Diagnosis and treatment of gastric and duodenal ulcers in the elderly

Abstract

Peptic ulcer disease (PUD) currently represents a significant medical challenge for the elderly (aged 65 and older). Although the overall incidence has shown a downward trend, the frequency of complications and mortality rates among the aging population have increased markedly due to the decline in gastric physiological function and the presence of comorbidities. The two leading etiologic factors are Helicobacter pylori (H. pylori) infection (accounting for approximately 70% of cases) and the use of mucosal-damaging agents such as non-steroidal anti-inflammatory drugs (NSAIDs) or aspirin. The aging process triggers profound changes, including immunosenescence, microcirculatory disturbances, and mucosal atrophy leading to hypochlorhydria. These alterations weaken the natural protective barrier, making the gastric mucosa susceptible to aggressive factors and resulting in "idiopathic" or drug-induced ulcers. In elderly patients, clinical symptoms are often atypical and easily masked by concomitant diseases. Only about one-third of patients present with classic epigastric pain; the remainder often exhibit vague symptoms such as anorexia and weight loss, or may even present initially with severe complications like gastrointestinal hemorrhage or perforation. Upper gastrointestinal endoscopy, combined with biopsy following the updated Sydney system, is considered the gold standard for identifying ulcer location, ruling out malignancy, and assessing H. pylori status. Treatment strategies must be strictly individualized. For H. pylori-associated ulcers, newer regimens such as bismuth-based quadruple therapy or Potassium-Competitive Acid Blockers (P-CABs) like Vonoprazan are showing superior efficacy. For drug-related ulcers, discontinuing NSAIDs is the top priority; if their use is mandatory, they must be co-administered with Proton Pump Inhibitors (PPIs) for mucosal protection. Prevention plays a pivotal role through risk stratification, routine prophylactic PPI use, and H. pylori screening and eradication before initiating long-term NSAID or aspirin therapy.