Peptic ulcer disease

Peptic ulcers usually present as chronic, upper abdominal pain related to eating a meal (dyspepsia).

Use of nonsteroidal 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 exam.

Endoscopy is diagnostic and may show an ulcer in the stomach or proximal duodenum. H pylori infection should be sought.

In the absence of "alarm" (red flag) symptoms or signs, testing for and treating H pylori and/or empiric acid inhibition therapy is appropriate.

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 peptic ulcer is 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, H pylori infection, NSAID use) and those mechanisms promoting gastroduodenal defense (prostaglandins, mucus, bicarbonate, mucosal blood flow).