Prevalence, anatomical pattern and modifiable risk factors of peptic ulcer disease among patients undergoing upper gastrointestinal endoscopy in central Nepal: a cross-sectional and nested matched case– control study

The Stomach's Silent War: Acid, Bugs, and Bad Habits

Imagine your stomach as a bustling, high-pressure factory. Its job is to churn food into a liquid soup using powerful acids and enzymes. Usually, the factory walls are lined with a thick, protective slime that keeps the acid from eating the building itself. But sometimes, this balance tips. If the acid gets too aggressive or the protective slime gets too thin, the acid starts chewing holes in the factory floor. These holes are called peptic ulcers. It's a painful condition that can cause bleeding or severe tummy aches.

For a long time, scientists thought the main culprit behind these holes was a tiny, spiral-shaped bacteria called Helicobacter pylori (or H. pylori for short). Think of this bacteria as a sneaky saboteur that weakens the factory's defenses. Another major suspect has always been NSAIDs—a common class of painkillers like ibuprofen that people take for headaches or sore muscles. These drugs are like a double-edged sword: they stop pain, but they also accidentally strip away the factory's protective slime. Finally, lifestyle habits like smoking and drinking alcohol have been suspected of making the walls more fragile.

But here's the mystery: in many parts of the world, almost everyone has the H. pylori saboteur living in their stomach, yet only some of them get ulcers. Why do some people get the holes while others, with the same bacteria, stay safe? To solve this puzzle, researchers in Nepal decided to take a closer look at the "factory floors" of hundreds of patients, using a special camera to see exactly what was happening and what habits might be pushing people over the edge.

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The Nepal Ulcer Detective Story

In the heart of central Nepal, a team of medical detectives gathered at a large teaching hospital to investigate a very specific question: Who gets stomach ulcers, and why? They didn't just guess; they looked at the records of 1,242 real people who had come in for a camera test (called an endoscopy) between April and December 2025. This wasn't a small sample; it was a massive snapshot of the local population.

The Big Reveal: How Common is it?
The team found that 18.0% of the people they checked had an ulcer. That's roughly one in five patients walking through the door. It's a big number, meaning ulcers are a major problem in this region.

Where do the holes appear?
The researchers mapped out exactly where the damage happened. They found that the ulcers weren't scattered randomly.

• The Antrum is the Hotspot: The bottom part of the stomach, called the antrum, was the most damaged area, involved in 67.9% of the cases.
• Stomach vs. Twisted Gut: Most ulcers were found only in the stomach (67.4%), while fewer were found only in the first part of the small intestine (the duodenum, 18.8%). Some people had holes in both places (13.8%).
• The Age Shift: Here's a fascinating pattern. In younger people (under 40), the ulcers were more likely to be in the small intestine. But as people got older, the damage shifted to the stomach. By the time people reached 60, the stomach was the main victim. Also, women seemed to get stomach ulcers more often than men, while men were slightly more likely to get the whole package.

The Great H. pylori Mystery
Now, let's talk about the famous bacteria, H. pylori. The researchers tested for it and found something shocking: 94.8% of the people tested had the bacteria.

• The Twist: The bacteria was almost everywhere! It was found in 97.8% of the people with ulcers, but also in 95.3% of the people without ulcers.
• The Conclusion: Because the bacteria was so common in everyone, it couldn't explain why some people got sick and others didn't. It's like finding that almost everyone in a city has a car; having a car doesn't tell you who is going to crash. In this specific group, the bacteria was a background noise, not the main cause of the new crashes.

The Real Culprits: Painkillers and Smoke
So, if the bacteria isn't the differentiator, what is? The researchers dug into the patients' habits and found two clear suspects that stood out:

1. NSAIDs (Painkillers): People who took non-steroidal anti-inflammatory drugs (like ibuprofen) were 7.41 times more likely to have an ulcer than those who didn't. This was a huge jump. It suggests that in a place where almost everyone has the bacteria, taking these painkillers is like removing the last bit of protection the stomach has.
2. Smoking: People who had ever smoked (current or former) were 2.11 times more likely to have an ulcer. Smoking seems to weaken the stomach's defenses, making it easier for the acid to do its damage.

What Didn't Matter?
The study looked at other factors too, like drinking alcohol, having other diseases (like diabetes or high blood pressure), and even the specific type of bleeding the ulcers caused. Surprisingly, alcohol and comorbidities (other health issues) did not show a strong link to getting ulcers in this group. Also, when they looked at the bleeding ulcers, most of them were actually "clean" and low-risk, meaning they weren't actively spurting blood, which is good news for how they can be treated.

How Sure Are They?
The researchers are very confident about the prevalence (18%) and the anatomical patterns (where the ulcers are). However, regarding the causes, they are careful. Because this study looked back at old records, they can't say for 100% certain that painkillers caused the ulcers in a cause-and-effect way. But the link is so strong and consistent that it strongly suggests that in this part of the world, where the bacteria is everywhere, NSAID use and smoking are the main keys that turn the "ulcer switch" on.

The Takeaway
This study paints a clear picture for central Nepal: Ulcers are common, they mostly hit the bottom of the stomach, and they are increasingly a problem for older people and women. While the H. pylori bacteria is practically a resident of every stomach there, it's not the one making the difference. Instead, the real danger lies in the modern habits of popping painkillers and smoking. The researchers suggest that to stop these ulcers, doctors and patients need to focus less on just killing the bacteria and more on managing how painkillers are used and helping people quit smoking.