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Review
, 30 (5), 559-70

A Systematic Approach for the Diagnosis and Treatment of Idiopathic Peptic Ulcers

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Review

A Systematic Approach for the Diagnosis and Treatment of Idiopathic Peptic Ulcers

Chen-Shuan Chung et al. Korean J Intern Med.

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: Endoscopy; Helicobacter pylori infection; Idiopathic peptic ulcer.

Conflict of interest statement

No potential conflict of interest relevant to this article was reported.

Figures

Figure 1.
Figure 1.
(A) Global incidence of clinical idiopathic peptic ulcer disease from 1991 to 2013 reported in large-scale studies with a sample size > 300 patients. (B) Reports of idiopathic peptic ulcer disease in Asian countries, excluding studies on bleeding peptic ulcers.
Figure 2.
Figure 2.
A case of gastric ulcer with a missed diagnosis of gastric cancer. (A) One healing gastric ulcer was seen at the lesser curvature of the lower body. A biopsy showed only chronic inf lammation. (B) The ulcer remained present on follow-up endoscopy at 3 months despite continuous proton-pump inhibitor treatment. A repeated biopsy showed a well-differentiated adenocarcinoma. (C) An image of the tumor margin delineated by arrows under chromoendoscopy with indigo carmine spraying before endoscopic resection. (D) An image of the en bloc resected specimen.
Figure 3.
Figure 3.
A case of Crohn’s disease with upper gastrointestinal manifestations. (A) One oral ulcer was found on the soft palate. (B) One gastric ulcer was noted on the posterior wall of the antrum. (C) Upon colonoscopic examination, multiple colonic ulcers were seen with a cobblestone appearance over the ascending colon and (D) descending colon.
Figure 4.
Figure 4.
A case of hyperacidity of the stomach due to Zollinger-Ellison syndrome. (A) Repeat upper endoscopy showed poorly healed duodenal ulcers and (B) reflux erosive esophagitis, suggestive of gastric acid over-production. (C) Upon abdominal sonography, a pancreatic tumor originating from the uncinate process of the pancreas was noted. (D) The pancreatic tumor specimen was confirmed as a neuroendocrine tumor (circle).
Figure 5.
Figure 5.
A case of gastric and duodenal ulcers due to cytomegalovirus infection. Multiple areas of erythema were found over the lower body (A) and antrum of the stomach (B) with a negative Helicobacter pylori test. (C) A bleeding ulcer was noted on the posterior wall of the gastric antrum. (D) Diffuse ulcerations in the jejunum found by the balloon-assisted enteroscopy. A biopsy was positive for cytomegalovirus inclusion bodies.
Figure 6.
Figure 6.
A case of a mucormycosis-related gastric ulcer. (A) Upon upper endoscopy, a gastric ulcer with greenish coating was noted in the greater curvature of the middle body. (B) Pathology showed numerous right-angled, pauci-septated, and ribbon-like hyphae (arrows), indicating a fungal infection (H&E, ×100).
Figure 7.
Figure 7.
A f low chart for the diagnosis and management of an idiopathic peptic ulcer disease. H. pylori, Helicobacter pylori; NSAID, nonsteroidal anti-inflammatory drug; ASA, acetylsalicylic acid (aspirin); H2RA, histamine-2 receptor antagonists; PPI, proton pump inhibitor. Adapted from Quan et al. [45], with permission from Nature Publishing Group.

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