When protective measures of the gastric and duodenal mucosa are overwhelmed, erosions of the lining occur.  Pain, nausea, anorexia, weight loss, hematochezia, melena and guiac positive stools are all potential symptoms of underlying ulcer disease.  When the patient is greater than 50 years of age, or has associated weight loss, vomiting, signs of gastrointestinal bleeding (guiac positive stools, hematochezia, or melena), and/or anemia, then endoscopy should be employed to evaluate the underlying etiology.  Also, symptoms which persistent despite aggressive medical therapy are an indication for endoscopy.  Younger patients (less than 50 years of age) without warning symptoms may undergo empiric treatment initially, and endoscopy may be withheld unless patients do not respond.

     An underlying etiology should be sought in all cases.  Therefore, patients should be questioned regarding alcohol use/abuse, tobacco abuse, and aspirin/NSAID use.  Also, all patients should be subjected to testing for Helicobacter pylori infection, and if present they should undergo appropriate treatment to eradicate the infection.  The possibility of underlying Zollinger-Ellison syndrome should be considered when none of the above mentioned common etiologies are present, when disease proves refractory to aggressive therapy, when there is a solitary duodenal-bulb lesion or large gastric folds noted on esophagogastroduodenoscopy, or when there is associated diarrhea or steatorrhea.  It may also be prudent to screen for an alternative or concomitant etiologyof abdominal pain (pancreatitis, cholelithiasis, irritable bowel syndrome, etc) when symptoms are refractory to appropriate therapy.  Stress ulcers are seen in hospitalized patients with severe physical trauma, burns, or multiple organ failure.

     Therapy is with histamine-2 receptor blockers or proton pump inhibitors.  Other less effective options include antacids or sucralfate.  Patients should be encouraged to discontinue alcohol and tobacco use.  NSAIDs should be discontinued until ulcers heal.  After ulcers resolve, alternate forms of pain management other than traditional NSAIDs (acetaminophen, or narcotics) should be employed to treat painful conditions.  Alternatively, the concomitant administration of a proton pump inhibitor or misoprostol along with an NSAID may help decrease the prevalence of ulcers as a side effect of NSAID therapy.  Appropriate H. pylori eradication therapy should be employed in all patients with proof of infection.