Peptic ulcer disease


  • 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)
  • Perforation most commonly occurs in anterior wall of duodenum.

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


  • Abrupt onset of severe epigastric pain
  • Patients may not have history of ulcer-like symptoms

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. pylori test)
  • Depending on clinical certainty can consider initial empiric treatment



Surgical emergency

  • Consult surgery
  • Antibiotics to cover abdominal flora
  • IVF



  • Normally outpatient management, unless complication (see below)

Red Flags

Any of the following suggest need for endoscopy referral:


  • Perforation (see above)
  • Hemorrhage
  • Obstruction, due to:
    • Scarring of gastric outlet
    • Edema due to active ulcer

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.
This article is issued from Wikem. The text is licensed under Creative Commons - Attribution - Sharealike. Additional terms may apply for the media files.