Peptic ulcer disease

Revision as of 17:08, 5 November 2019 by Hkm91450 (talk | contribs) (Background)


  • 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)

Clinical Features

  • 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


  • Hemorrhage
  • Perforation
    • 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
  • Obstruction
    • Occurs due to:
      • Scarring of gastric outlet
      • Edema due to active ulcer

Differential Diagnosis

Epigastric Pain

Upper gastrointestinal bleeding

Mimics of GI Bleeding



  • 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


  • Diagnosis not typically definitively made in ED (requires endoscopy or H pilori test)
  • Depending on clinical certainty can consider initial empiric treatment



  • Normally outpatient management, unless complication (see below)

Red Flags

Any of the following suggest need for endoscopy referral:

See Also


  1. Vakil N. Peptic ulcer disease: Management. UpToDate. treatment&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H1. Published September 16, 2019. Accessed November 5, 2019.