vvMI7E">epinephrine</a> injection. Treatment is indicated if there is active bleeding in the stomach, visible vessels, or an adherent clot. Endoscopy is also helpful in identifying people who are suitable for hospital discharge. <a href="/facts/Prokinetic_agent/1UWsrM0h">Prokinetic agents</a> such as <a href="/facts/Erythromycin/dPt7avsU">erythromycin</a> and <a href="/facts/Metoclopramide/3Gadd8hg">metoclopramide</a> can be given before endoscopy to improve endoscopic view. Either high- or low-dose PPIs are equally effective in reducing bleeding after endoscopy. High-dose intravenous PPI is defined as a bolus dose of 80 mg followed by an infusion of 8 mg per hour for 72 hours—in other words, the continuous infusion of PPI of greater than 192 mg per day. Intravenous PPI can be changed to oral once there is no high risk of rebleeding from peptic ulcer.<a class="footnote-ref" id="fnref:86" href="#fn:86"><sup>86</sup></a> </p><p>For those with <a href="/facts/Hypovolemic_shock/f0hWLC8R">hypovolemic shock</a> and ulcer size of greater than 2 cm, there is a high chance that the endoscopic treatment would fail. Therefore, surgery and angiographic embolism are reserved for these complicated cases. However, there is a higher rate of complication for those who underwent surgery to patch the stomach bleeding site when compared to repeated endoscopy. <a href="/facts/Angiographic_embolisation/zPNry9cY">Angiographic embolisation</a> has a higher rebleeding rate but a similar rate of death to surgery.<a class="footnote-ref" id="fnref:87" href="#fn:87"><sup>87</sup></a> </p> <h3>Anticoagulants</h3> <p>According to expert opinion, for those who are already on anticoagulants, the <a href="/facts/International_normalized_ratio/pkLRGqcY">international normalized ratio</a> (INR) should be kept at 1.5. For aspirin users who required endoscopic treatment for bleeding peptic ulcer, there is two times increased risk of rebleeding but with ten times reduced risk of death at eight weeks following the resumption of aspirin. For those who were on double antiplatelet agents for indwelling stent in blood vessels, both antiplatelet agents should not be stopped because there is a high risk of stent thrombosis. For those who were under <a href="/facts/Warfarin/kMnH6tb0">warfarin</a> treatment, <a href="/facts/Fresh_frozen_plasma/QRs8fF4y">fresh frozen plasma</a> (FFP), vitamin K, prothrombin complex concentrates, or recombinant factor VIIa can be given to reverse the effect of warfarin. High doses of vitamin K should be avoided to reduce the time for rewarfarinisation once the stomach bleeding has stopped. Prothrombin complex concentrates are preferred for severe bleeding. Recombinant factor VIIa is reserved for life-threatening bleeding because of its high risk of thromboembolism.<a class="footnote-ref" id="fnref:88" href="#fn:88"><sup>88</sup></a> <a href="/facts/Anticoagulant/cARpjm0G">Direct oral anticoagulants</a> (DOAC) are recommended instead of warfarin as they are more effective in preventing thromboembolism. In case of bleeding caused by DOAC, <a href="/facts/Activated_carbon/YAbaXCcb">activated charcoal</a> within four hours is the antidote of choice. </p> <h2 id="epidemiology">Epidemiology</h2> <p>The lifetime risk for developing a peptic ulcer is approximately 5% to 10%<a class="footnote-ref" id="fnref:89" href="#fn:89"><sup>89</sup></a><a class="footnote-ref" id="fnref:90" href="#fn:90"><sup>90</sup></a> with the rate of 0.1% to 0.3% per year.<a class="footnote-ref" id="fnref:91" href="#fn:91"><sup>91</sup></a> Peptic ulcers resulted in 301,000 deaths in 2013, down from 327,000 in 1990.<a class="footnote-ref" id="fnref:92" href="#fn:92"><sup>92</sup></a> </p><p>In Western countries, the percentage of people with <i>H. pylori</i> infections roughly matches age (i.e., 20% at age 20, 30% at age 30, 80% at age 80, etc.). Prevalence is higher in third world countries, where it is estimated at 70% of the population, whereas developed countries show a maximum of a 40% ratio. Overall, <i>H. pylori</i> infections show a worldwide decrease, more so in developed countries. Transmission occurs via food, contaminated groundwater, or human saliva (such as from kissing or sharing food utensils).<a class="footnote-ref" id="fnref:93" href="#fn:93"><sup>93</sup></a> </p><p>Peptic ulcer disease had a tremendous effect on morbidity and mortality until the last decades of the 20th century when epidemiological trends started to point to an impressive fall in its incidence. The reason that the rates of peptic ulcer disease decreased is thought to be the development of new effective medication and acid suppressants and the rational use of <a href="/facts/Nonsteroidal_anti-inflammatory_drug/coIkzl4s">nonsteroidal anti-inflammatory drugs</a> (NSAIDs).<a class="footnote-ref" id="fnref:94" href="#fn:94"><sup>94</sup></a> </p> <h2 id="history">History</h2> <p class="note">See also: <a href="/facts/Timeline_of_peptic_ulcer_disease_and_Helicobacter_pylori/6MnR3zmI">Timeline of peptic ulcer disease and Helicobacter pylori</a></p> <p><a href="/facts/John_Lykoudis/4H3VjTAY">John Lykoudis</a>, a <a href="/facts/General_practitioner/nTnFHcBA">general practitioner</a> in <a href="/facts/Greece/lqHw8bTB">Greece</a>, treated people for peptic ulcer disease with <a href="/facts/Antibiotics/sF1kIfxg">antibiotics</a> beginning in 1958, long before it was commonly recognized that bacteria were a dominant cause for the disease.<a class="footnote-ref" id="fnref:95" href="#fn:95"><sup>95</sup></a> </p><p><i><a href="/facts/Helicobacter_pylori/9q4H68LP">Helicobacter pylori</a></i> was identified in 1982 by two <a href="/facts/Australia/qLHpbppq">Australian</a> scientists, <a href="/facts/Robin_Warren/BlrzCxvp">Robin Warren</a> and <a href="/facts/Barry_Marshall/HYDLEkr6">Barry J. Marshall</a>, as a causative factor for ulcers.<a class="footnote-ref" id="fnref:96" href="#fn:96"><sup>96</sup></a> In their original paper, Warren and Marshall contended that most gastric ulcers and gastritis were caused by colonization with this bacterium, not by <a href="/facts/Stress_(medicine)/H29jPp2B">stress</a> or <a href="/facts/Spicy_food/rKbfU6EX">spicy food</a>, as had been assumed before.<a class="footnote-ref" id="fnref:97" href="#fn:97"><sup>97</sup></a> </p><p>The <i>H. pylori</i> hypothesis was still poorly received,<a class="footnote-ref" id="fnref:98" href="#fn:98"><sup>98</sup></a> so in an act of <a href="/facts/Self-experimentation/Mzp5LG75">self-experimentation</a> Marshall drank a <a href="/facts/Petri_dish/NmTlB7Ed">Petri dish</a> containing a culture of organisms extracted from a person with an ulcer and five days later developed gastritis. His symptoms disappeared after two weeks, but he took antibiotics to kill the remaining bacteria at the urging of his wife, since <a href="/facts/Halitosis/8RGDp13v">halitosis</a> is one of the symptoms of infection.<a class="footnote-ref" id="fnref:99" href="#fn:99"><sup>99</sup></a> This experiment was published in 1984 in the <i><a href="/facts/Australian_Medical_Journal/vbqrtjQW">Australian Medical Journal</a></i> and is among the most cited articles from the journal. </p><p>In 1997, the <a href="/facts/Centers_for_Disease_Control_and_Prevention/NmoJNDV5">Centers for Disease Control and Prevention</a>, with other government agencies, academic institutions, and industry, launched a national education campaign to inform health care providers and consumers about the link between <i>H. pylori</i> and ulcers. This campaign reinforced the news that ulcers are a curable infection and that health can be greatly improved and money saved by disseminating information about <i>H. pylori</i>.<a class="footnote-ref" id="fnref:100" href="#fn:100"><sup>100</sup></a> </p><p>In 2005, the <a href="/facts/Karolinska_Institutet/aNIW18x9">Karolinska Institute in Stockholm</a> awarded the <a href="/facts/Nobel_Prize_in_Physiology_or_Medicine/rlnpJX84">Nobel Prize in Physiology or Medicine</a> to Marshall and his long-time collaborator Warren "for their discovery of the bacterium <i>Helicobacter pylori</i> and its role in <a href="/facts/Gastritis/YxIqy1MP">gastritis</a> and peptic ulcer disease." Marshall continues research related to <i>H. pylori</i> and runs a molecular biology lab at <a href="/facts/University_of_Western_Australia/hlE24CKF">UWA</a> in Perth, Western Australia. </p><p>A 1998 New England Medical Journal study found that <a href="/facts/Mastic_gum/oz36MPmH">mastic gum</a>, a tree resin extract, actively eliminated the <i>H. pylori</i> bacteria.<a class="footnote-ref" id="fnref:101" href="#fn:101"><sup>101</sup></a> However, multiple subsequent studies (in mice and in vivo) have found no effect of using mastic gum on reducing <i>H. pylori</i> levels.<a class="footnote-ref" id="fnref:102" href="#fn:102"><sup>102</sup></a><a class="footnote-ref" id="fnref:103" href="#fn:103"><sup>103</sup></a> </p> <h2 id="notes">Notes</h2> <h2 id="external-links">External links</h2> Wikimedia Commons has media related to Peptic ulcers. <ul><li><a href="https://web.archive.org/web/20120719000141/http://rad.usuhs.edu/medpix/parent.php3?mode=pt_finder&srchstr=gastric%20ulcer#top">Gastric ulcer images</a></li> <li><a href="https://web.archive.org/web/20200416082316/https://medlineplus.gov/pepticulcer.html">"Peptic Ulcer"</a>. <i>MedlinePlus</i>. U.S. National Library of Medicine. Archived from <a href="https://medlineplus.gov/pepticulcer.html">the original</a> on 16 April 2020. Retrieved 20 May 2020.</li></ul> <h2 id="references">References</h2> <ol> <li id="fn:1"><p>Najm WI (September 2011). "Peptic ulcer disease". Primary Care. 38 (3): 383–94, vii. doi:10.1016/j.pop.2011.05.001. PMID 21872087. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:1" class="footnote-back-ref">↩</a></p></li> <li id="fn:2"><p>Najm WI (September 2011). "Peptic ulcer disease". Primary Care. 38 (3): 383–94, vii. doi:10.1016/j.pop.2011.05.001. PMID 21872087. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:2" class="footnote-back-ref">↩</a></p></li> <li id="fn:3"><p>Rao SD (2014). Clinical Manual of Surgery. Elsevier Health Sciences. p. 526. ISBN 9788131238714. <a href="9788131238714" target="_blank">9788131238714</a> <a href="#fnref:3" class="footnote-back-ref">↩</a></p></li> <li id="fn:4"><p>Najm WI (September 2011). "Peptic ulcer disease". Primary Care. 38 (3): 383–94, vii. doi:10.1016/j.pop.2011.05.001. PMID 21872087. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:4" class="footnote-back-ref">↩</a></p></li> <li id="fn:5"><p>Najm WI (September 2011). "Peptic ulcer disease". Primary Care. 38 (3): 383–94, vii. doi:10.1016/j.pop.2011.05.001. PMID 21872087. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:5" class="footnote-back-ref">↩</a></p></li> <li id="fn:6"><p>Najm WI (September 2011). "Peptic ulcer disease". Primary Care. 38 (3): 383–94, vii. doi:10.1016/j.pop.2011.05.001. PMID 21872087. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:6" class="footnote-back-ref">↩</a></p></li> <li id="fn:7"><p>Milosavljevic T, Kostić-Milosavljević M, Jovanović I, Krstić M (2011). "Complications of peptic ulcer disease". Digestive Diseases. 29 (5): 491–3. doi:10.1159/000331517. PMID 22095016. S2CID 25464311. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:7" class="footnote-back-ref">↩</a></p></li> <li id="fn:8"><p>Milosavljevic T, Kostić-Milosavljević M, Jovanović I, Krstić M (2011). "Complications of peptic ulcer disease". Digestive Diseases. 29 (5): 491–3. doi:10.1159/000331517. PMID 22095016. S2CID 25464311. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:8" class="footnote-back-ref">↩</a></p></li> <li id="fn:9"><p>Najm WI (September 2011). "Peptic ulcer disease". Primary Care. 38 (3): 383–94, vii. doi:10.1016/j.pop.2011.05.001. PMID 21872087. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:9" class="footnote-back-ref">↩</a></p></li> <li id="fn:10"><p>Najm WI (September 2011). "Peptic ulcer disease". Primary Care. 38 (3): 383–94, vii. doi:10.1016/j.pop.2011.05.001. PMID 21872087. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:10" class="footnote-back-ref">↩</a></p></li> <li id="fn:11"><p>Steinberg KP (June 2002). "Stress-related mucosal disease in the critically ill patient: risk factors and strategies to prevent stress-related bleeding in the intensive care unit". Critical Care Medicine. 30 (6 Suppl): S362–4. doi:10.1097/00003246-200206001-00005. PMID 12072662. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:11" class="footnote-back-ref">↩</a></p></li> <li id="fn:12"><p>Najm WI (September 2011). "Peptic ulcer disease". Primary Care. 38 (3): 383–94, vii. doi:10.1016/j.pop.2011.05.001. PMID 21872087. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:12" class="footnote-back-ref">↩</a></p></li> <li id="fn:13"><p>Najm WI (September 2011). "Peptic ulcer disease". Primary Care. 38 (3): 383–94, vii. doi:10.1016/j.pop.2011.05.001. PMID 21872087. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:13" class="footnote-back-ref">↩</a></p></li> <li id="fn:14"><p>Najm WI (September 2011). "Peptic ulcer disease". Primary Care. 38 (3): 383–94, vii. doi:10.1016/j.pop.2011.05.001. PMID 21872087. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:14" class="footnote-back-ref">↩</a></p></li> <li id="fn:15"><p>Najm WI (September 2011). "Peptic ulcer disease". Primary Care. 38 (3): 383–94, vii. doi:10.1016/j.pop.2011.05.001. PMID 21872087. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:15" class="footnote-back-ref">↩</a></p></li> <li id="fn:16"><p>"Eating, Diet, and Nutrition for Peptic Ulcer Disease". National Institute of Diabetes and Digestive and Kidney Diseases. Archived from the original on 20 March 2015. Retrieved 28 February 2015. <a href="https://web.archive.org/web/20150320061357/http://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/peptic-ulcer/Pages/eating-diet-nutrition.aspx" target="_blank">https://web.archive.org/web/20150320061357/http://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/peptic-ulcer/Pages/eating-diet-nutrition.aspx</a> <a href="#fnref:16" class="footnote-back-ref">↩</a></p></li> <li id="fn:17"><p>Najm WI (September 2011). "Peptic ulcer disease". Primary Care. 38 (3): 383–94, vii. doi:10.1016/j.pop.2011.05.001. PMID 21872087. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:17" class="footnote-back-ref">↩</a></p></li> <li id="fn:18"><p>Najm WI (September 2011). "Peptic ulcer disease". Primary Care. 38 (3): 383–94, vii. doi:10.1016/j.pop.2011.05.001. PMID 21872087. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:18" class="footnote-back-ref">↩</a></p></li> <li id="fn:19"><p>Wang AY, Peura DA (October 2011). "The prevalence and incidence of Helicobacter pylori-associated peptic ulcer disease and upper gastrointestinal bleeding throughout the world". Gastrointestinal Endoscopy Clinics of North America. 21 (4): 613–35. doi:10.1016/j.giec.2011.07.011. PMID 21944414. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:19" class="footnote-back-ref">↩</a></p></li> <li id="fn:20"><p>Wang AY, Peura DA (October 2011). "The prevalence and incidence of Helicobacter pylori-associated peptic ulcer disease and upper gastrointestinal bleeding throughout the world". Gastrointestinal Endoscopy Clinics of North America. 21 (4): 613–35. doi:10.1016/j.giec.2011.07.011. PMID 21944414. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:20" class="footnote-back-ref">↩</a></p></li> <li id="fn:21"><p>Milosavljevic T, Kostić-Milosavljević M, Jovanović I, Krstić M (2011). "Complications of peptic ulcer disease". Digestive Diseases. 29 (5): 491–3. doi:10.1159/000331517. PMID 22095016. S2CID 25464311. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:21" class="footnote-back-ref">↩</a></p></li> <li id="fn:22"><p>Najm WI (September 2011). "Peptic ulcer disease". Primary Care. 38 (3): 383–94, vii. doi:10.1016/j.pop.2011.05.001. PMID 21872087. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:22" class="footnote-back-ref">↩</a></p></li> <li id="fn:23"><p>"Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015". Lancet. 388 (10053): 1545–1602. October 2016. doi:10.1016/S0140-6736(16)31678-6. PMC 5055577. PMID 27733282. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5055577" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5055577</a> <a href="#fnref:23" class="footnote-back-ref">↩</a></p></li> <li id="fn:24"><p>Snowden FM (October 2008). "Emerging and reemerging diseases: a historical perspective". Immunological Reviews. 225 (1): 9–26. doi:10.1111/j.1600-065X.2008.00677.x. PMC 7165909. PMID 18837773. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7165909" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7165909</a> <a href="#fnref:24" class="footnote-back-ref">↩</a></p></li> <li id="fn:25"><p>Wang H, Naghavi M, Allen C, Barber RM, Bhutta ZA, Carter A, Casey DC, Charlson FJ, Chen AZ, Coates MM, Coggeshall M, Dandona L, Dicker DJ, Erskine HE, Ferrari AJ, Fitzmaurice C, Foreman K, Forouzanfar MH, Fraser MS, Fullman N, Gething PW, Goldberg EM, Graetz N, Haagsma JA, Hay SI, Huynh C, Johnson CO, Kassebaum NJ, Kinfu Y, Kulikoff XR (October 2016). "Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015". Lancet. 388 (10053): 1459–1544. doi:10.1016/s0140-6736(16)31012-1. PMC 5388903. PMID 27733281. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5388903" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5388903</a> <a href="#fnref:25" class="footnote-back-ref">↩</a></p></li> <li id="fn:26"><p>"Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013". Lancet. 385 (9963): 117–71. January 2015. doi:10.1016/S0140-6736(14)61682-2. PMC 4340604. PMID 25530442. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4340604" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4340604</a> <a href="#fnref:26" class="footnote-back-ref">↩</a></p></li> <li id="fn:27"><p>Milosavljevic T, Kostić-Milosavljević M, Jovanović I, Krstić M (2011). "Complications of peptic ulcer disease". Digestive Diseases. 29 (5): 491–3. doi:10.1159/000331517. PMID 22095016. S2CID 25464311. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:27" class="footnote-back-ref">↩</a></p></li> <li id="fn:28"><p>Wang AY, Peura DA (October 2011). "The prevalence and incidence of Helicobacter pylori-associated peptic ulcer disease and upper gastrointestinal bleeding throughout the world". Gastrointestinal Endoscopy Clinics of North America. 21 (4): 613–35. doi:10.1016/j.giec.2011.07.011. PMID 21944414. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:28" class="footnote-back-ref">↩</a></p></li> <li id="fn:29"><p>"The Nobel Prize in Physiology or Medicine 2005". nobelprize.org. Nobel Media AB. Archived from the original on 12 May 2015. Retrieved 3 June 2015. <a href="https://www.nobelprize.org/nobel_prizes/medicine/laureates/2005/" target="_blank">https://www.nobelprize.org/nobel_prizes/medicine/laureates/2005/</a> <a href="#fnref:29" class="footnote-back-ref">↩</a></p></li> <li id="fn:30"><p>"Symptoms & Causes of Peptic Ulcers (Stomach or Duodenal Ulcers) - NIDDK". National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved 7 June 2024. <a href="https://www.niddk.nih.gov/health-information/digestive-diseases/peptic-ulcers-stomach-ulcers/symptoms-causes" target="_blank">https://www.niddk.nih.gov/health-information/digestive-diseases/peptic-ulcers-stomach-ulcers/symptoms-causes</a> <a href="#fnref:30" class="footnote-back-ref">↩</a></p></li> <li id="fn:31"><p>Bhat S (2013). SRB's Manual of Surgery. JP Medical. p. 364. ISBN 9789350259443. <a href="9789350259443" target="_blank">9789350259443</a> <a href="#fnref:31" class="footnote-back-ref">↩</a></p></li> <li id="fn:32"><p>"Treatment for Peptic Ulcers (Stomach or Duodenal Ulcers) - NIDDK". National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved 7 June 2024. <a href="https://www.niddk.nih.gov/health-information/digestive-diseases/peptic-ulcers-stomach-ulcers/treatment" target="_blank">https://www.niddk.nih.gov/health-information/digestive-diseases/peptic-ulcers-stomach-ulcers/treatment</a> <a href="#fnref:32" class="footnote-back-ref">↩</a></p></li> <li id="fn:33"><p>Lanas A, Chan FK (August 2017). "Peptic ulcer disease". Lancet. 390 (10094): 613–624. doi:10.1016/S0140-6736(16)32404-7. PMID 28242110. S2CID 4547048. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:33" class="footnote-back-ref">↩</a></p></li> <li id="fn:34"><p>"Peptic Ulcer". Home Health Handbook for Patients & Caregivers. Merck Manuals. October 2006. Archived from the original on 28 December 2011. <a href="http://www.merckmanuals.com/home/digestive_disorders/peptic_disorders/peptic_ulcer.html" target="_blank">http://www.merckmanuals.com/home/digestive_disorders/peptic_disorders/peptic_ulcer.html</a> <a href="#fnref:34" class="footnote-back-ref">↩</a></p></li> <li id="fn:35"><p>"Peptic ulcer". Archived from the original on 14 February 2012. Retrieved 18 June 2010. <a href="http://www.mayoclinic.com/health/peptic-ulcer/ds00242/dsection=symptoms" target="_blank">http://www.mayoclinic.com/health/peptic-ulcer/ds00242/dsection=symptoms</a> <a href="#fnref:35" class="footnote-back-ref">↩</a></p></li> <li id="fn:36"><p>"Ulcer Disease Facts and Myths". Archived from the original on 5 June 2010. Retrieved 18 June 2010. <a href="https://web.archive.org/web/20100605040219/http://ulcerdisease.net/" target="_blank">https://web.archive.org/web/20100605040219/http://ulcerdisease.net/</a> <a href="#fnref:36" class="footnote-back-ref">↩</a></p></li> <li id="fn:37"><p>Cullen DJ, Hawkey GM, Greenwood DC, Humphreys H, Shepherd V, Logan RF, Hawkey CJ (October 1997). "Peptic ulcer bleeding in the elderly: relative roles of Helicobacter pylori and non-steroidal anti-inflammatory drugs". Gut. 41 (4): 459–62. doi:10.1136/gut.41.4.459. PMC 1891536. PMID 9391242. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1891536" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1891536</a> <a href="#fnref:37" class="footnote-back-ref">↩</a></p></li> <li id="fn:38"><p>Blackford, John W., Williams, Robert H. (1940). "Fatal Hemorrhage from Peptic Ulcer: One Hundred and Sixteen Cases Collected from Vital Statistics of Seattle During the Years 1935-1939 Inclusive". Journal of the American Medical Association. 115 (21): 1774–1779. doi:10.1001/jama.1940.02810470018005. <a href="/wiki/Robert_Hardin_Williams" target="_blank">/wiki/Robert_Hardin_Williams</a> <a href="#fnref:38" class="footnote-back-ref">↩</a></p></li> <li id="fn:39"><p>Lanas A, Chan FK (August 2017). "Peptic ulcer disease". Lancet. 390 (10094): 613–624. doi:10.1016/S0140-6736(16)32404-7. PMID 28242110. S2CID 4547048. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:39" class="footnote-back-ref">↩</a></p></li> <li id="fn:40"><p>Gossman W, Tuma F, Kamel BG, Cassaro S (2019). "Gastric Perforation". StatPearls. StatPearls Publishing. PMID 30137838. <a href="https://www.ncbi.nlm.nih.gov/books/NBK519554/" target="_blank">https://www.ncbi.nlm.nih.gov/books/NBK519554/</a> <a href="#fnref:40" class="footnote-back-ref">↩</a></p></li> <li id="fn:41"><p>Lanas A, Chan FK (August 2017). "Peptic ulcer disease". Lancet. 390 (10094): 613–624. doi:10.1016/S0140-6736(16)32404-7. PMID 28242110. S2CID 4547048. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:41" class="footnote-back-ref">↩</a></p></li> <li id="fn:42"><p>Weledji EP (9 November 2020). "An Overview of Gastroduodenal Perforation". Frontiers in Surgery. 7: 573901. doi:10.3389/fsurg.2020.573901. ISSN 2296-875X. PMC 7680839. PMID 33240923. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7680839" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7680839</a> <a href="#fnref:42" class="footnote-back-ref">↩</a></p></li> <li id="fn:43"><p>Lanas A, Chan FK (August 2017). "Peptic ulcer disease". Lancet. 390 (10094): 613–624. doi:10.1016/S0140-6736(16)32404-7. PMID 28242110. S2CID 4547048. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:43" class="footnote-back-ref">↩</a></p></li> <li id="fn:44"><p>"Peptic Ulcer". Home Health Handbook for Patients & Caregivers. Merck Manuals. October 2006. Archived from the original on 28 December 2011. <a href="http://www.merckmanuals.com/home/digestive_disorders/peptic_disorders/peptic_ulcer.html" target="_blank">http://www.merckmanuals.com/home/digestive_disorders/peptic_disorders/peptic_ulcer.html</a> <a href="#fnref:44" class="footnote-back-ref">↩</a></p></li> <li id="fn:45"><p>Lanas A, Chan FK (August 2017). "Peptic ulcer disease". Lancet. 390 (10094): 613–624. doi:10.1016/S0140-6736(16)32404-7. PMID 28242110. S2CID 4547048. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:45" class="footnote-back-ref">↩</a></p></li> <li id="fn:46"><p>"Peptic Ulcer". Home Health Handbook for Patients & Caregivers. Merck Manuals. October 2006. Archived from the original on 28 December 2011. <a href="http://www.merckmanuals.com/home/digestive_disorders/peptic_disorders/peptic_ulcer.html" target="_blank">http://www.merckmanuals.com/home/digestive_disorders/peptic_disorders/peptic_ulcer.html</a> <a href="#fnref:46" class="footnote-back-ref">↩</a></p></li> <li id="fn:47"><p>Søgaard KK, Farkas DK, Pedersen L, Lund JL, Thomsen RW, Sørensen HT (2016). "Long-term risk of gastrointestinal cancers in persons with gastric or duodenal ulcers". Cancer Medicine. 5 (6): 1341–1351. doi:10.1002/cam4.680. PMC 4924392. PMID 26923747. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4924392" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4924392</a> <a href="#fnref:47" class="footnote-back-ref">↩</a></p></li> <li id="fn:48"><p>Lanas A, Chan FK (August 2017). "Peptic ulcer disease". Lancet. 390 (10094): 613–624. doi:10.1016/S0140-6736(16)32404-7. PMID 28242110. S2CID 4547048. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:48" class="footnote-back-ref">↩</a></p></li> <li id="fn:49"><p>Lanas A, Chan FK (August 2017). "Peptic ulcer disease". Lancet. 390 (10094): 613–624. doi:10.1016/S0140-6736(16)32404-7. PMID 28242110. S2CID 4547048. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:49" class="footnote-back-ref">↩</a></p></li> <li id="fn:50"><p>Lanas A, Chan FK (August 2017). "Peptic ulcer disease". Lancet. 390 (10094): 613–624. doi:10.1016/S0140-6736(16)32404-7. PMID 28242110. S2CID 4547048. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:50" class="footnote-back-ref">↩</a></p></li> <li id="fn:51"><p>Chan FK, Graham DY (15 May 2004). "Review article: prevention of non-steroidal anti-inflammatory drug gastrointestinal complications--review and recommendations based on risk assessment". Aliment Pharmacol Ther. 19 (10): 1051–61. doi:10.1111/j.1365-2036.2004.01935.x. PMID 15142194. S2CID 24654342. Retrieved 27 February 2022. <a href="https://onlinelibrary.wiley.com/doi/10.1111/j.1365-2036.2004.01935.x" target="_blank">https://onlinelibrary.wiley.com/doi/10.1111/j.1365-2036.2004.01935.x</a> <a href="#fnref:51" class="footnote-back-ref">↩</a></p></li> <li id="fn:52"><p>Lanas A, Chan FK (August 2017). "Peptic ulcer disease". Lancet. 390 (10094): 613–624. doi:10.1016/S0140-6736(16)32404-7. PMID 28242110. S2CID 4547048. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:52" class="footnote-back-ref">↩</a></p></li> <li id="fn:53"><p>"NSAIDs: When To Use Them and for How Long". Cleveland Clinic. Retrieved 7 June 2024. <a href="https://my.clevelandclinic.org/health/treatments/11086-non-steroidal-anti-inflammatory-medicines-nsaids" target="_blank">https://my.clevelandclinic.org/health/treatments/11086-non-steroidal-anti-inflammatory-medicines-nsaids</a> <a href="#fnref:53" class="footnote-back-ref">↩</a></p></li> <li id="fn:54"><p>Ghlichloo I, Gerriets V (2024), "Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 31613522, retrieved 7 June 2024 <a href="http://www.ncbi.nlm.nih.gov/books/NBK547742/" target="_blank">http://www.ncbi.nlm.nih.gov/books/NBK547742/</a> <a href="#fnref:54" class="footnote-back-ref">↩</a></p></li> <li id="fn:55"><p>Steinberg KP (June 2002). "Stress-related mucosal disease in the critically ill patient: risk factors and strategies to prevent stress-related bleeding in the intensive care unit". Critical Care Medicine. 30 (6 Suppl): S362–4. doi:10.1097/00003246-200206001-00005. PMID 12072662. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:55" class="footnote-back-ref">↩</a></p></li> <li id="fn:56"><p>Fink G (February 2011). "Stress controversies: post-traumatic stress disorder, hippocampal volume, gastroduodenal ulceration*". Journal of Neuroendocrinology. 23 (2): 107–17. doi:10.1111/j.1365-2826.2010.02089.x. PMID 20973838. S2CID 30231594. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:56" class="footnote-back-ref">↩</a></p></li> <li id="fn:57"><p>Fink G (February 2011). "Stress controversies: post-traumatic stress disorder, hippocampal volume, gastroduodenal ulceration*". Journal of Neuroendocrinology. 23 (2): 107–17. doi:10.1111/j.1365-2826.2010.02089.x. PMID 20973838. S2CID 30231594. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:57" class="footnote-back-ref">↩</a></p></li> <li id="fn:58"><p>Yeomans ND (January 2011). "The ulcer sleuths: The search for the cause of peptic ulcers". Journal of Gastroenterology and Hepatology. 26 (Suppl 1): 35–41. doi:10.1111/j.1440-1746.2010.06537.x. PMID 21199512. S2CID 42592868. <a href="https://doi.org/10.1111%2Fj.1440-1746.2010.06537.x" target="_blank">https://doi.org/10.1111%2Fj.1440-1746.2010.06537.x</a> <a href="#fnref:58" class="footnote-back-ref">↩</a></p></li> <li id="fn:59"><p>For nearly 100 years, scientists and doctors thought that ulcers were caused by stress, spicy food, and alcohol. Treatment involved bed rest and a bland diet. Later, researchers added stomach acid to the list of causes and began treating ulcers with antacids. National Digestive Diseases Information Clearinghouse Archived 5 July 2006 at the Wayback Machine <a href="/wiki/Bed_rest" target="_blank">/wiki/Bed_rest</a> <a href="#fnref:59" class="footnote-back-ref">↩</a></p></li> <li id="fn:60"><p>Ryan-Harshman M, Aldoori W (May 2004). "How diet and lifestyle affect duodenal ulcers. Review of the evidence". Canadian Family Physician. 50: 727–32. PMC 2214597. PMID 15171675. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2214597" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2214597</a> <a href="#fnref:60" class="footnote-back-ref">↩</a></p></li> <li id="fn:61"><p>Rubin R, Strayer DS, Rubin E (1 February 2011). Rubin's pathology : clinicopathologic foundations of medicine (Sixth ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. p. 623. ISBN 978-1-60547-968-2. <a href="978-1-60547-968-2" target="_blank">978-1-60547-968-2</a> <a href="#fnref:61" class="footnote-back-ref">↩</a></p></li> <li id="fn:62"><p>Salih BA, Abasiyanik MF, Bayyurt N, Sander E (June 2007). "H pylori infection and other risk factors associated with peptic ulcers in Turkish patients: a retrospective study". World Journal of Gastroenterology. 13 (23): 3245–8. doi:10.3748/wjg.v13.i23.3245. PMC 4436612. PMID 17589905. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4436612" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4436612</a> <a href="#fnref:62" class="footnote-back-ref">↩</a></p></li> <li id="fn:63"><p>Sonnenberg A, Müller-Lissner SA, Vogel E, Schmid P, Gonvers JJ, Peter P, Strohmeyer G, Blum AL (December 1981). "Predictors of duodenal ulcer healing and relapse". Gastroenterology. 81 (6): 1061–7. doi:10.1016/S0016-5085(81)80012-1. PMID 7026344. <a href="https://doi.org/10.1016%2FS0016-5085%2881%2980012-1" target="_blank">https://doi.org/10.1016%2FS0016-5085%2881%2980012-1</a> <a href="#fnref:63" class="footnote-back-ref">↩</a></p></li> <li id="fn:64"><p>Sonnenberg in his study cautiously concludes that, among other potential factors that were found to correlate to ulcer healing, "moderate alcohol intake might [also] favor ulcer healing." (p. 1066) <a href="#fnref:64" class="footnote-back-ref">↩</a></p></li> <li id="fn:65"><p>Lanas A, Chan FK (August 2017). "Peptic ulcer disease". Lancet. 390 (10094): 613–624. doi:10.1016/S0140-6736(16)32404-7. PMID 28242110. S2CID 4547048. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:65" class="footnote-back-ref">↩</a></p></li> <li id="fn:66"><p>Feliberti E, Hughes MS, Perry RR, Vinik A, Feingold KR, Anawalt B, Boyce A, Chrousos G, Dungan K, Grossman A, Hershman JM, Kaltsas G, Koch C, Kopp P, Korbonits M, McLachlan R, Morley JE, New M, Perreault L, Purnell J, Rebar R, Singer F, Trence DL, Vinik A, Wilson DP (28 November 2013). "Gastrinoma Zollinger-Ellison-Syndrome". Endotext. PMID 25905301. <a href="/wiki/PMID_(identifier)" target="_blank">/wiki/PMID_(identifier)</a> <a href="#fnref:66" class="footnote-back-ref">↩</a></p></li> <li id="fn:67"><p>Lanas A, Chan FK (August 2017). "Peptic ulcer disease". Lancet. 390 (10094): 613–624. doi:10.1016/S0140-6736(16)32404-7. PMID 28242110. S2CID 4547048. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:67" class="footnote-back-ref">↩</a></p></li> <li id="fn:68"><p>"Symptoms & Causes of Peptic Ulcers (Stomach or Duodenal Ulcers) - NIDDK". National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved 7 June 2024. <a href="https://www.niddk.nih.gov/health-information/digestive-diseases/peptic-ulcers-stomach-ulcers/symptoms-causes" target="_blank">https://www.niddk.nih.gov/health-information/digestive-diseases/peptic-ulcers-stomach-ulcers/symptoms-causes</a> <a href="#fnref:68" class="footnote-back-ref">↩</a></p></li> <li id="fn:69"><p>"Peptic Ulcer Disease". Archived from the original on 13 January 2016. Retrieved 17 January 2016. <a href="http://www.merckmanuals.com/professional/gastrointestinal-disorders/gastritis-and-peptic-ulcer-disease/peptic-ulcer-disease" target="_blank">http://www.merckmanuals.com/professional/gastrointestinal-disorders/gastritis-and-peptic-ulcer-disease/peptic-ulcer-disease</a> <a href="#fnref:69" class="footnote-back-ref">↩</a></p></li> <li id="fn:70"><p>"Peptic Ulcer". Home Health Handbook for Patients & Caregivers. Merck Manuals. October 2006. Archived from the original on 28 December 2011. <a href="http://www.merckmanuals.com/home/digestive_disorders/peptic_disorders/peptic_ulcer.html" target="_blank">http://www.merckmanuals.com/home/digestive_disorders/peptic_disorders/peptic_ulcer.html</a> <a href="#fnref:70" class="footnote-back-ref">↩</a></p></li> <li id="fn:71"><p>Lanas A, Chan FK (August 2017). "Peptic ulcer disease". Lancet. 390 (10094): 613–624. doi:10.1016/S0140-6736(16)32404-7. PMID 28242110. S2CID 4547048. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:71" class="footnote-back-ref">↩</a></p></li> <li id="fn:72"><p>"Peptic ulcer". Archived from the original on 9 February 2010. Retrieved 18 June 2010. <a href="http://www.mayoclinic.com/health/peptic-ulcer/DS00242/DSECTION=tests-and-diagnosis" target="_blank">http://www.mayoclinic.com/health/peptic-ulcer/DS00242/DSECTION=tests-and-diagnosis</a> <a href="#fnref:72" class="footnote-back-ref">↩</a></p></li> <li id="fn:73"><p>Lanas A, Chan FK (August 2017). "Peptic ulcer disease". Lancet. 390 (10094): 613–624. doi:10.1016/S0140-6736(16)32404-7. PMID 28242110. S2CID 4547048. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:73" class="footnote-back-ref">↩</a></p></li> <li id="fn:74"><p>Stenström B, Mendis A, Marshall B (August 2008). "Helicobacter pylori--the latest in diagnosis and treatment". Australian Family Physician. 37 (8): 608–12. PMID 18704207. <a href="/wiki/PMID_(identifier)" target="_blank">/wiki/PMID_(identifier)</a> <a href="#fnref:74" class="footnote-back-ref">↩</a></p></li> <li id="fn:75"><p>"Tests and diagnosis". Archived from the original on 9 February 2010. Retrieved 18 June 2010. <a href="http://www.mayoclinic.com/health/peptic-ulcer/DS00242/DSECTION=tests-and-diagnosis" target="_blank">http://www.mayoclinic.com/health/peptic-ulcer/DS00242/DSECTION=tests-and-diagnosis</a> <a href="#fnref:75" class="footnote-back-ref">↩</a></p></li> <li id="fn:76"><p>"ATLAS OF PATHOLOGY". Archived from the original on 9 February 2009. Retrieved 26 August 2007. <a href="http://www.pathologyatlas.ro/chronic-peptic-ulcer.php" target="_blank">http://www.pathologyatlas.ro/chronic-peptic-ulcer.php</a> <a href="#fnref:76" class="footnote-back-ref">↩</a></p></li> <li id="fn:77"><p>Lanas A, Chan FK (August 2017). "Peptic ulcer disease". Lancet. 390 (10094): 613–624. doi:10.1016/S0140-6736(16)32404-7. PMID 28242110. S2CID 4547048. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:77" class="footnote-back-ref">↩</a></p></li> <li id="fn:78"><p>Lanas A, Chan FK (August 2017). "Peptic ulcer disease". Lancet. 390 (10094): 613–624. doi:10.1016/S0140-6736(16)32404-7. PMID 28242110. S2CID 4547048. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:78" class="footnote-back-ref">↩</a></p></li> <li id="fn:79"><p>Lanas A, Chan FK (August 2017). "Peptic ulcer disease". Lancet. 390 (10094): 613–624. doi:10.1016/S0140-6736(16)32404-7. PMID 28242110. S2CID 4547048. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:79" class="footnote-back-ref">↩</a></p></li> <li id="fn:80"><p>Lanas A, Chan FK (August 2017). "Peptic ulcer disease". Lancet. 390 (10094): 613–624. doi:10.1016/S0140-6736(16)32404-7. PMID 28242110. S2CID 4547048. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:80" class="footnote-back-ref">↩</a></p></li> <li id="fn:81"><p>Lanas A, Chan FK (August 2017). "Peptic ulcer disease". Lancet. 390 (10094): 613–624. doi:10.1016/S0140-6736(16)32404-7. PMID 28242110. S2CID 4547048. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:81" class="footnote-back-ref">↩</a></p></li> <li id="fn:82"><p>Lanas A, Chan FK (August 2017). "Peptic ulcer disease". Lancet. 390 (10094): 613–624. doi:10.1016/S0140-6736(16)32404-7. PMID 28242110. S2CID 4547048. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:82" class="footnote-back-ref">↩</a></p></li> <li id="fn:83"><p>Lanas A, Chan FK (August 2017). "Peptic ulcer disease". Lancet. 390 (10094): 613–624. doi:10.1016/S0140-6736(16)32404-7. PMID 28242110. S2CID 4547048. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:83" class="footnote-back-ref">↩</a></p></li> <li id="fn:84"><p>Lanas A, Chan FK (August 2017). "Peptic ulcer disease". Lancet. 390 (10094): 613–624. doi:10.1016/S0140-6736(16)32404-7. PMID 28242110. S2CID 4547048. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:84" class="footnote-back-ref">↩</a></p></li> <li id="fn:85"><p>Lanas A, Chan FK (August 2017). "Peptic ulcer disease". Lancet. 390 (10094): 613–624. doi:10.1016/S0140-6736(16)32404-7. PMID 28242110. S2CID 4547048. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:85" class="footnote-back-ref">↩</a></p></li> <li id="fn:86"><p>Lanas A, Chan FK (August 2017). "Peptic ulcer disease". Lancet. 390 (10094): 613–624. doi:10.1016/S0140-6736(16)32404-7. PMID 28242110. S2CID 4547048. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:86" class="footnote-back-ref">↩</a></p></li> <li id="fn:87"><p>Lanas A, Chan FK (August 2017). "Peptic ulcer disease". Lancet. 390 (10094): 613–624. doi:10.1016/S0140-6736(16)32404-7. PMID 28242110. S2CID 4547048. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:87" class="footnote-back-ref">↩</a></p></li> <li id="fn:88"><p>Lanas A, Chan FK (August 2017). "Peptic ulcer disease". Lancet. 390 (10094): 613–624. doi:10.1016/S0140-6736(16)32404-7. PMID 28242110. S2CID 4547048. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:88" class="footnote-back-ref">↩</a></p></li> <li id="fn:89"><p>Snowden FM (October 2008). "Emerging and reemerging diseases: a historical perspective". Immunological Reviews. 225 (1): 9–26. doi:10.1111/j.1600-065X.2008.00677.x. PMC 7165909. PMID 18837773. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7165909" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7165909</a> <a href="#fnref:89" class="footnote-back-ref">↩</a></p></li> <li id="fn:90"><p>Lanas A, Chan FK (August 2017). "Peptic ulcer disease". Lancet. 390 (10094): 613–624. doi:10.1016/S0140-6736(16)32404-7. PMID 28242110. S2CID 4547048. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:90" class="footnote-back-ref">↩</a></p></li> <li id="fn:91"><p>Lanas A, Chan FK (August 2017). "Peptic ulcer disease". Lancet. 390 (10094): 613–624. doi:10.1016/S0140-6736(16)32404-7. PMID 28242110. S2CID 4547048. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:91" class="footnote-back-ref">↩</a></p></li> <li id="fn:92"><p>"Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013". Lancet. 385 (9963): 117–71. January 2015. doi:10.1016/S0140-6736(14)61682-2. PMC 4340604. PMID 25530442. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4340604" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4340604</a> <a href="#fnref:92" class="footnote-back-ref">↩</a></p></li> <li id="fn:93"><p>Brown LM (2000). "Helicobacter pylori: epidemiology and routes of transmission". Epidemiologic Reviews. 22 (2): 283–97. doi:10.1093/oxfordjournals.epirev.a018040. PMID 11218379. <a href="https://doi.org/10.1093%2Foxfordjournals.epirev.a018040" target="_blank">https://doi.org/10.1093%2Foxfordjournals.epirev.a018040</a> <a href="#fnref:93" class="footnote-back-ref">↩</a></p></li> <li id="fn:94"><p>Lanas A, Chan FK (August 2017). "Peptic ulcer disease". Lancet. 390 (10094): 613–624. doi:10.1016/S0140-6736(16)32404-7. PMID 28242110. S2CID 4547048. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:94" class="footnote-back-ref">↩</a></p></li> <li id="fn:95"><p>Rigas B, Papavasassiliou ED (22 May 2002). "Ch. 7 John Lykoudis. The general practitioner in Greece who in 1958 discovered the etiology of, and a treatment for, peptic ulcer disease.". In Marshall BJ (ed.). Helicobacter pioneers: firsthand accounts from the scientists who discovered helicobacters, 1892–1982. John Wiley & Sons. pp. 74–88. ISBN 978-0-86793-035-1. Archived from the original on 21 May 2016. <a href="978-0-86793-035-1" target="_blank">978-0-86793-035-1</a> <a href="#fnref:95" class="footnote-back-ref">↩</a></p></li> <li id="fn:96"><p>Warren JR, Marshall B (June 1983). "Unidentified curved bacilli on gastric epithelium in active chronic gastritis". Lancet. 1 (8336): 1273–5. doi:10.1016/S0140-6736(83)92719-8. PMID 6134060. S2CID 1641856. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:96" class="footnote-back-ref">↩</a></p></li> <li id="fn:97"><p>Marshall BJ, Warren JR (June 1984). "Unidentified curved bacilli in the stomach of patients with gastritis and peptic ulceration". Lancet. 1 (8390): 1311–5. doi:10.1016/S0140-6736(84)91816-6. PMID 6145023. S2CID 10066001. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:97" class="footnote-back-ref">↩</a></p></li> <li id="fn:98"><p>Schulz K (9 September 2010). "Stress Doesn't Cause Ulcers! Or, How To Win a Nobel Prize in One Easy Lesson: Barry Marshall on Being ... Right". The Wrong Stuff. Slate. Archived from the original on 5 August 2011. Retrieved 17 July 2011. <a href="/wiki/Kathryn_Schulz" target="_blank">/wiki/Kathryn_Schulz</a> <a href="#fnref:98" class="footnote-back-ref">↩</a></p></li> <li id="fn:99"><p>Van Der Weyden MB, Armstrong RM, Gregory AT (2005). "The 2005 Nobel Prize in physiology or medicine". The Medical Journal of Australia. 183 (11–12): 612–4. doi:10.5694/j.1326-5377.2005.tb00052.x. PMID 16336147. S2CID 45487832. Archived from the original on 27 June 2009. <a href="http://www.mja.com.au/public/issues/183_11_051205/van11000_fm.html#0_i1091639" target="_blank">http://www.mja.com.au/public/issues/183_11_051205/van11000_fm.html#0_i1091639</a> <a href="#fnref:99" class="footnote-back-ref">↩</a></p></li> <li id="fn:100"><p>"Ulcer, Diagnosis and Treatment - CDC Bacterial, Mycotic Diseases". Cdc.gov. Archived from the original on 3 December 2013. Retrieved 27 February 2014. <a href="https://www.cdc.gov/ulcer/history.htm" target="_blank">https://www.cdc.gov/ulcer/history.htm</a> <a href="#fnref:100" class="footnote-back-ref">↩</a></p></li> <li id="fn:101"><p>Huwez FU, Thirlwell D, Cockayne A, Ala'Aldeen DA (December 1998). "Mastic gum kills Helicobacter pylori". The New England Journal of Medicine. 339 (26): 1946. doi:10.1056/NEJM199812243392618. PMID 9874617. Archived from the original on 15 September 2008. See also their corrections in the next volume Archived 5 October 2008 at the Wayback Machine. <a href="http://content.nejm.org/cgi/content/extract/339/26/1946" target="_blank">http://content.nejm.org/cgi/content/extract/339/26/1946</a> <a href="#fnref:101" class="footnote-back-ref">↩</a></p></li> <li id="fn:102"><p>Loughlin MF, Ala'Aldeen DA, Jenks PJ (February 2003). "Monotherapy with mastic does not eradicate Helicobacter pylori infection from mice". The Journal of Antimicrobial Chemotherapy. 51 (2): 367–71. doi:10.1093/jac/dkg057. PMID 12562704. <a href="https://doi.org/10.1093%2Fjac%2Fdkg057" target="_blank">https://doi.org/10.1093%2Fjac%2Fdkg057</a> <a href="#fnref:102" class="footnote-back-ref">↩</a></p></li> <li id="fn:103"><p>Bebb JR, Bailey-Flitter N, Ala'Aldeen D, Atherton JC (September 2003). "Mastic gum has no effect on Helicobacter pylori load in vivo". The Journal of Antimicrobial Chemotherapy. 52 (3): 522–3. doi:10.1093/jac/dkg366. PMID 12888582. <a href="https://doi.org/10.1093%2Fjac%2Fdkg366" target="_blank">https://doi.org/10.1093%2Fjac%2Fdkg366</a> <a href="#fnref:103" class="footnote-back-ref">↩</a></p></li> </ol>