Peptic ulcer disease usually presents as chronic, upper abdominal pain related to eating a meal (dyspepsia).
Use of non-steroidal anti-inflammatory drugs (NSAIDs) and Helicobacter pylori infection are the most common causes.
There may be some epigastric tenderness, but often there are no other signs on physical examination.
Endoscopy is diagnostic and may show an ulcer in the stomach or proximal duodenum. H pylori infection should be sought.
The most common complication is gastroduodenal bleeding. Perforation is a less frequent but potentially life-threatening complication. Either of these may be the presenting symptom, particularly in patients taking NSAIDs.
A break in the mucosal lining of the stomach or duodenum more than 5 mm in diameter, with depth to the submucosa. Ulcers smaller than this or without obvious depth are called erosions. Peptic ulcers result from an imbalance between factors promoting mucosal damage (gastric acid, pepsin, Helicobacter pylori infection, non-steroidal anti-inflammatory drug use) and those mechanisms promoting gastroduodenal defence (prostaglandins, mucus, bicarbonate, mucosal blood flow).
History and exam
Key diagnostic factors
- abdominal pain
- presence of risk factors
- 'pointing sign'
Other diagnostic factors
- epigastric tenderness
- nausea or vomiting
- early satiety
- weight loss or anorexia
- symptoms of anaemia
- gastrointestinal bleeding
- hypotension or septic shock
- succussion splash
- Helicobacter pylori infection
- non-steroidal anti-inflammatory drug (NSAID) use
- increasing age
- personal history of peptic ulcer disease
- family history of peptic ulcer disease
- patient in intensive care
1st investigations to order
- upper gastrointestinal endoscopy
- Helicobacter pylori carbon-13 urea breath test or stool antigen test
Investigations to consider
- fasting serum gastrin level
- urine NSAID screen
active bleeding ulcer
no active bleeding: Helicobacter pylori negative
no active bleeding: Helicobacter pylori positive
recurrent or refractory ulcers
Ian Beales, BSc, MD, FRCP, FEBG
Clinical Associate Professor
Norwich Medical School
Department of Gastroenterology
Norfolk and Norwich University Hospital
IB declares that he has no competing interests.
Kristle Lee Lynch, MD
Assistant Professor of Clinical Medicine
Division of Gastroenterology
Department of Medicine
Hospital of the University of Pennsylvania
University of Pennsylvania
Perelman School of Medicine
KLL declares that she has no competing interests.
Dr Kristle Lynch would like to gratefully acknowledge Dr Marty M Meyer and Dr Steven Moss, previous contributors to this topic.
Alexander C Ford, MBChB, MD, FRCP
Professor of Gastroenterology
Honorary Consultant Gastroenterologist
Leeds Institute of Medical Research at St. James's
University of Leeds
Leeds Gastroenterology Institute
Leeds Teaching Hospitals Trust
ACF served on the National Institute for Health and Care Excellence (NICE) guideline committee for clinical guideline CG184: Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management.
ACF declares that he has no competing interests. ACF is an author of a Cochrane systematic review cited in this topic.
Section Editor, BMJ Best Practice
CP declares that she has no competing interests.
Head of Editorial, BMJ Knowledge Centre
JH declares that she has no competing interests.
Drug Editor, BMJ Best Practice
AM declares that he has no competing interests.
Comorbidities Editor, BMJ Best Practice
JC declares that she has no competing interests.
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