Stress

Altered behavior

Altered physiology

↑ Smoking

↑ Drinking

↑ NSAIDs

↓ Breakfast

↓ Sleep

↓ Blood

flow

↑ Acid

secretion?

Δ Motility

↑ Gastric

↓ Duodenal

↓ Immune

defenses

↓ Mucosal defenses

↑ Duodenal acid load

↑ H. pylori

Duodenal ulcer