A 48-year-old woman from Mumbai with a 10-year history of dyspepsia undergoes upper endoscopy. Biopsies from the antrum and body of the stomach are positive for urease test. Which is the most common cause of peptic ulcer disease in India?

Explanation

## Most Common Cause of Peptic Ulcer Disease **Key Point:** Helicobacter pylori (H. pylori) infection is the most common cause of peptic ulcer disease globally and in India, accounting for 60–90% of duodenal ulcers and 60–70% of gastric ulcers. ### Epidemiology in India **High-Yield:** H. pylori prevalence in India is 40–50%, making it the leading cause of peptic ulcer disease in the Indian population. The prevalence is higher in lower socioeconomic groups due to poor sanitation and crowded living conditions. ### Pathophysiology of H. pylori–Induced Ulceration 1. **Colonization:** H. pylori colonizes the gastric mucosa via the urease enzyme, which neutralizes gastric acid locally. 2. **Inflammation:** Triggers chronic active gastritis with release of pro-inflammatory cytokines (IL-1β, IL-6, TNF-α). 3. **Acid Hypersecretion:** Leads to increased acid secretion, particularly in duodenal ulcers. 4. **Mucosal Damage:** Bacterial toxins (CagA, VacA) and inflammatory mediators damage the mucosa, leading to ulcer formation. ### Comparison of Common Causes of Peptic Ulcer | Cause | Frequency | Key Features | Diagnostic Test | | --- | --- | --- | --- | | **H. pylori** | 60–90% | Chronic, recurrent; antral predominance | Urease test, serology, stool antigen | | **NSAIDs** | 10–25% | Often asymptomatic; gastric > duodenal | History of NSAID use; endoscopy | | **Zollinger–Ellison** | <1% | Multiple/refractory ulcers; severe diarrhea | Fasting gastrin >1000 pg/mL; pH <2 | | **Stress/Crohn's** | <5% | Associated conditions; rare in isolation | Clinical context; endoscopy | ### Clinical Pearl **Clinical Pearl:** The urease test (as performed in this case) is the most rapid and cost-effective bedside diagnostic test for H. pylori, with sensitivity and specificity >95% when the patient has not taken PPIs or antibiotics in the preceding 2 weeks. **Mnemonic:** **CHAMP** — Common causes of peptic ulcer: - **C**rohn's disease - **H**elicobacter pylori (most common) - **A**spirin/NSAIDs - **M**alignancy (gastric cancer) - **P**ancreatitis (erosive gastritis) ### Treatment Implications H. pylori eradication therapy (triple or quadruple regimen) is the cornerstone of management and prevents ulcer recurrence in >95% of cases. [cite:Harrison 21e Ch 297]