Summary
Definition
History and exam
Key diagnostic factors
- abdominal pain
- "pointing sign"
Other diagnostic factors
- epigastric tenderness
- nausea or vomiting
- early satiety
- weight loss or anorexia
- diarrhea
- symptoms of anemia
- gastrointestinal (GI) bleeding
- hypotensive or septic shock
- succussion splash
Risk factors
- Helicobacter pylori infection
- nonsteroidal anti-inflammatory drug (NSAID) use
- smoking
- increasing age
- personal history of peptic ulcer disease
- family history of peptic ulcer disease
- patient in intensive care
Diagnostic tests
1st tests to order
- Helicobacter pylori urea breath test or stool antigen test
- upper gastrointestinal endoscopy
- CBC
Tests to avoid
- Serology
Tests to consider
- fasting serum gastrin level
- CTA abdomen and pelvis without and with contrast
- arteriography visceral
Treatment algorithm
active bleeding ulcer
no active bleeding: Helicobacter pylori negative
no active bleeding: Helicobacter pylori positive
frequent recurrences, large or refractory ulcers
NSAID-associated ulcer refractory to acid suppression therapy
Contributors
Authors
Nimish Vakil, MD, FACP, AGAF, FASGE, FACG
Clinical Adjunct Professor
School of Medicine and Public Health
University of Wisconsin
Madison
WI
Disclosures
NM is a consultant for Phathom Pharmaceuticals, Redhill Pharmaceuticals, and ISOThrive Inc. NM is an author of the Merck Manual.
Acknowledgements
The contributors would like to gratefully acknowledge Dr Marty M Meyer and Dr Steven Moss, previous contributors to this topic.
Disclosures
SM is on the speaker's bureau for Otsuka, the manufacturer of Helicobacter pylori breath-test kits. MMM declares that he has no competing interests.
Peer reviewers
Lise Lotte Gluud, MD
Consultant
Gastrounit Medical Division
Copenhagen University Hospital Hvidovre
Copenhagen
Denmark
Disclosures
LLG declares that she has no competing interests.
References
Key articles
Moayyedi PM, Lacy BE, Andrews CN, et al. ACG and CAG clinical guideline: management of dyspepsia. Am J Gastroenterol. 2017 Jul;112(7):988-1013.Full text Abstract
Chey WD, Leontiadis GI, Howden CW, et al. ACG clinical guideline: treatment of Helicobacter pylori infection. Am J Gastroenterol. 2017 Feb;112(2):212-39.Full text Abstract
Laine L, Barkun AN, Saltzman JR, et al. ACG clinical guideline: upper gastrointestinal and ulcer bleeding. Am J Gastroenterol. 2021 May 1;116(5):899-917. Abstract
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
Differentials
- Esophageal cancer
- Stomach cancer
- Gastroesophageal reflux disease (GERD)
More DifferentialsGuidelines
- ACR appropriateness criteria: nonvariceal upper gastrointestinal bleeding
- ACG clinical guideline: treatment of Helicobacter pylori infection
More GuidelinesPatient information
Peptic ulcers
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