Peptic Ulcer Disease | MRCEM EXPERT

Peptic Ulcer Summary

Main Causes

H. pylori (95% duodenal, 70-80% gastric)
NSAIDs/aspirin
Smoking & alcohol
Stress

Key Symptoms

Epigastric pain/discomfort
Heartburn/acid reflux
Nausea/vomiting
Dyspepsia ≥4 weeks

Red Flags

Age ≥60 years
≥55 with weight loss
Requires urgent endoscopy
Exclude malignancy

H. pylori Treatment

First-line: PPI + Amoxicillin + Clarithromycin
Penicillin allergy: PPI + Clarithromycin + Metronidazole
7-day triple therapy

Investigations

Endoscopy (gold standard)
Urea breath test
Stool antigen test
Stop PPIs 2 weeks before testing

Complications

Bleeding (5-10% mortality)
Perforation (20% mortality)
Gastric outlet obstruction
Increased cancer risk

Definition

Peptic ulcer disease describes a breach in the epithelium of the gastric or duodenal mucosa that penetrates the muscularis mucosae, confirmed on endoscopy (typically >5mm in diameter with depth to submucosa).

Risk Factors

Major Factors

H. pylori infection (95% duodenal, 70-80% gastric ulcers)
NSAIDs/aspirin (4x risk with NSAIDs, 2x with aspirin)

Other Factors

Smoking
Alcohol consumption
Stress
Other medications (bisphosphonates, corticosteroids, SSRIs)
Zollinger-Ellison syndrome (rare)

Clinical Features

Dyspepsia (≥4 weeks duration):
- Epigastric pain/discomfort
- Heartburn/acid reflux
- Nausea/vomiting
May have epigastric tenderness
Often no physical signs

Red flags: Age ≥60 years (≥55 with weight loss) requires urgent endoscopy to exclude malignancy.

Differential Diagnosis

GI Causes

GORD
Functional dyspepsia
Upper GI malignancy
Gallbladder disease

Other Systems

Pancreatic disease
Cardiac disease
Coeliac disease
AAA (rare)

Investigations

Endoscopy: Gold standard for diagnosis (required for those ≥60 years or with alarm symptoms)
H. pylori testing:
- Urea breath test or stool antigen test (preferred)
- Serology if others unavailable
- Note: Stop PPIs 2 weeks, antibiotics 4 weeks before testing

Management

Lifestyle Measures

Weight loss if overweight
Avoid trigger foods (coffee, chocolate, spicy/fatty foods)
Smaller, earlier evening meals
Smoking cessation
Reduce alcohol
Stress management

Medication Review

Stop NSAIDs completely if possible. Consider reducing/stopping other ulcerogenic drugs (aspirin, bisphosphonates, corticosteroids, SSRIs).

H. pylori Positive

With NSAID Use

Full-dose PPI for 2 months
Then eradication therapy

Without NSAID Use

First-line eradication therapy only

First-line Eradication Therapy

Scenario	Treatment Regimen	Duration
Standard therapy	PPI twice daily + Amoxicillin 1g twice daily + Clarithromycin 500mg twice daily	7 days
Penicillin allergy	PPI + Clarithromycin + Metronidazole	7 days
Penicillin allergy + previous Clarithromycin	PPI + Metronidazole + Tetracycline + Bismuth	7-14 days

H. pylori Negative

Full-dose PPI for 4-8 weeks

Follow-up: Repeat endoscopy at 6-8 weeks for gastric ulcers to confirm healing and re-test H. pylori if appropriate.

Complications

Bleeding

Acute hemorrhage (5-10% mortality)
Chronic blood loss → iron deficiency

Perforation

Peritonitis (up to 20% mortality)

Other

Gastric outlet obstruction
Increased gastric cancer risk (H. pylori+)