Peptic ulcer disease

By Dr. Bahir Hadi — Consultant Surgeon, PhD

Peptic ulcer disease: symptoms, causes, diagnosis and treatment

Woman with burning pain in the upper abdomen, a typical symptom of a stomach ulcer

Anatomical illustration of an ulcer in the stomach

Peptic ulcer disease (PUD) is a defect in the mucosa of the stomach (gastric ulcer) or duodenum (duodenal ulcer) extending more than 5 mm through the muscularis mucosae. Approximately 5-10 % of adults develop a peptic ulcer during their lifetime [1]. More than 90 % of cases are caused by either Helicobacter pylori infection or NSAID use (ibuprofen, diclofenac, aspirin).

Symptoms

The classical symptom is burning or gnawing epigastric pain:

Duodenal ulcer: pain 2-5 hours after meals and at night - relieved by food or antacids.
Gastric ulcer: pain triggered or worsened by eating - patients often lose weight.

Other symptoms: nausea, bloating, early satiety, heartburn, acid regurgitation.

Alarm symptoms (urgent gastroscopy):

Black tarry stool (melena) or hematemesis
Unexplained weight loss
Persistent vomiting
Dysphagia
Iron-deficiency anemia

Causes

Cause	Share	Mechanism
Helicobacter pylori	50-70 %	Disrupts mucosal barrier, increases acid output
NSAID/aspirin	20-30 %	Inhibits COX-1 → reduced prostaglandin protection
Stress ulcer	<5 %	ICU patients, burns, critical illness
Zollinger-Ellison syndrome	<1 %	Gastrin-producing tumor → extreme acid output
Idiopathic	5-10 %	No identifiable cause

Risk factors: smoking, alcohol, older age, concomitant steroids or anticoagulants.

Diagnosis

Oral or nasal gastroscopy - gold standard. Direct visualization, biopsy to exclude malignancy (all gastric ulcers), and CLO test for H. pylori.
H. pylori testing: ¹³C-urea breath test, stool antigen, or serology.
Blood tests: hemoglobin, ferritin (iron deficiency from chronic bleeding), gastrin (suspected ZES).
Repeat gastroscopy after 8-12 weeks for gastric ulcers to confirm healing and rule out cancer [2].

Treatment

First-line - H. pylori eradication (positive test):

Triple therapy 14 days: PPI bid + amoxicillin 1 g bid + clarithromycin 500 mg bid.
Bismuth quadruple therapy if clarithromycin resistance suspected.
Eradication reduces recurrence from ~60 % to <10 % [3].

General ulcer healing:

Proton pump inhibitor (PPI) - omeprazole/pantoprazole 40 mg daily for 4-8 weeks.
Stop NSAIDs - or switch to a selective COX-2 inhibitor with PPI cover.
Smoking cessation and alcohol reduction accelerate healing.

Surgery (rare - complications only):

Perforation (acute peritonitis → emergency laparotomy)
Uncontrolled bleeding despite endoscopy
Gastric outlet obstruction
Suspected malignancy

Complications

Bleeding (15-20 %) - presents as melena or hematemesis.
Perforation (5-10 %) - sudden, knife-like abdominal pain, "board-like" abdomen.
Penetration into pancreas - back pain, raised amylase.
Stenosis (1-2 %) - vomiting of undigested food.

Prevention

Test and treat H. pylori in patients with family history of gastric cancer.
Co-prescribe PPI with long-term NSAIDs in patients >65 or with previous ulcers.
Minimize NSAID dose; consider paracetamol first-line.

Treatment at Kirurgen.dk

We offer outpatient oral and nasal gastroscopy with direct CLO testing for H. pylori, biopsy and photo documentation - typically within 1-2 weeks. See also: Helicobacter pylori, GERD reflux, black stool, nasal vs. oral gastroscopy.

References

Lanas A, Chan FKL. Peptic ulcer disease. Lancet 2017;390(10094):613-24.
Banerjee S, Cash BD, Dominitz JA, et al. The role of endoscopy in the management of patients with peptic ulcer disease. Gastrointest Endosc 2010;71(4):663-8.
Ford AC, Gurusamy KS, Delaney B, Forman D, Moayyedi P. Eradication therapy for peptic ulcer disease in Helicobacter pylori-positive people. Cochrane Database Syst Rev 2016;(4):CD003840.

Peptic ulcer disease