#35 – Peptic Ulcer Disease



  • Dyspepsia
    • Upper abdominal pain or discomfort
  • Gastritis
    • Epithelial or endothelial damage with histologic evidence of inflammation
  • 2 types
    • Gastric
    • Duodenal


  • Annual incidence in developed countries 0.1-0.19%, or 0.7 cases per 1000 person-years
  • Lifetime prevalence of PUD in 10-20% in pylori (+) patients vs 5-10% in H.pylori (-) patients
  • Increases with age
    • 13x higher risk of bleeding in patients > 70yo
  • More common in males
  • Differences between Gastric and Duodenal Ulcers
    • DU occur up to 20 years before GU
    • DU 5x more common than GU


There are numerous causes of PUD and include infections, stress, medications, alcohol, cirrhosis, neoplasms, etc.  The two main causes in developed countries are:

  • Helicobacter pylori
    • Spiral gram negative rod
    • Decreasing incidence due to better hygiene, OTC medications, and antibiotic use
  • Non-Steroidal Antiflammatory Drugs (NSAIDs)
    • 1-4% per year risk of PUD
    • Risk factors
      • Prior history of PUD or pylori infection
      • Dose
      • Duration
      • Age > 75 years
      • Co-therapy
        • Corticosteroids, anticoagulants, SSRI, bisphosphonates, antiplatelets

Clinical Manifestations

  • Up to 70% of peptic ulcers are asymptomatic
    • Present later with complications
    • Up to 80% present with bleeding without preceding symptoms
  • Dyspepsia is the most common symptoms
    • May also have radiation to the back
  • Relation to food intake
    • GU – Worse
    • DU – Better
  • Night symptoms
    • GU – 1/3 of patients
    • DU – 2/3 of patients
  • Nausea, vomiting, anorexia, early satiety, epigastric fullness


  • Bleeding
  • Gastric Outlet Obstruction
  • Penetration
    • Change in typical symptoms
  • Perforation
    • 2-10% perforation rate
      • Duodenal – 60%
      • Antrum – 20%
      • Gastric Body – 20%

Red Flags


  • Endoscopy
    • Up to 90% sensitivity in identifying ulcer
    • Next step if any red flags
    • Malignant features requiring biopsy:
      • Ulcerated mass protruding from lumen
      • Nodular, clubbed, or fused folds
      • Overhanging, irregular, or thickened ulcer margins
  • H/pylori Testing
    • pylori serology and stool antigen testing
      • May be falsely negative if on concurrent PPI
    • Biopsy testing and histology from endoscopy
    • Urea Breath Test

Initial Management

  • Withdrawal of offending or contributing factors
    • Stop NSAIDs, smoking, EtOH, precipitant foods
  • Antisecretory therapy
    • (+) H. pylori Ulcer
      • Uncomplicated – 14 days
      • Complicated – up to 12 weeks
    • NSAID Induced
      • If stopping – 8 weeks
      • If continuing – indefinitely
    • Non-H.pylori, non-NSAID Ulcer
      • 4-8 weeks
    • PPIs out perform H2A
      • Esomeprazole (Nexium) – 20-40mg daily
      • Lansoprazole (Prevacid) – 15-30mg daily
      • Omeprazole (Prilosec) – 20-40mg daily
      • Pantoprazole (Protonix) – 20-40mg daily
    • High Risk Groups Requiring Indefinite Prophylaxis
      • > 2 cm ulcer on endoscopy and age > 50yo
      • Refractory H. pylori negative, NSAID negative ulcer
      • Failure to eradicate H. pylori
      • Frequently recurrent peptic ulcers (> 2 cases in 1 one)
      • Continued NSAID use
  • H. pylori Eradication
    • Risk factors for Macrolide resistance
      • Prior exposure to macrolide therapy
      • ≥ 15% clarithromycin local resistance rates
      • < 85% eradication rates with clarithromycin triple therapy
    • Initial Therapy
    • Salvage Therapy
      • 20% of patients will fail initial H. pylori eradication


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