Gastrointestinal ulcers, role of aspirin, and clinical outcomes: pathobiology, diagnosis, and treatment

Figures & data

Figure 1 Hospitalizations based on ulcer type from 1998–2005.

Note: Data from Feinstein et al.²

Table 1 General classifications of peptic ulcers

Aspirin use	H. pylori infection
	Yes	No
Yes	H. pylori and aspirin-positive	Aspirin-induced
No	H. pylori-positive	Other rare causes
		– Acid hyper-secretion (eg, Zollinger-Ellison syndrome)
		– Tumors
		– Crohn’s disease
		– Viral infections
		– Idiopathic ulcers

Abbreviation: H. pylori, Helicobacter pylori.

Figure 2 Model of peptic ulcer formation. In the stomach, both Helicobacter pylori and aspirin are able to induce gastric ulcer formation. Proton pump inhibitors act to reduce gastric acid production, thereby reducing ulceration in the stomach lining.

Abbreviations: ASA, aspirin; H⁺, hydrogen; PPI, proton pump inhibitor; H. pylori, Helicobacter pylori.

Table 2 Risk factors for aspirin-induced ulcers

Aspirin-relateda

High aspirin dose

Concomitant use with

– Other NSAIDs

– Corticosteroids

– Anticoagulants

• Ticagrelor

• Prasugrel

• Clopidogrel

Triple antithrombotic therapy (aspirin, clopidogrel, and warfarin)

Patient-related

Helicobacter pylori infection

History of peptic ulcer disease or GI bleeding

Older age

Presence of severe comorbidities

Notes:

a It is important for physicians to be aware of the potential drug-drug interactions and subsequent adverse events (eg, gastric ulcers) in patients prescribed aspirin therapies for cardiovascular disease. Data from Valkhoff et al²⁴, Lanza et al⁹⁰, Quinlan et al⁹¹.

Abbreviations: NSAIDs, nonsteroidal anti-inflammatory drugs; GI, gastrointestinal.

Table 3 Classification of treatments for peptic ulcers

Ulcer treatment	Typical use	Rating	H. pylori status
PPI	Standard treatment of H. pylori-positive and -negative ulcers; prevention of NSAID/aspirin-induced ulcers; intravenous administration for bleeding ulcers	Most potent acid inhibition	+ or −
– Omeprazole
– Pantoprazole
– Lansoprazole
– Rabeprazole
– Esomeprazole
H. pylori eradication + PPI	Standard for H. pylori-positive ulcers	Most potent acid inhibition + cure for infection	+
H2 receptor antagonists	H. pylori-negative ulcers	Acid inhibition	−
– Cimetidine
– Ranitidine
– Famotidine
– Nizatidine
– Roxaditine
Prostaglandin analogs	H. pylori-negative ulcers; prevention of NSAID/aspirin-induced ulcers	Weak acid inhibition	−
– Misoprostol
Bismuth salts	Quadruple therapy for H. pylori eradication	weak antibacterial effect	+
– Subcitrate
– Subsalicylate
Phosphatidylcholine-aspirin	H. pylori-negative ulcers; prevention of aspirin-induced ulcers	Acid inhibition	−
– PL2200

Abbreviations: H. pylori, Helicobacter pylori; PPI, proton pump inhibitor; NSAID, nonsteroidal anti-inflammatory drug.

Figure 3 Flow chart of recommended management to prevent recurrent ulcer bleeding based on type. Reprinted by permission from Macmillan Publishers Ltd: American Journal of Gastroenterology. Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol. 2012;107(3):345–360. Copyright 2012.³

Abbreviations: LDA, low-dose aspirin; PPI, proton pump inhibitor; NSAID, nonsteroidal anti-inflammatory drug; coxib, cyclooxygenase-2 inhibitor; H. pylori, Helicobacter pylori.

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