Peptic ulcer or gastric ulcer results from H. pylori bacteria residing in your gut. Stomach ulcer symptoms include heartburn, burning stomach pain, and belching.

Peptic Ulcer

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Saad Ullah Siddiqui

Overview

Peptic ulcer illness is a condition where uncomfortable cysts or ulcers foster in the covering of the stomach, or the initial segment of the small digestive tract (the duodenum). Ordinarily, a thick layer of bodily fluid safeguards the stomach lining from the impact of its digestive corrosive fluids. However, numerous things can lessen this defensive layer, permitting stomach acid to harm the tissue.

Peptic ulcers are open cysts-like wounds that foster within the covering of the stomach and the upper piece of the small digestive tract. The most well-known side effect of a peptic ulcer is unbearable stomach pain. There is a possibility that an individual might feel no side effects, or they might feel distressed or consuming pain. Peptic ulcers can prompt inner bleeding, which in some cases can mean that the individual will require blood transfusions in the medical clinic. 
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Peptic ulcers affect different parts of the digestive system, including the small intestine, the stomach, and even the esophagus. There are three types of peptic ulcers: 
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<ul>
	<li>Gastric Ulcers: They are more commonly referred to under the umbrella term of stomach ulcers. This type of peptic ulcer promotes the formation of sores along the walls of the stomach. The protective mucus-like lining dissipates owing to a highly corrosive environment<a href="#accordion">[13]</a>.&nbsp;</li>
	<li>Esophageal&nbsp;Ulcers: The esophagus is the long hollow tube that connects the mouth with the stomach. This tube allows edible matter to travel to the stomach for digestion. Esophageal ulcers develop inside the esophagus due to a variety of reasons. The creation of such sores on the esophagus causes difficulty in swallowing<a href="#accordion">[3]</a>.</li>
	<li>Duodenal Ulcers: A duodenal ulcer refers to the formation of a sensitive sore situated in the coating of the duodenum. The duodenum is the initial segment of the small intestine, the anatomical segment of the digestive system that directs food to go through straight after it leaves the stomach<a href="#accordion">[13]</a>. 
	&nbsp;</li>
</ul>

Causes

For an exceptionally long period, people believed misconceptions regarding the origin of peptic ulcer diseases (PUD), i.e. held certain food groups accountable. While it is important to maintain a healthy diet rich in fruits and vegetables, the blame for ulcers should be directed towards causes that have been proven guilty, such as: 
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<ul>
	<li>H. Pylori Bacteria 
	H. pylori is one of the most common causes of peptic ulcers, this is because pathologists reveal that the H. pylori bacteria is a common bacterium found in the stomachs of over half of the total population of the world. But most H. pylori infections go unnoticed because of minimum or negligent symptoms. Research indicates the possibility of human-to-human transmission of H. pylori, especially during a younger age. The H. pylori are microscopic organisms that adhere to the layer of bodily fluid (mucus) in the gastrointestinal system and trigger the muscles to inflame and irritate, which can render the protective covering futile and useless. This decomposition is an issue because the stomach is a sack of strong acidic fluids with the aim and objective to digest food completely. Without the bodily fluid layer to safeguard it, the acid can scrape off and diminish into the stomach tissue. In any case, for the vast majority, the presence of H. pylori does not prove to be catastrophic with adverse consequences. Simply 10% to 15% of individuals with H. pylori develop ulcers<a href="#accordion">[14]</a>. 
	&nbsp;</li>
	<li>Pain Relievers&nbsp; 
	One more significant reason for peptic ulcer disease is the frequent intake of non-steroidal&nbsp;anti-inflammatory drugs (NSAIDs), an acronym for a specific unit of medicated drugs prescribed to patients for pain relief. NSAIDs when taken regularly, due to their effectiveness, can erode the natural bodily fluid layer in the gastrointestinal system<a href="#accordion">[13]</a>. These medications can promote peptic ulcers: aspirin, naproxen and ibuprofen. 
	Acetaminophen is not classified as an NSAID and according to reports will not contribute to harming the mucus lining of the stomach. Individuals who cannot take NSAIDs (due to any reason) are frequently prescribed to take acetaminophen<a href="#accordion">[14]</a>. For patients battling chronic illnesses, it is important to note that not every person prescribed a version of an NSAID will foster ulcers, other factors are also crucial. NSAID dosage combined with H. pylori disease is possibly the most hazardous. Individuals who have H. pylori and who regularly use NSAIDs are bound to have adverse effects on the bodily fluid layer, and their harm can be more serious<a href="#accordion">[14]</a>. 
	&nbsp;</li>
</ul>

<ul>
	<li>Smoking Tobacco And Consuming Alcohol 
	Inhaling tobacco or smoking cigarettes has reserved itself as a probable cause for the formation, perseverance, and frequent recurrence of peptic ulcer disease. Smoking conflictingly affects gastric acid release. However, it does possess a consistent effect on the upper gastrointestinal capability that can add to the pathogenesis of peptic ulcer infection. These adverse consequences can include the disturbance of the normal action of histamine-2 antagonists, the increase in the rate of gastric purging of fluids, the advancement of duodenogastric reflux, the restraint of pancreatic bicarbonate discharge, the decreasing rate in the mucosal bloodstream, and the hindrance of mucosal prostaglandin creation<a href="#accordion">[15]</a>. 
	There has been research to trace links between chronic active gastritis and frequent alcohol consumption. However, there is a possibility that the inflammatory fluctuations within the digestive tract relate to simultaneous Helicobacter pylori disease that is also a common infection that recurs among heavy alcohol drinkers. Besides, constant liquor addiction is additionally connected with the presence of gastric metaplasia. Both clinically and tentatively, liquor had been displayed to influence the mucosal boundary and histology. These ulcerogenic impacts assume an important part in modifying gastric mucosal defense components<a href="#">[7]</a>. 
	&nbsp;</li>
	<li>Rare Diseases 
	Apart from the common causes of the disease, rare medical conditions such as the Zollinger-Ellison syndrome (gastrinoma) can trigger peptic ulcer disease in some individuals. The condition allows and supports the festering and growth of acid-delivering cells in the gastrointestinal system, creating an excessively acidic and corrosive environment. These growths are risky as their nature could be cancerous or noncancerous. The cells produce extreme measures of corrosive fluids that harm stomach tissue, damaging the mucus laye<a href="#accordion">[14]</a>. 
	&nbsp;</li>
</ul>

Diagnosis

The diagnosis of peptic ulcer disease (PUD) necessitates the task of history taking, anatomical assessment, and invasive or minimally-invasive clinical tests. The physician should focus on cautiously noting history to identify and alert the presence of any irregularities and abnormalities. Patient complaining of epigastric abdominal pain, early satiety, and loss of appetite following a dinner raises doubt of PUD. The aggravation of gastric ulcers builds 2 to 3 hours after consumption of edible items, and may bring about weight reduction. While the unbearable pain of duodenal ulcers diminishes with dinner, which can bring about weight gain. Any patient reporting persistent symptoms of <a href="https://www.merisehat.pk/disease/anemia" target="_blank">anemia</a>, melena, hematemesis, or weight reduction ought to be additionally examined for complications of PUD, primarily internal bleeding, perforation, or cancer. A physical examination might uncover epigastric stomach tenderness and indications of <a href="https://www.merisehat.pk/disease/anemia" target="_blank">anemia</a>. As peptic ulcers may have a differential diagnosis, a doctor may recommend the following tests to receive a confirmation: 
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<ul>
	<li>Endoscopy 
	The primary care provider to perform this procedure will rely on a scope to inspect the stomach and related parts of the upper digestive system (endoscopy). During the endoscopy, the doctor inserts an empty cylinder furnished with a focal point (endoscope) down the throat and into the areas that may support the formation of ulcers such as the esophagus, stomach, and small intestine. With the help of the endoscope, the doctor searches for ulcers. However, on the off chance that the primary care physician finds an ulcer, a little tissue sample (biopsy) might be retrieved for assessment in a lab<a href="#accordion">[13]</a>. A biopsy can likewise distinguish whether H. pylori is present in the stomach lining. Certain factors could contribute to the doctor relying on and suggesting an endoscopy such as age (older patients are more vulnerable to complications, presenting with bleeding), or have recently encountered weight reduction or trouble eating and swallowing. Assuming the endoscopy shows an ulcer in the stomach, a subsequent endoscopy ought to be performed after treatment to show that it has recuperated, regardless of whether the symptoms lessen<a href="#accordion">[11]</a>.</li>
</ul>

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<ul>
	<li>Upper Gastrointestinal (GI) Series 
	Also referred to as the Barium swallow test, this test checks out the organs lying within the initial parts of the digestive system. It inspects the hollow food pipe (esophagus) that travels down the throat, the stomach, and the initial segment of the small intestine (the duodenum). The patient will be instructed to swallow a metallic liquid called barium. Barium covers the organs so they should be visible on an X-ray<a href="#accordion">[6]</a>. 
	&nbsp;</li>
	<li>H. Pylori Tests 
	To determine whether the symptoms presented are because of peptic ulcers, the doctor might prescribe tests to decide if traces of the bacterium H. pylori are present in the body. The person in question might search for H. pylori utilising a blood, stool, or breath test. The breath test is the most dependable, because of its highest accuracy<a href="#accordion">[11]</a>. To detect the bacteria through a breath test, the patient is instructed to consume any type of food or liquid that contains radioactive carbon. 
	H. pylori separates the substance in the stomach. Afterward, the patient must blow into a sack, which is then secured to trap the blown air as a specimen. If a person has been contaminated with H. pylori, the breath test will highlight the radioactive carbon as carbon dioxide. However, like any other test, it is important to inform the doctor of any medication the patient might be taking. For the H. pylori test, the physician should be informed if the patient has taken an antacid prior to the test. Contingent on which test is preferred, the individual might have to stop the drug for a while because acid neutralisers can prompt misleading false-negative outcomes<a href="#accordion">[11]</a>. 
	&nbsp;</li>
</ul>

Apart from these commonly used tests, doctors may recommend other imaging tests such as X-rays and CT scans, which also involve consuming a dye of sorts to be more prominent on the screen. To confirm a diagnosis, an individual must seek the help and advice of a licensed professional, rather than seek comfort in DIY tests and home remedies.&nbsp; 
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Treatment

Treatment for Peptic Ulcers varies depending on the nature, type, and extent of the ulcer. If the patient presents with bleeding, the doctor may rely on treating the sores during the endoscopy by injecting the necessary medications. The most common procedure to seal a wound from bleeding is cauterization where the infected tissue is burned off to stop the bleeding<a href="#accordion">[14]</a>. There is also a possibility that the ulcer may not require extensive medical treatment and would heal on its own but patients displaying symptoms of Peptic Ulcers and PUD should not heavily rely on that assumption and seek medical advice for treatment for one of the following options: 
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<ul>
	<li>Antibiotics 
	Antibiotics are the primary preference for the treatment of peptic ulcers as they are used to eradicate H. pylori infections. If the signs and symptoms indicate the presence of H. pylori within the gastrointestinal system, the primary care physician might prescribe a group of antibiotics to kill the bacterium. Common antibiotics preferred may incorporate amoxicillin (Amoxil), clarithromycin (Biaxin), metronidazole (Flagyl), tinidazole (Tindamax), tetracycline, and levofloxacin<a href="#accordion">[11]</a>. The antibiotics prescribed will be contingent on where the individual resides and will consider any persisting antibiotics resistance rates. The patient will ideally be instructed to take the prescribed antibiotics for 14 days, as well as supplementary drugs to regulate bearable levels of stomach acid, including a proton siphon inhibitor and perhaps bismuth subsalicylate (Pepto-Bismol)<a href="#accordion">[11]</a>. 
	&nbsp;</li>
	<li>Proton Pump Inhibitors 
	Proton pump inhibitors &mdash; commonly referred to as PPIs &mdash; lessen stomach acid by impeding the activity of the compositions of cells that are responsible for producing the acid. These medications range from prescription to non-prescription drugs, easily available at pharmacies such as omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), esomeprazole (Nexium), and pantoprazole (Protonix). Prolonged usage of proton pump inhibitors, especially at high dosages, would result in growing the threat of the individual developing bone fractures of the hip, wrist, and spine. To ensure the bones persevere and remain strong, consult with a doctor to find out a calcium supplement that would decrease the concern<a href="#accordion">[11]</a>. 
	&nbsp;</li>
	<li>Acid Blockers 
	Histamine receptor inhibitors help decrease the production of acid. These medications are prescribed to target the regulation of the hormone histamine, which contributes to the assimilation and release of the stomach acid that internally corrodes the protective mucosal layer of the digestive tract<a href="#accordion">[6]</a>.&nbsp;</li>
</ul>

&nbsp;

<ul>
	<li>Antacids To Neutralize Stomach Acid 
	The physician may be willing to prescribe antacids and other stomach-settling agents to neutralize the corrosive and damaging effects of stomach acid or recommend medication to decrease the overall production of acid by the body. Antacids provide relief from the pain and burning sensation caused by peptic ulcers, for the patient&rsquo;s ease. While these may not be directly useful for the recuperation of ulcers, antacids help alleviate uncomfortable and inconvenient symptoms of peptic ulcers<a href="#accordion">[13]</a>.&nbsp; 
	&nbsp;</li>
	<li>Protective Agents 
	Like the actions performed by a fluid gauze, these prescribed agents cover the ulcer in a defensive layer to keep further harm from stomach-related acids and compounds. Physicians endorse and rely on drugs such as cytoprotective agents which can assist with safeguarding the covering of the stomach or small intestine while the ulcer is healing<a href="#accordion">[13]</a>. 
	In most cases, once the H. pylori infection is dealt with, there is little to no recurrence of the peptic ulcers. Commonly, medicated drugs suffice in the treatment of ulcers and surgery is a rarity. However, if the conditions do not improve, stricter and more invasive procedures may be utilized to deal with the complications of peptic ulcers. 
	&nbsp;</li>
</ul>

While abdominal pain, persistent nausea, frequent bloating, and severe heartburn are symptoms that raise alarms for peptic ulcer disease (PUD), sometimes these signs can be overlooked. This is not the ideal approach since if left untreated, peptic ulcers can deteriorate to cause severe and grave consequences and medical complications such as: 
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<h5>Internal Bleeding</h5>

Upper gastrointestinal (UGI) bleeding is the most often experienced complication of peptic ulcer infection. After the patient is examined and the infection is diagnosed, anti-microbial treatment is upheld through oral antibiotics. Adequate proof corroborates the idea that the H. pylori (HP) infection elimination can offer recuperation from the severe ulcer, and show promising results in diminishing the probability of re-bleeding. With rising awareness of the impacts of H. pylori contamination, the etiologies of bleeding peptic ulcers have moved to NSAID use, old age, and sickness comorbidity<a href="#accordion">[5]</a>. 
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<h5>Perforation In The Stomach Wall</h5>

It may seem unrealistic, but sometimes peptic ulcers can exacerbate to create significant holes in the stomach. Perforated peptic ulcer (PPU) is an inconvenient and grave consequence of PUD, and patients with PPU frequently present with intense abdominal pain that favors high chances for morbidity and mortality. The lifetime commonness of perforations in patients with PUD is around 5%. PPU-related mortality varies from 1.3% to 20%. It is crucial to treat such a complication with patience and expertise. Diagnosis at an early stage, brief revival, and earnest surgical procedures are fundamental to positive outcomes. Exploratory laparotomy and omental fix reign are the gold standards. The laparoscopic medical procedure ought to be thought about when available. Gastrectomy is suggested in patients with huge or dangerous ulcers<a href="#accordion">[1]</a>. 
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<h5>Gastric Cancer</h5>

The connection between peptic ulcers and malignant growths leading to gastric cancer-also known as stomach cancer has for quite some time been questioned, yet there is amassing proof that gastric ulcer illness is decidedly related and duodenal ulcerations are adversely connected with the unfortunate probability of creating stomach cancer. Moreover, a few excerpts from the latest research prove that extended duration of therapy with proton pump inhibitors might speed up the improvement of atrophic gastritis, which is considered a risk factor for stomach cancer, in people contaminated with H. pylori<a href="#accordion">[4]</a>. 
&nbsp;

<h5>Obstruction</h5>

Ulcers that are found where the duodenum joins the stomach are focal points for intense swelling and tissue scarring. This can obstruct or even block the opening to the duodenum due to the narrowing of the opening. Ingested food is unable to leave the stomach and enter the other parts of the digestive system including the small intestine. The lack of proper and timely digestion could increase nausea and vomiting, which, therefore, decreases an individual&#39;s daily food intake<a href="#accordion">[6]</a>.

Other complications that may necessitate medical assistance or surgery include excessive vomiting, frequent spells of unconsciousness, disorientation without the influence of any drug, sharp and severe abdominal pain, and the sight of blood in vomit or stool. If any of such situations arise, the individual should immediately contact a doctor to receive prompt and effective treatment. 
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Even with the higher chances of infection due to the rising H. pylori contamination becoming endemic, the occurrence of indicative and asymptomatic PUD found on screening endoscopy was 1.0% and 2.4%, respectively. Older age, chain smoking, and H. pylori disease were autonomous risk factors for both symptomatic and asymptomatic PUD. Moreover, it is worthy to state that the reliance on and frequent intake of NSAIDs was an autonomous risk factor only for symptomatic PUD. These outcomes suggest that NSAID-actuated PUD might prompt side effects more frequently than H. pylori-related PUD. Binge consumption of alcohol and active-stage ulcers were autonomous risk factors for the presence of gastroduodenal side effects in patients with PUD. Active stage ulcers might set off additional side effects than recuperating stage ulcers, no matter what their area of recurrence or frequency<a href="#accordion">[8]</a>. 
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Although it is healthy to avoid irrelevant stress and maintain a balanced diet for regular functioning, these factors do not assist the body in warding off peptic ulcers. If an individual wishes to prevent themselves from the burning pain of an ulcer, they should practice and take into consideration the following: 
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<h5>Be Wary Of Pain Relievers</h5>

Certain individuals who have joint inflammation or diseases that cause ongoing pain rely on the daily use of non-steroidal calming medications (NSAIDs) for weeks or months to decrease discomfort and inflammation. These drugs tend to adversely influence the bodily fluid that safeguards the stomach against acid and makes the individual more susceptible to developing peptic ulcers. To avoid the risk of ulcers, individuals undergoing chronic pain should consult with a doctor to find proton pump inhibitors or H-2 blockers that would protect them from the side effects of their dosages<a href="#accordion">[2]</a>. 
&nbsp;

<h5>Limit Alcohol And Cigarettes&nbsp;</h5>

Cigarettes and alcohol have contributed to worsening the situation and increasing the risk of individuals developing peptic ulcers. They cause a decrease in the bodily fluid (mucus) release, growing levels of leukotriene B4, increasing rates of inducible nitric oxide synthase, xanthine oxidase, and myeloperoxidase, and the expression of adhesion substances in the gastric mucosa accumulated with such potentiating impacts in individuals who heavily consumed alcohol and participated in chain-smoking<a href="#accordion">[7]</a>.

&nbsp;

<h5>Introduce Probiotics Into Life</h5>

The gut and neighboring parts of the digestive system are home to a million microorganisms. Some, like H. pylori, cause infection. Others are great for the immune system since they assist with swarming out destructive microscopic organisms. These supportive microorganisms are called probiotics. They are continuously being examined to prove their beneficial role. However, currently, scientists have proposed that they might assist with peptic ulcers. Such useful probiotics can be easily found in many food sources such as dairy products like yogurt and cheese, sauerkraut, miso, and tempeh<a href="#accordion">[13]</a>.

Investigating areas of concern can help decrease the chances of individuals developing peptic ulcers. Stress may contribute to exacerbating existing systems, which is why doctors encourage regular meditation and calming exercises to regulate serotonin. Moreover, while scientists have yet to confirm the vectors of transmission of H. pylori, they believe it to be through humans, which is why practicing oral and general hygiene such as regular showers and sanitizing hands is crucial for a healthy digestive system.

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The latest research in peptic ulcers has successfully identified the molecular mechanisms of the specific protein responsible for making the stomach acidic. The H+/K+ ATPase protein is a chemical that siphons hydrogen particles (H+) into the stomach to help the assimilation and termination of any bugs that can be swallowed with edible substances without notice. Exorbitant stomach acidification can prompt ulcers. Drugs that block the protein&#39;s action can in this way lessen the increasing acidity and simple ulcer side effects<a href="#accordion">[12]</a>.&nbsp;

To plan more viable medications, researchers need to know how the protein functions. In recent research, scientists showed it has an uncommon component. To siphon the hydrogen particles into the stomach, the protein necessarily must first tie to a potassium particle (K+). Comparative proteins ordinarily tie two such potassium particles to set off the siphon component. However, H+/K+ ATPase needs only one. The discoveries assist researchers in understanding the reason why these significant siphon proteins tie to various quantities of particles. They can utilize that data to unpick the sub-atomic instruments of comparative proteins somewhere else<a href="#accordion">[12]</a>. 
&nbsp;&nbsp;

Key Points

Peptic ulcer disease (PUD) is common due to a few reasons, but previous long-held misconceptions of certain foods aggravating the ulcers have been recently debunked. If vigilant and responsible, peptic ulcers can be treated without severe complications. It is important to remember: 
&nbsp;

<ul>
	<li>These ulcers appear in the form of varying sizes of sores in parts of the digestive tract, mainly the esophagus, the stomach, and the small intestine.</li>
	<li>The corrosive environment of the stomach due to digestive enzymes, fluids, and acids supports the creation of ulcers by damaging the protective lining of the digestive organs.</li>
	<li>Most ulcers have originated due to the deterioration of the H. pylori infection caused by the eponymous bacteria. The other most common cause of ulcers is the prolonged use of painkillers.</li>
	<li>Symptoms of peptic ulcers include nausea, vomiting, fullness, indigestion, and dull or burning pain in the abdominal region above the belly button.</li>
	<li>Some ulcers are mild and can dissipate on their own while others require antibiotics and acid blockers to treat affected areas; surgery is seldom performed. 
	&nbsp;</li>
</ul>

[1] Chung, K. T., & Shelat, V. G. (2017). Perforated peptic ulcer - an update. World Journal of Gastrointestinal Surgery, 9(1), 1–12.

[2] Ekström, P., Carling, L., Wetterhus, S., Wingren, P. E., Anker-Hansen, O., Lundegårdh, G., . . . Unge, P. (1996). Prevention of peptic ulcer and dyspeptic symptoms with omeprazole in patients receiving continuous non-steroidal anti-inflammatory drug therapy. A Nordic multicentre study. Scandinavian journal of gastroenterology, 31(8), 753–758.

[3] Graham, R. (2020, April 13). Peptic Ulcer. Retrieved from Healthline.

[4] Hansson, L. E. (2000). Risk of stomach cancer in patients with peptic ulcer disease. World journal of surgery, 24(3), 315–320.

[5] Huang, T. C., & Lee, C. L. (2014). Diagnosis, treatment, and outcome in patients with bleeding peptic ulcers and Helicobacter pylori infections. BioMed research international.

[6] John Hopkins Medicine. (2022). Stomach and Duodenal Ulcers (Peptic Ulcers). Retrieved from John Hopkins Medicine.

[7] Ko, J. K., & Cho, C. H. (2000). Alcohol drinking and cigarette smoking: a "partner" for gastric ulceration. Zhonghua yi xue za zhi = Chinese medical journal; Free China ed, 63(12), 845–854.

[8] Lee, S. P., Sung, I. K., Kim, J. H., Lee, S. Y., Park, H. S., & Shim, C. S. (2017). Risk Factors for the Presence of Symptoms in Peptic Ulcer Disease. Clinical Endoscopy, 50(6), 578–584.

[9] Lee, S. P., Sung, I. K., Kim, J. H., Lee, S. Y., Park, H. S., & Shim, C. S. (2017). Risk Factors for the Presence of Symptoms in Peptic Ulcer Disease. Clinical Endoscopy, 50(6), 578–584.

[10] Malik, T., Gnanapandithan, K., & Singh, K. (2021, July 29). Peptic Ulcer Disease. Retrieved from National Library of Medicine.

[11] Mayo Clinic. (2022, June 11). Peptic Ulcer. Retrieved from Mayo Clinic.

[12] Nagoya University. (2021, October 14). Unique underpinnings revealed for stomach’s acid pump: New understandings of a stomach enzyme could lead to better anti-ulcer drugs. Retrieved from Science Daily.