A 58-year-old woman from Mumbai with a 10-year history of rheumatoid arthritis on regular ibuprofen develops epigastric pain and melena. Endoscopy reveals a gastric ulcer. Which is the most common site of peptic ulcer in NSAID-induced ulcer disease?

Explanation

## Most Common Site of NSAID-Induced Peptic Ulcer **Key Point:** The gastric body along the lesser curve is the most common site of NSAID-induced gastric ulcers, accounting for approximately 70–80% of gastric ulcers in NSAID users. ### Anatomical Distribution of NSAID-Induced Ulcers | Site | Frequency | Characteristics | |------|-----------|------------------| | Gastric body (lesser curve) | 70–80% | Most common; deeper penetration; higher bleeding risk | | Gastric antrum | 10–15% | Less common; shallower ulcers | | First part of duodenum | 5–10% | Rare in NSAID-induced PUD | | Second part of duodenum | <5% | Uncommon in NSAID-induced disease | ### Why the Gastric Body? 1. **Direct mucosal contact:** NSAIDs accumulate in the gastric mucosa, especially at the lesser curve where blood flow is relatively lower 2. **Acid secretion pattern:** The body produces more acid than the antrum 3. **Reduced prostaglandin synthesis:** NSAIDs inhibit COX-1, reducing protective prostaglandins (PGE₂, PGI₂) in the gastric body 4. **Deeper ulceration:** NSAID ulcers penetrate deeper into the muscularis propria, increasing bleeding and perforation risk **High-Yield:** NSAID-induced gastric ulcers are more common in the elderly and carry higher morbidity (bleeding, perforation) compared to H. pylori–induced duodenal ulcers. **Clinical Pearl:** In contrast, H. pylori–induced peptic ulcers most commonly occur in the duodenum (duodenal bulb), not the gastric body. This anatomical difference is a key distinguishing feature between the two etiologies. ### Comparison: H. pylori vs. NSAID-Induced Ulcers | Feature | H. pylori | NSAIDs | |---------|-----------|--------| | Most common site | Duodenal bulb | Gastric body (lesser curve) | | Age group | Younger patients | Elderly patients | | Risk factors | Infection | Chronic NSAID use, age >65 | | Bleeding risk | Moderate | High | | Perforation risk | Moderate | High | ### Diagnostic Approach - **Endoscopy:** Visualize ulcer location and morphology - **Biopsy:** Rule out malignancy in gastric ulcers (especially >1 cm) - **H. pylori testing:** Serology, stool antigen, or urea breath test to exclude concurrent infection - **PPI therapy:** Standard treatment; NSAIDs should be discontinued or replaced with safer alternatives