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Peptic Ulcer Disease

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Overview

Peptic ulcer disease (PUD) is an umbrella term describing gastric and duodenal ulcers. PUD usually presents as epigastric pain following eating a meal. Peptic ulcers can lead to upper gastrointestinal bleeding or perforation leading to an acute abdomen requiring emergency treatment.

Epidemiology

  • Around 13% of patients who undergo endoscopy have peptic ulcers
  • Duodenal ulcers tend to present between 45-65 years of age and are more common in men
  • Gastric ulcers tend to present more with increased age and the incidence is similar between men and women

Risk Factors

  • H. pylori infection:
    • 95% of duodenal ulcers and 80% of gastric ulcers are associated with H. pylori
  • Drugs:
    • NSAIDs and aspirin – the main causes
    • Aspirin
    • Bisphosphonates
    • Corticosteroids
    • Selective serotonin reuptake inhibitors (SSRIs)
  • Smoking
  • Alcohol consumption
  • Stress and anxiety
  • Zollinger-Ellison syndrome

Presentation

Uncomplicated peptic ulcer

Patients present with dyspepsia. The nature of epigastric pain can help narrow down the likely diagnosis:

  • Duodenal ulcers tend to have epigastric pain that is relieved when eating
  • Gastric ulcers tent to have epigastric pain that is worse when eating

Bleeding peptic ulcer

The gastroduodenal artery may be affected in bleeding due to peptic ulcer disease. Patients may have:

  • Melaena – black, tarry stools
    • The stools are black and tarry due to digested blood
  • Haematemesis – vomiting blood, often similar to coffee grounds
  • Features of iron-deficiency anaemia
  • Features of shock – tachycardia and hypotension

Perforated peptic ulcer

Patients have an acute abdomen characterised by severe epigastric pain that may become more generalised. Features of peritonitis may be present such as rigidity and guarding.

Investigations

Uncomplicated peptic ulcer

  • Full blood count:
    • To rule out iron-deficiency anaemia due to bleeding
  • H. pylori testing:
    • The test of choice is a carbon-13 urea breath test

Bleeding peptic ulcer

  • Immediate same-day referral for endoscopy:
    • Endoscopy is the gold-standard test for peptic ulcer disease and can also be used in treatment

Perforated peptic ulcer

  • Immediate admission to hospital
  • Erect chest x-ray:
    • May show pneumoperitoneum – free air under the diaphragm

Management

Uncomplicated peptic ulcer

  • H. pylori-positive: eradication therapy. See Helicobacter pylori for more details
  • H. pylori-negative: give proton pump inhibitors (PPIs) until the ulcer has healed

Bleeding peptic ulcer

Immediate same-day referral to hospital as bleeding peptic ulcers require urgent assessment. See Acute upper gastrointestinal bleeding for more details.

Perforated peptic ulcer

Immediate same-day hospital admission is necessary as a perforated peptic ulcer is a medical emergency. An ABCDE approach should be carried out including antibiotic coverage. Surgery may be necessary.

Patient Advice

Patients should avoid NSAIDs where possible, however, they should continue aspirin if indicated for secondary prevention of cardiovascular disease

Complications

Prognosis

  • Most peptic ulcers resolve if underlying causes are addressed

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