II. Epidemiology

  1. Incidence: 500,000 cases per year in U.S.

III. Etiologies

  1. Nonsteroidal Antiinflammatory Drugs (NSAIDs)
    1. Peptic ulcers occur in 5-20% of longterm NSAID use
  2. Helicobacter Pylori
    1. Duodenal Ulcer: 90-100% Prevalence
    2. Gastric Ulcer: 70-90% Prevalence
  3. Acid Induced Ulcers
    1. Idiopathic
    2. Zollinger-Ellison Syndrome
  4. Chronic Disease
    1. Stress Ulcers in chronic debilitated conditions
    2. Chronic Obstructive Pulmonary Disease
    3. Cystic Fibrosis
    4. Alpha-1-Antitrypsin Deficiency
    5. Systemic Mastocytosis
    6. Basophilic Leukemia
    7. Chronic Renal Failure
    8. Cirrhosis

IV. Risk Factors

V. Symptoms

  1. Duodenal Ulcer
    1. Mid-Epigastric Pain, deep recurring ache
    2. Relieved with food or Antacids
    3. Aggravated by general irritants (below)
    4. Nocturnal pain is present
  2. Gastric Ulcer
    1. Mid-Epigastric Pain
    2. Relieved by Antacids
    3. Aggravated by food and general irritants (below)
    4. Constitutional symptoms
      1. Anorexia
      2. Weight loss
      3. Nausea or Vomiting

VI. Red Flags

VII. Presentations: Special cohorts

  1. Children (rare): Presents with poorly localized Abdominal Pain
  2. Elderly
    1. Presents asymptomatically or non-specifically (e.g. confusion, Abdominal Distention)
    2. High risk of perforation and mortality
  3. Stress Ulcers
    1. Presents in seriously ill hospitalized patients (Mechanical Ventilation, Burn Injury)
  4. Pregnancy
    1. See Dyspepsia in Pregnancy

VIII. Differential Diagnosis

  1. See Dyspepsia Causes
  2. See Medication Causes of Dyspepsia
  3. Most common misdiagnoses for Peptic Ulcer Disease
    1. Functional Dyspepsia
    2. Esophagitis
    3. Gastroesophageal Reflux
    4. Gastritis
    5. Gastroenteritis
  4. Less common misdiagnoses for Peptic Ulcer Disease
    1. Biliary tract disease (Cholecystitis, Cholelithiasis, Ascending Cholangitis)
    2. Celiac Sprue (Gluten Sensitive Enteropathy)
    3. Inflammatory Bowel Disease
    4. Irritable Bowel Syndrome
    5. Pancreatitis
    6. Appendicitis
  5. Uncommon misdiagnoses for Peptic Ulcer Disease
    1. Abdominal Aortic Aneurysm
    2. Acute Coronary Syndrome
    3. Barrett Esophagus
    4. Gastric Cancer
    5. Ischemic bowel disease in the elderly
    6. Viral Hepatitis
    7. Zollinger-Ellison Syndrome

IX. Diagnostics

  1. See Dyspepsia for evaluation protocol
  2. No additional investigation necessary if
    1. Symptoms consistent with Duodenal Ulcer and
    2. Medication leads to healing within 6 weeks
  3. Upper Endoscopy Indications
    1. Assess and reassess Gastric Ulcers
    2. Evaluate for Gastric Carcinoma in high risk groups
      1. See Dyspepsia Red Flags
  4. Upper GI with Follow Through
    1. May be sufficient for Duodenal Ulcers
  5. Helicobacter Pylori testing if ulcer not NSAID related
    1. See Helicobacter pylori Noninvasive Testing

X. Management: General Measures

  1. Avoid Gastric Irritants
    1. Avoid Alcohol
    2. Avoid Tobacco
    3. Avoid Caffeine
  2. Avoid bland diets (not effective)
    1. May stimulate greater acid production
  3. Avoid Glycopyrolate Dartisla ODT
    1. Glycopyrolate was originally used in the 1960s for peptic ulcers to reduce gastric secretions
    2. However, since that time, much more effective medications are available (e.g. H2 Blockers, Proton Pump Inhibitors)
    3. Yet, in 2022 Dartisla ODT was released in 2022, at $500/90 tablets, a 10 fold markup over generic glycopyrolate
    4. Avoid glycopyrolate (including Dartisla ODT) in Peptic Ulcer Disease (we have much better. less expensive treatments)
    5. (2022) Presc Lett 29(4): 24

XI. Management: Cause specific

XII. Management: Refractory Peptic Ulcer

  1. Causes
    1. Persistent NSAID use
    2. Resistant Helicobacter Pylori infection
    3. Gastric Cancer
    4. Zollinger-Ellison Syndrome
  2. Measures
    1. Continue Proton Pump Inhibitors
    2. Consider surgical intervention in severe cases or those at high risk of complications
      1. Duodenal Ulcer: Vagotomy or Partial Gastrectomy
      2. Gastric Ulcer: Partial Gastrectomy

XIII. Prevention

  1. Avoid NSAIDs
    1. See NSAID Gastrointestinal Adverse Effects for risks (and prophylaxis options if NSAIDS are needed)

XIV. Prognosis

  1. Proton Pump Inhibitors have higher efficacy than H2 Antagonists
  2. On Proton Pump Inhibitor
    1. Duodenal Ulcers heal in 95% of cases within 4 week
    2. Gastric Ulcers heal in 80-90% of cases within 8 weeks
  3. Recurrence risk (Duodenal Ulcers)
    1. Non-smoker recurrence in 1 year: 60%
    2. Smoker recurrence in 1 year: >75%

XV. Complications

  1. Complications occur in 25% of cases (especially in Elderly taking NSAIDs)
  2. Gastrointestinal Hemorrhage (15-20% of cases)
    1. See Upper Gastrointestinal Bleeding
  3. Gastrointestinal Perforation
    1. Incidence: 1 per 10,000 per year for non-NSAID related peptic ulcer perforation
    2. Presents with severe Abdominal Pain, Acute Abdomen, with regional inflammation (Pancreatitis, hepatitis)
    3. Lowest mortality (6-14%) is associated with the earliest management in younger patients without comorbidity
  4. Gastric Outlet Obstruction (rare)
    1. Duodenum narrows with recurrent or persistent ulceration and secondary inflammation and scarring
    2. Presents with Retching and hematemsis
    3. Evaluate differential diagnosis including cancer

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Related Studies

Ontology: Duodenal Ulcer (C0013295)

Definition (MSHCZE) Ulcus duodeni – lat. dvanáctníkový vřed, defekt (ulkus) ve sliznici duodena. (cit. Velký lékařský slovník online, 2013 http://lekarske.slovniky.cz/ )
Definition (NCI_CTCAE) A disorder characterized by a circumscribed, inflammatory and necrotic erosive lesion on the mucosal surface of the duodenal wall.
Definition (NCI) An ulcer in the duodenal wall.
Definition (MSH) A PEPTIC ULCER located in the DUODENUM.
Definition (CSP) peptic ulcer located in the duodenum, the shortest and widest portion of the small intestine adjacent to the pylorus of the stomach.
Concepts Disease or Syndrome (T047)
MSH D004381
ICD9 532
ICD10 K26
SnomedCT 553009, 155700000, 196669008, 155691003, 196680008, 196651004, 196679005, 196672001, 235703009, 51868009, 367474008
English Duodenal Ulcers, Ulcers, Duodenal, DUODENAL ULCER, Ulcer, Duodenal, Duodenal ulcer NOS, Peptic ulcer of duodenum, Unspecified duodenal ulcer, Unspecified duodenal ulcer NOS, Duodenal Ulcer, duodenal ulcer, duodenal ulcer (diagnosis), Ulcer duodenal, duodenum ulcer (peptic), Duodenal Ulcer [Disease/Finding], duodenal ulceration, duodenum ulcer, Ulcer;duodenal, duodenum ulcers, duodenal ulcers, DU, Duodenal ulcer (disorder), Unspecified duodenal ulcer NOS (disorder), Unspecified duodenal ulcer (disorder), Duodenal ulcer NOS (disorder), Peptic ulcer of duodenum (disorder), Duodenal ulcer, DU - Duodenal ulcer, DUD - Duodenal ulcer disease, Duodenal ulcer disease, Common duodenal ulcer (disorder), Common duodenal ulcer, Duodenal ulcer disease (disorder), duodenum; ulcer, ulcer; duodenum, Common duodenal ulcer, NOS, Duodenal ulcer disease, NOS, Duodenal ulcer, NOS, Peptic ulcer of duodenum, NOS, Common duodenal ulcer (disorder) [Ambiguous]
French ULCERE DUODENAL, UD, Ulcère duodénal, Ulcère du duodénum, Ulcères duodénaux
Portuguese ULCERA DUODENAL, Úlcera duodenal, Úlcera Duodenal
Spanish ULCERA DUODENAL, Úlcera duodenal, UD, úlcera de duodeno (trastorno), úlcera duodenal no especificada (trastorno), DU - úlcera Duodenal, úlcera de duodeno, úlcera duodenal no especificada, SAI, úlcera duodenal no especificada, úlcera duodenal no especificada, SAI (trastorno), úlcera duodenal, SAI (trastorno), úlcera péptica del duodeno, Duodenal ulcer NOS, úlcera duodenal, SAI, úlcera duodenal, úlcera duodenal (trastorno), enfermedad ulcerosa del duodeno (trastorno), enfermedad ulcerosa del duodeno, úlcera duodenal (concepto no activo), úlcera duodenal común (trastorno), úlcera duodenal común, Úlcera de duodeno, Úlcera Duodenal
Swedish Tolvfingertarmssår
Japanese ジュウニシチョウカイヨウ, カーリング潰瘍, 十二指腸潰瘍, Curling潰瘍
Finnish Pohjukaissuolihaava
German ULKUS DUODENI, Ulcus duodeni, DU, Ulkus duodeni, Zwölffingerdarmgeschwür
Czech Duodenální vřed, vředová choroba duodena, duodenální vřed, duodenum - vředy, dvanáctníkový vřed, duodenální vředy, dvanáctníkové vředy, ulcus duodeni
Korean 십이지장궤양
Polish Wrzód dwunastnicy, Wrzód Curlinga
Dutch DU, duodenum; ulcus, ulcus; duodenum, duodenumulcus, Ulcus duodeni, Duodenumulcus, Ulcus, duodenum-
Hungarian Duodenalis fekély, UD (ulcus duodeni), Duodenalis ulcus
Norwegian Tolvfingertarmsår, Duodenalsår, Ulcus duodeni
Italian Ulcera duodenale

Ontology: Peptic Ulcer (C0030920)

Definition (MEDLINEPLUS)

A peptic ulcer is a sore in the lining of your stomach or your duodenum, the first part of your small intestine. A burning stomach pain is the most common symptom. The pain

  • Starts between meals or during the night
  • Briefly stops if you eat or take antacids
  • Lasts for minutes to hours
  • Comes and goes for several days or weeks

Peptic ulcers happen when the acids that help you digest food damage the walls of the stomach or duodenum. The most common cause is infection with a bacterium called Helicobacter pylori. Another cause is the long-term use of nonsteroidal anti-inflammatory medicines (NSAIDs) such as aspirin and ibuprofen. Stress and spicy foods do not cause ulcers, but can make them worse.

To see if you have an H. pylori infection, your doctor will test your blood, breath, or stool. Your doctor also may look inside your stomach and duodenum by doing an endoscopy or x-ray.

Peptic ulcers will get worse if not treated. Treatment may include medicines to reduce stomach acids or antibiotics to kill H. pylori. Antacids and milk can't heal peptic ulcers. Not smoking and avoiding alcohol can help. You may need surgery if your ulcers don't heal.

NIH: National Institute of Diabetes and Digestive and Kidney Diseases

Definition (MSHCZE) Defekt (ulkus) ve sliznici žaludku či dvanáctníku, na jehož vzniku se uplatňuje žaludeční kyselina chlorovodíková a snížené obranné schopnosti sliznice. Přispívají k němu dědičné a psychické vlivy. Negativně působí i některé léky zejm. nesteroidní antirevmatika, kortikoidy a některá onemocnění (jaterní cirhóza). Významným patogenetickým faktorem je bakterie Helicobacter pylori. Základním příznakem je bolest, která u vředu na dvanáctníku je vázána na hlad (např. v noci) a po jídle se zmírňuje. Obtíže jsou často sezónní - zhoršují se na jaře a na podzim. V některých případech se objevují závažné akutní komplikace vředu: krvácení, perforace, penetrace, popř. vznik obstrukce. V diagnóze se uplatňuje zejm. gastroskopie, event. rentgenové metody. Léčba spočívá v podávání antiulcerózních látek (inhibitory protonové pumpy, H2-antagonisté v kombinaci s antibiotiky k eradikaci H. pylori; popř. se mohou podávat antacida či spasmolytika). Význam mají i režimová opatření. Účinná léčba snížila počet prováděných chirurgických zákroků. P. v. může recidivovat. Histologické vyšetření u p. v. v žaludku je nutné s ohledem na vyloučení event. karcinomu (zejm. při snížené aciditě). Příznaky podobné vředu mohou někdy být důsledkem funkční dyspepsie. (cit. Velký lékařský slovník online, 2013 http://lekarske.slovniky.cz/ )
Definition (NCI) A mucosal erosion that occurs in the esophagus, stomach or duodenum. Symptoms can include abdominal pain, nausea and vomiting, and bleeding.
Definition (NCI_NCI-GLOSS) A break in the lining of the lower part of the esophagus, the stomach, or the upper part of the small intestine. Peptic ulcers form when cells on the surface of the lining become inflamed and die. They are usually caused by Helicobacter pylori bacteria and by certain medicines, such as aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs). Peptic ulcers may be linked to cancer and other diseases.
Definition (MSH) Ulcer that occurs in the regions of the GASTROINTESTINAL TRACT which come into contact with GASTRIC JUICE containing PEPSIN and GASTRIC ACID. It occurs when there are defects in the MUCOSA barrier. The common forms of peptic ulcers are associated with HELICOBACTER PYLORI and the consumption of nonsteroidal anti-inflammatory drugs (NSAIDS).
Definition (CSP) local defect produced by the sloughing of inflammatory necrotic tissue that occurs in the regions of the gastrointestinal tract which come into contact with gastric juice; occurs when there are defects in the mucosa barrier; common forms of peptic ulcers are associated with Helicobacter pylori and the consumption of nonsteroidal antiinflammatory drugs.
Concepts Disease or Syndrome (T047)
MSH D010437
ICD9 533
ICD10 K27
SnomedCT 266437002, 155710009, 155701001, 196681007, 196704007, 266501005, 196705008, 196697002, 13200003
English Gastroduodenal Ulcer, Gastroduodenal Ulcers, Peptic Ulcer, Ulcer, Gastroduodenal, Ulcers, Gastroduodenal, Ulcers, Peptic, PEPTIC ULCER, PEPTIC ULCER DISEASE, Ulcer, Peptic, Peptic ulcer, site unspecified, Peptic ulcer - (PU) site unsp., Peptic ulcer - (PU) site unspecified, Peptic ulcer NOS, Unspecified peptic ulcer, Unspecified peptic ulcer NOS, gastroduodenal ulcer, peptic ulcer (diagnosis), peptic ulcer, Ulcer gastroduodenal, GDU, Peptic ulcer syndrome, Syndrome peptic ulcer, Ulcer syndrome peptic, Ulcer peptic, PUD, gastroduodenal ulcer NOS, peptic ulcer NOS, Peptic Ulcer [Disease/Finding], peptic ulcer disorder, peptic ulcer nos, Ulcer;peptic, ulcer of the gastrointestinal tract, peptic ulcer disease, peptic ulcers, Peptic ulcer - (PU) site unspecified (disorder), Peptic ulcer NOS (disorder), Peptic ulcer NOS = PU, Unspecified peptic ulcer NOS (disorder), Unspecified peptic ulcer (disorder), Peptic ulcer disease, Peptic ulcer, PU - Peptic ulcer, PUD - Peptic ulcer disease, Peptic ulceration, Gastroduodenal ulcer, Peptic ulcer (disorder), peptic; ulcer, ulcer; peptic, Gastroduodenal ulcer, NOS, Peptic ulcer, NOS, Peptic Ulcers, Peptic Ulcer Disease, Peptic ulcer; site unspecified
French ULCERE PEPTIQUE, Syndrome d'ulcère peptique, Maladie ulcéreuse gastrique, Ulcère peptique, site non précisé, Ulcération peptique, MUP, Ulcère gastroduodénal, Ulcère peptique, Ulcère gastro-duodénal, Ulcères gastro-duodénaux, Ulcères gastroduodénaux
Portuguese ULCERA PEPTICA, Doença de úlcera péptica, Úlcera péptica, localização NE, Síndrome de úlcera péptica, Ulceração péptica, Úlcera gastroduodenal, Úlcera péptica, Úlcera Gastroduodenal, Úlcera Péptica
Spanish ULCERA PEPTICA, Síndrome ulceroso péptico, Síndrome de úlcera péptica, Úlcera péptica de localización no especificada, UGD, Enfermedad ulcerosa péptica, Ulceración péptica, EUP, úlcera péptica - localización no especificada (trastorno), úlcera péptica no especificada (trastorno), úlcera péptica, SAI, úlcera péptica no especificada, SAI, úlcera péptica, SAI (trastorno), úlcera péptica - localización no especificada, úlcera péptica no especificada, úlcera péptica no especificada, SAI (trastorno), Peptic ulcer NOS, enfermedad pélvica ulcerosa, úlcera gastroduodenal, úlcera péptica (trastorno), úlcera péptica, Úlcera gastroduodenal, Úlcera péptica, Úlcera Gastroduodenal, Úlcera Péptica
Dutch peptisch ulcus plaats niet gespecificeerd, peptisch ulcus ziekte, peptisch ulcus syndroom, ulcus pepticum, ulcus pepticum syndroom, peptische ulceratie, ulcus gastroduodenaal, peptisch; ulcus, ulcus; peptisch, gastroduodenale ulcus, peptisch ulcus, Ulcus pepticum, lokalisatie niet gespecificeerd, Gastroduodenaal ulcus, Ulcus pepticum
German GDU, peptisches Ulkus, Stelle unspezifisch, Syndrom peptisches Ulkus, Ulkus peptisch, peptisches Ulkussyndrom, PUD, Ulkussyndrom peptisch, peptische Ulkuskrankheit, peptische Ulzeration, Ulkus, gastroduodenal, ULKUS PEPTICUM, Ulcus pepticum, Lokalisation nicht naeher bezeichnet, Gastroduodenalulkus, peptisches Ulkus, Ulcus gastroduodenale, Ulcus pepticum
Italian Ulcerazione peptica, Malattia ulcerosa peptica, Sindrome da ulcera peptica, Ulcera peptica, sito non specificato, Ulcera gastro-duodenale, Ulcera gastroduodenale, Ulcera peptica
Japanese 消化性潰瘍疾患, 部位不明の消化性潰瘍, 消化性潰瘍症候群, イジュウニシチョウカイヨウ, ショウカセイカイヨウシッカン, ショウカセイカイヨウ, ショウカセイカイヨウショウコウグン, ブイフメイノショウカセイカイヨウ, ストレス潰瘍, 辺縁性潰瘍, 辺縁潰瘍, 吻合口潰瘍, 吻合部潰瘍, 胃・十二指腸潰瘍, 術後空腸潰瘍, 吻合口縁辺潰瘍, 消化性潰瘍, 胃十二指腸潰瘍
Swedish Peptiskt sår
Czech peptický vřed, Gastroduodenální vřed, Peptický vřed, Vředová choroba, Syndrom peptického vředu, Peptický vřed blíže neurčené lokalizace
Finnish Peptinen haava
Korean 상세불명 부위의 소화성 궤양
Polish Wrzód brzeżny, Wrzód trawienny, Choroba wrzodowa
Hungarian PUD, Gyomor-patkóbél fekély, Peptikus fekély, Peptikus ulceratio, Gastroduodenalis fekély, Peptikus fekély szindróma, GDU, Peptikus fekélybetegség, Peptikus fekély, hely meghatározása nélkül, Peptikus fekély syndroma
Norwegian Peptisk ulcus, Peptisk sår

Ontology: Gastric ulcer (C0038358)

Definition (NCI) An ulcerated lesion in the mucosal surface of the stomach. It may progress to involve the deeper layers of the gastric wall.
Definition (NCI_CTCAE) A disorder characterized by a circumscribed, inflammatory and necrotic erosive lesion on the mucosal surface of the stomach.
Definition (MSH) Ulceration of the GASTRIC MUCOSA due to contact with GASTRIC JUICE. It is often associated with HELICOBACTER PYLORI infection or consumption of nonsteroidal anti-inflammatory drugs (NSAIDS).
Concepts Disease or Syndrome (T047)
MSH D013276
ICD9 531
ICD10 K25
SnomedCT 6034002, 196627009, 196642007, 196649003, 155681009, 266436006, 155690002, 196650003, 397825006
English Stomach Ulcer, Stomach Ulcers, Ulcers, Stomach, GASTRIC ULCER, STOMACH ULCER, ULCUS VENTRICULI, Ulcer, Stomach, Gastric ulcer NOS, Unspecified gastric ulcer, Unspecified gastric ulcer NOS, gastric ulcer (diagnosis), gastric ulcer, stomach ulcer, Ulcer gastric, Ulcer stomach, Ulcus ventriculi, Stomach Ulcer [Disease/Finding], Ulcer;gastric, Ulcer;stomach, gastric ulceration, gastric ulcer disease, gastric ulcers, ulcus ventriculi, gastric ulcerations, stomach ulcers, GU, Gastric ulcer - (GU), Unspecified gastric ulcer (disorder), Unspecified gastric ulcer NOS (disorder), Gastric ulcer NOS (disorder), Stomach--Ulcers, GU - Gastric ulcer, Gastric ulceration, Stomach ulcer, Gastric ulcer (disorder), stomach; ulcer, ulcer; gastric, Gastric ulcer, NOS, Stomach ulcer, NOS, Gastric Ulcer, Gastric Ulcers, Ulcers, Gastric, Ulcer, Gastric, Gastric ulcer
French ULCERE GASTRIQUE, Ulcère à l'estomac, UG, Ulcère gastrique, Ulcère de l'estomac
Portuguese ULCERA GASTRICA, Úlcera do estômago, ULCERADE ESTOMAGO, ULCUS VENTRICULI, Úlcera gástrica, Úlcera do Estômago, Úlcera Gástrica
Spanish ULCERA GASTRICA, Úlcera de estómago, Ulcus ventriculi, ULCERA DE ESTOMAGO, ULCUS VENTRICULI, UG, úlcera gástrica no especificada, SAI, úlcera de estómago, úlcera gástrica no especificada (trastorno), Gastric ulcer NOS, úlcera gástrica, SAI, úlcera gástrica, SAI (trastorno), úlcera gástrica no especificada, SAI (trastorno), úlcera gástrica no especificada, úlcera gástrica (trastorno), úlcera gástrica, Úlcera gástrica, Úlcera Gástrica, Úlcera del Estómago
German MAGENGESCHWUER, Geschwuer, Magen, MAGENULKUS, ULKUS VENTRICULI, GU, Magengeschwuer, Ulcus ventriculi, Magengeschwür
Dutch maagzweer, ulcus ventriculi, maag; ulcus, ulcus; maag, maagulcus, Maagulcus, Ulcus ventriculi, Ulcus, maag-, Maagzweer, Zweer, maag-
Swedish Magsår
Japanese イカイヨウ, 胃潰瘍, 胃かいよう
Finnish Mahahaava
Czech Žaludeční vřed, žaludeční vředy, vředová choroba žaludku, žaludek - vředy
Italian Ulcera gastrica, Ulcera dello stomaco
Korean 위궤양
Polish Choroba wrzodowa żołądka, Wrzód żołądka
Hungarian Gyomor fekélye, Gyomorfekély, GU
Norwegian Ventrikkelulcus, Ulcus ventriculi, Magesår