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For further information, see CMDT Part 15-23: Peptic Ulcer Disease

Key Features

Essentials of Diagnosis

  • History of dyspepsia in 80–90% with variable relationship to meals

  • Ulcer symptoms are characterized by rhythmicity and periodicity

  • Ulcer complications without antecedent symptoms occur in 10–20%

  • Most nonsteroidal anti-inflammatory drug (NSAID)-induced ulcers are asymptomatic

  • Upper endoscopy with gastric biopsy for Helicobacter pylori is diagnostic

  • Gastric ulcer biopsy or documentation of complete healing is necessary to exclude gastric malignancy

General Considerations

  • Peptic ulcer is a break in the gastric or duodenal mucosa, extending through the muscularis mucosa, and usually > 5 mm in diameter

  • In the stomach, benign ulcers are most common

    • In the antrum (60%)

    • At the junction of the antrum and body on the lesser curvature (25%)

  • Major causes of peptic ulcer disease

    • NSAIDs

    • Chronic H pylori infection

  • Less than 5–10% of ulcers are caused by other conditions, including

    • Acid hypersecretory states such as Zollinger-Ellison syndrome or systemic mastocytosis

    • Cytomegalovirus (especially in transplant recipients)

    • Crohn disease

    • Lymphoma

    • Medications (eg, alendronate)

    • Chronic medical illness (cirrhosis or chronic kidney disease)

  • Up to 10% of ulcers are idiopathic

  • In duodenal ulcer patients, prevalence of H pylori infection is ~70–90%; however, ulcers develop in only about 10% of infected persons

  • In persons who take NSAIDs long-term, prevalence of gastric ulcers is 10–20% and duodenal ulcers is 2–5%

  • H pylori infection increases risk of NSAID-induced ulcers and complications


  • In the United States, ~500,000 new ulcer cases and 4 million ulcer recurrences per year

  • Incidence of duodenal ulcer disease has been declining dramatically for the past 30 years (due to the eradication of H pylori)

  • However, the incidence of gastric ulcers has not been declining (due to the widespread use of NSAIDs and low-dose aspirin)

  • Lifetime prevalence of ulcers in adults is ~10%

  • Duodenal ulcers are most common between the ages of 30 and 55

  • Gastric ulcers are most common between the ages of 55 and 70

Clinical Findings

Symptoms and Signs

  • Epigastric pain (dyspepsia)

    • Present in 80–90% of persons, but such pain is not sensitive or specific enough to serve as a reliable diagnostic criterion

    • Typically well localized to epigastrium and not severe

    • Described as gnawing, dull, aching, or "hunger-like"

    • Relieved by food or antacids in about 50%

  • Ulcer complications, such as bleeding, occur in 20% with no antecedent symptoms ("silent ulcers")

  • Nocturnal pain awakens two-thirds of patients with duodenal ulcers and one-third of patients with gastric ulcers

  • Most patients have symptomatic periods lasting several weeks with intervals of months to years in which they are pain free (periodicity)

  • Nausea and anorexia

  • Significant vomiting and weight loss suggest gastric outlet obstruction or gastric malignancy

  • Physical examination often normal

  • Mild, localized epigastric tenderness to deep palpation

Differential Diagnosis


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