Peptic Ulcer Disease
Also known as: PUD
Mucosal break through the muscularis mucosae in stomach or duodenum, from H. pylori infection or NSAID/aspirin use predominantly (less commonly Zollinger-Ellison syndrome, stress-related, malignancy, especially gastric ulcers).
Epigastric pain (classic duodenal pattern, improves with eating, recurs 2-3h later/at night; classic gastric pattern: worsens with eating, though unreliable clinically), nausea, bloating.
Complications: bleeding (most common, hematemesis/melena), perforation (sudden severe pain, peritonism, possible referred shoulder pain: surgical emergency), gastric outlet obstruction (early satiety, vomiting, weight loss).
Upper GI endoscopy: definitive, mandatory biopsy for ALL gastric ulcers (exclude malignancy) and H. pylori testing. H. pylori: urea breath test/stool antigen if endoscopy not needed.
FBC (anemia). Fasting gastrin if Zollinger-Ellison suspected.
Repeat endoscopy mandatory for gastric ulcers (6-8 weeks) to confirm healing; not required for duodenal ulcers if symptoms resolve.
Differentials: functional dyspepsia, GERD, gastritis, gastric malignancy, biliary colic, pancreatitis, cardiac ischemia.
- H. pylori eradication if positive
- PPI: omeprazole 20-40mg od, duodenal ulcer 4 weeks, gastric ulcer 8 weeks
- NSAID-induced: stop NSAID if possible; switch to COX-2 selective and/or long-term PPI cover if ongoing need; low-dose aspirin, usually continue with PPI cover rather than stop
- Bleeding ulcer: resuscitation, high-dose IV PPI, urgent endoscopy (within 24h, sooner if unstable) for hemostasis
- Perforation: EMERGENCY, resuscitation, NPO, NG decompression, IV PPI, antibiotics, urgent surgical repair
- Gastric outlet obstruction: NG decompression, IV PPI, correct fluid/electrolytes, endoscopic dilation or surgery
- Confirm H. pylori eradication and gastric ulcer healing
Referral: gastroenterology for endoscopy, complicated/recurrent ulcers, suspected Zollinger-Ellison; surgery for perforation/refractory bleeding/obstruction.
