Peptic ulcer disease is a break in the lining of the stomach or duodenum, caused mainly by Helicobacter pylori infection and NSAIDs. Its serious complications are bleeding, perforation and gastric outlet obstruction.
Key symptoms
- Burning or gnawing epigastric pain
- Duodenal ulcer pain often eases with food; gastric ulcer pain often worsens
- Nausea, bloating and early fullness
- Black stools or vomiting blood when it bleeds
- Sudden severe pain spreading across the belly with perforation
What you find on exam
- Epigastric tenderness
- Vital signs and orthostatic changes for blood loss
- Rigid, board-like abdomen with perforation
- Rectal exam for melena when bleeding is suspected
Tests
- H. pylori test: urea breath test, stool antigen or biopsy
- Upper endoscopy for alarm features, bleeding or age 60 and older
- Blood count; BUN rises with upper GI bleeding
- Upright chest X-ray or CT for free air if perforation is suspected
Treatment basics
- Proton pump inhibitor such as omeprazole for 4 to 8 weeks
- Eradicate H. pylori with bismuth quadruple therapy and confirm cure
- Stop NSAIDs; if they are essential, add a PPI
- Bleeding: IV PPI, transfusion if hemoglobin is under 7, endoscopic therapy
- Perforation: emergency surgery
Red flags
- Vomiting blood, coffee-ground vomit or black stools
- Sudden severe abdominal pain with a rigid belly
- Persistent vomiting or weight loss (outlet obstruction or cancer)
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.