The Enigma of Peptic Ulcer

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Abstract
The etiology of [human] peptic ulcer disease may be multi-componental, as a result of which both the control over the proteolytic potential for auto-digestion, or the forces which resist this, can be altered to disadvantage. But why then does not the whole of the mucosa under attack simply disintegrate and slough off? When a gastric ulcer in man is excised, as was once an accepted surgical procedure, the chances of another crater forming in the immediately adjacent mucosa or not were equal. If the crater sites represent loci minoris resistentiae then whey does not the original ulcer continually extend circumferentially? A major contributor to ulceration of the duodenum is thought to be the inappropriate secretion of acid and pepsin when the intragastric digestive conditions do not require either. Whether this disease is heterogenic (i.e., though representing a single clinical manifestation, having many pathogenetic factors both genetic and non-genetic which end in a similar end-point) or polygenic (i.e., requiring a contribution for many genes giving a continuum of predisposition with perhaps environmental boosters) is unknown. In duodenal ulcer subjects of blood group O there is a greater tendency to bleed, to perforate and to recur than in those of the other groups, even while the acid secretory capacity remains within normal limits. Other sub-groups in ulcer population bear consideration. Thus, there is a sub-group in which duodenal ulcer arises in childhood, supranormal secretion of acid is usual and the family history of the disease is strong. Another part of the ulcer enigmata yet unresolved is the great variation in prevalence in different ethnic groups, and in different parts of the world, and in whom there are differences in gastric secretory function. Diet factors have been proposed in the explanation for the high incidence of gastric ulcer. The remarkable protective influence against peptic ulcer conferred by pregnancy remains to be exploited. There are curiosities in the relationship of analgesics to upper alimentary ulceration. Pain is the final enigmatic aspect of peptic ulcer which merits consideration. Serial endoscopy during and between bouts of symptoms has demonstrated the absence of correlation between the state of healing of ulcers and the presence or otherwise of symptoms.