Peptic ulcer disease

Last reviewed: 27 Dec 2022
Last updated: 15 Nov 2022



History and exam

Key diagnostic factors

  • abdominal pain
  • "pointing sign"
More key diagnostic factors

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
Other diagnostic factors

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
More risk factors

Diagnostic investigations

1st investigations to order

  • Helicobacter pylori urea breath test or stool antigen test
  • upper gastrointestinal endoscopy
  • CBC
More 1st investigations to order

Investigations to consider

  • fasting serum gastrin level
More investigations to consider

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



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.


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


Gastrounit Medical Division

Copenhagen University Hospital Hvidovre




LLG declares that she has no competing interests.

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  • Guidelines

    • ACG and CAG clinical guideline: management of anticoagulants and antiplatelets during acute gastrointestinal bleeding and the periendoscopic period
    • ACG clinical guideline: upper gastrointestinal and ulcer bleeding
    More Guidelines
  • Patient leaflets

    Peptic ulcers

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