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 examination.
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 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, nonsteroidal anti-inflammatory drug use) and those mechanisms promoting gastroduodenal defense (prostaglandins, mucus, bicarbonate, mucosal blood flow).
History and exam
Key diagnostic factors
- abdominal pain
- "pointing sign"
Other diagnostic factors
- epigastric tenderness
- nausea or vomiting
- early satiety
- weight loss or anorexia
- symptoms of anemia
- gastrointestinal (GI) bleeding
- hypotensive or septic shock
- succussion splash
- Helicobacter pylori infection
- nonsteroidal 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
- Helicobacter pylori urea breath test or stool antigen test
- upper gastrointestinal endoscopy
Investigations to consider
- fasting serum gastrin level
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
- Esophageal cancer
- Stomach cancer
- Gastroesophageal reflux disease (GERD)
- 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
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