Peptic ulcer disease: Difference between revisions
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==Background==
==Background==
[[File:Gray1046.png|thumb|Stomach anatomy]]
[[File:Illu stomach2.jpg|thumb|Stomach wall anatomy]]
[[File:Duodenumanatomy.jpg|thumb|Duodenum with major anatomical landmarks.]]
[[File:Benign gastric ulcer 1.jpg|thumb|A benign gastric ulcer (from the antrum of a gastrectomy specimen).]]
[[File:Benign gastric ulcer 1.jpg|thumb|A benign gastric ulcer (from the antrum of a gastrectomy specimen).]]
*Recurrent ulcerations in the stomach and proximal duodenum
*Recurrent ulcerations in the stomach and proximal duodenum
**Defect in the gastric or duodenal wall that extends through the muscularis mucosa into the deeper layers of the wall<ref>Vakil N. Peptic ulcer disease: Management. UpToDate. https://www.uptodate.com/contents/peptic-ulcer-disease-management?search=ulcer treatment&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H1. Published September 16, 2019. Accessed November 5, 2019.</ref>
**Defect in the gastric or duodenal wall that extends through the muscularis mucosa into the deeper layers of the wall<ref>Vakil N. Peptic ulcer disease: Management. UpToDate. https://www.uptodate.com/contents/peptic-ulcer-disease-management?search=ulcer treatment&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H1. Published September 16, 2019. Accessed November 5, 2019.</ref>
*Majority of cases related to [[H. pylori]] or [[NSAID]] use
*Majority of cases related to [[Special:MyLanguage/H. pylori|H. pylori]] or [[Special:MyLanguage/NSAID|NSAID]] use
**[[H. pylori]] found in 30-40% of U.S. population
**[[Special:MyLanguage/H. pylori|H. pylori]] found in 30-40% of U.S. population
**[[NSAIDs]] inhibit prostaglandin synthesis (decreases mucus and bicarb production)
**[[Special:MyLanguage/NSAIDs|NSAIDs]] inhibit prostaglandin synthesis (decreases mucus and bicarb production)
*Perforation most commonly occurs in anterior wall of duodenum.
 


==Clinical Features==
==Clinical Features==
*Burning [[epigastric pain]]
 
 
===Non-Perforated===
 
*Burning [[Special:MyLanguage/epigastric pain|epigastric pain]]
**May awaken patient at night (gastric contents empty)
**May awaken patient at night (gastric contents empty)
*Abrupt onset of severe pain may indicate perforation
*Abrupt onset of severe pain may indicate perforation
*Abrupt onset of [[back pain]] may indicate penetration into the pancreas
*Abrupt onset of [[Special:MyLanguage/back pain|back pain]] may indicate penetration into the pancreas
*The following symptoms are NOT associated with PUD:
*The following symptoms are NOT associated with PUD:
**Postprandial pain, food intolerance, nausea, retrosternal pain, belching
**Postprandial pain, food intolerance, nausea, retrosternal pain, belching




==Complications==
===Perforated===
*Hemorrhage
 
**[[Upper GI Bleeding]]
*Abrupt onset of severe epigastric pain
*Perforation
*Patients may not have history of ulcer-like symptoms
**Most commonly occurs in anterior wall of duodenum. 
 
**Abrupt onset of severe epigastric pain
**Patients may not have history of ulcer-like symptoms
**Upright or left lateral decub XR for intraabdominal air
**Consult surgery
*[[SBO|Obstruction]]
**Occurs due to:
***Scarring of gastric outlet
***Edema due to active ulcer


==Differential Diagnosis==
==Differential Diagnosis==
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{{Abdominal Pain DDX Epigastric}}
{{Abdominal Pain DDX Epigastric}}
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</translate>
{{UGIB DDX}}
{{UGIB DDX}}
<translate>


==Evaluation==
==Evaluation==
[[File:Free air under diaphram.png|thumb|Free intra-abdominal air below the diaphragm (a complication of perforated ulcer).]]
[[File:PMC3835032 1752-1947-7-257-2.png|thumb|Perforated duodenal ulcer presenting with a subphrenic abscess: (A) air-fluid collection (asterisk) with stranding (arrow). (B) air-fluid collection (asterisk) extends to the perihepatic space with extraluminal air bubbles (arrow).]]
[[File:PMC3835032 1752-1947-7-257-2.png|thumb|Perforated duodenal ulcer presenting with a subphrenic abscess: (A) air-fluid collection (asterisk) with stranding (arrow). (B) air-fluid collection (asterisk) extends to the perihepatic space with extraluminal air bubbles (arrow).]]
===Work-Up===
===Work-Up===
*CBC (rule out anemia)
*CBC (rule out anemia)
*[[LFTs]]
*[[Special:MyLanguage/LFTs|LFTs]]
*Lipase
*Lipase
*Consider [[acute abdominal series]] if concern for perforation (>50 years old; concerning abdominal exam)
*Consider [[Special:MyLanguage/acute abdominal series|acute abdominal series]] if concern for perforation (>50 years old; concerning abdominal exam)
*Consider [[RUQ US]]
*Consider [[Special:MyLanguage/RUQ US|RUQ US]]
*Consider [[ECG]]
*Consider [[Special:MyLanguage/ECG|ECG]]
*Consider troponin
*Consider troponin


===Evaluation===
===Evaluation===
[[File:Duodenal ulcer01.jpg|thumb|Acute duodenal acute duodenal mucosal ulcer on endoscopy]]  
[[File:Duodenal ulcer01.jpg|thumb|Acute duodenal acute duodenal mucosal ulcer on endoscopy]]  
*Diagnosis not typically definitively made in ED (requires endoscopy or [[H. pylori]] test)
*Diagnosis not typically definitively made in ED (requires endoscopy or [[Special:MyLanguage/H. pylori|H. pylori]] test)
*Depending on clinical certainty can consider initial empiric treatment
*Depending on clinical certainty can consider initial empiric treatment


==Management==
==Management==
*Stop [[NSAIDs]] and [[ETOH]]
 
*[[PPI]]
 
**Generally heal ulcers faster than H2 blockers
===Perforated===
**[[Omeprazole]] 20-40mg QD
 
*[[H2 blocker]]
''Surgical emergency''
**[[Famotidine]] 20-40mg QD
*Consult surgery
**[[Ranitidine]] 75-150mg BID
*[[Special:MyLanguage/Antibiotics|Antibiotics]] to cover abdominal flora
*Eradicate [[H. pylori]] if identified in symptomatic patient
*[[Special:MyLanguage/IVF|IVF]]
**Triple Therapy: PPI + [[clarithromycin]] 500mg BID + ([[amoxicillin]] 1g or [[metronidazole]] 500mg) BID x 10-14d
 
**Quadruple Therapy: [[PPI]] + [[bismuth subsalicylate]] 524mg QID + [[metronidazole]] 250mg QID and [[tetracycline]] 500mg QID x 10-14d
 
===Non-Perforated===
 
*Stop [[Special:MyLanguage/NSAIDs|NSAIDs]] and [[Special:MyLanguage/ETOH|ETOH]]
*[[Special:MyLanguage/PPI|PPI]]
**Generally heal ulcers faster than H2 blockers<ref>Walan A, Bader JP, Classen M, Lamers CB, Piper DW, Rutgersson K, Eriksson S. Effect of omeprazole and ranitidine on ulcer healing and relapse rates in patients with benign gastric ulcer. N Engl J Med. 1989 Jan 12;320(2):69-75. doi: 10.1056/NEJM198901123200201. PMID: 2643037.</ref>
**[[Special:MyLanguage/Omeprazole|Omeprazole]] 20-40mg QD
*[[Special:MyLanguage/H2 blocker|H2 blocker]]
**[[Special:MyLanguage/Famotidine|Famotidine]] 20-40mg QD
**[[Special:MyLanguage/Ranitidine|Ranitidine]] 75-150mg BID
*Eradicate [[Special:MyLanguage/H. pylori|H. pylori]] if identified in symptomatic patient
**Triple Therapy: PPI + [[Special:MyLanguage/clarithromycin|clarithromycin]] 500mg BID + ([[Special:MyLanguage/amoxicillin|amoxicillin]] 1g or [[Special:MyLanguage/metronidazole|metronidazole]] 500mg) BID x 10-14d
**Quadruple Therapy: [[Special:MyLanguage/PPI|PPI]] + [[Special:MyLanguage/bismuth subsalicylate|bismuth subsalicylate]] 524mg QID + [[Special:MyLanguage/metronidazole|metronidazole]] 250mg QID and [[Special:MyLanguage/tetracycline|tetracycline]] 500mg QID x 10-14d
 


==Disposition==
==Disposition==
*Normally outpatient management, unless complication (see below)
*Normally outpatient management, unless complication (see below)


===Red Flags===
===Red Flags===
Any of the following suggest need for endoscopy referral:
Any of the following suggest need for endoscopy referral:
*Age >55yr
*Age >55yr
*Unexplained weight loss
*Unexplained weight loss
*Early satiety
*Early satiety
*Persistent [[vomiting]]
*Persistent [[Special:MyLanguage/vomiting|vomiting]]
*[[Dysphagia]]
*[[Special:MyLanguage/Dysphagia|Dysphagia]]
*[[Anemia]] or [[GI bleeding]]
*[[Special:MyLanguage/Anemia|Anemia]] or [[Special:MyLanguage/GI bleeding|GI bleeding]]
*Abdominal mass
*Abdominal mass
*Persistent anorexia
*Persistent anorexia
*[[Jaundice]]
*[[Special:MyLanguage/Jaundice|Jaundice]]
 
 
==Complications==
 
*Perforation (see above)
*Hemorrhage
**[[Special:MyLanguage/Upper GI Bleeding|Upper GI Bleeding]]
*[[Special:MyLanguage/SBO|Obstruction]], due to:
**Scarring of gastric outlet
**Edema due to active ulcer
 


==See Also==
==See Also==
*[[Epigastric abdominal pain]]
 
*[[Special:MyLanguage/Epigastric abdominal pain|Epigastric abdominal pain]]
 


==References==
==References==
<references/>
<references/>
[[Category:GI]]
[[Category:GI]]
</translate>

Latest revision as of 23:51, 4 January 2026


Background

Stomach anatomy
Stomach wall anatomy
Duodenum with major anatomical landmarks.
A benign gastric ulcer (from the antrum of a gastrectomy specimen).
  • Recurrent ulcerations in the stomach and proximal duodenum
    • Defect in the gastric or duodenal wall that extends through the muscularis mucosa into the deeper layers of the wall[1]
  • Majority of cases related to H. pylori or NSAID use
    • H. pylori found in 30-40% of U.S. population
    • NSAIDs inhibit prostaglandin synthesis (decreases mucus and bicarb production)
  • Perforation most commonly occurs in anterior wall of duodenum.


Clinical Features

Non-Perforated

  • Burning epigastric pain
    • May awaken patient at night (gastric contents empty)
  • Abrupt onset of severe pain may indicate perforation
  • Abrupt onset of back pain may indicate penetration into the pancreas
  • The following symptoms are NOT associated with PUD:
    • Postprandial pain, food intolerance, nausea, retrosternal pain, belching


Perforated

  • Abrupt onset of severe epigastric pain
  • Patients may not have history of ulcer-like symptoms


Differential Diagnosis

Epigastric Pain

Upper gastrointestinal bleeding

Mimics of GI Bleeding


Evaluation

Free intra-abdominal air below the diaphragm (a complication of perforated ulcer).
Perforated duodenal ulcer presenting with a subphrenic abscess: (A) air-fluid collection (asterisk) with stranding (arrow). (B) air-fluid collection (asterisk) extends to the perihepatic space with extraluminal air bubbles (arrow).


Work-Up

  • CBC (rule out anemia)
  • LFTs
  • Lipase
  • Consider acute abdominal series if concern for perforation (>50 years old; concerning abdominal exam)
  • Consider RUQ US
  • Consider ECG
  • Consider troponin


Evaluation

Acute duodenal acute duodenal mucosal ulcer on endoscopy
  • Diagnosis not typically definitively made in ED (requires endoscopy or H. pylori test)
  • Depending on clinical certainty can consider initial empiric treatment


Management

Perforated

Surgical emergency


Non-Perforated


Disposition

  • Normally outpatient management, unless complication (see below)


Red Flags

Any of the following suggest need for endoscopy referral:


Complications


See Also


References

  1. ↑ Vakil N. Peptic ulcer disease: Management. UpToDate. https://www.uptodate.com/contents/peptic-ulcer-disease-management?search=ulcer treatment&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H1. Published September 16, 2019. Accessed November 5, 2019.
  2. ↑ Walan A, Bader JP, Classen M, Lamers CB, Piper DW, Rutgersson K, Eriksson S. Effect of omeprazole and ranitidine on ulcer healing and relapse rates in patients with benign gastric ulcer. N Engl J Med. 1989 Jan 12;320(2):69-75. doi: 10.1056/NEJM198901123200201. PMID: 2643037.
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