Peptic ulcer disease

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Most peptic ulcers are in the duodenum.[1]


History and physical examination

One study found that the best predictions of abnormal investigations were: history of an ulcer, age 50 or more, pain better with food or milk, pain occurs < one hour after eating. [2]

If the ulcer is in the duodenum, the pain may be relieved by eating; whereas eating may exacerbate the pain of a gastric ulcer.[3][4][1][2] As most ulcers are duodenal, in general eating relieves ulcer pain.

Some patients may have chest symptoms such as heartburn or reflux.[5][6]

On physical examination, pallor of conjunctiva, nail-bed or palmar crease, or the absence of nail-bed blanching are predictive of significant anemia (hemoglobin less than 12 gm/dl).[7]

Laboratory testing

The accuracy of the H. pylori breath test for detecting peptic ulcer disease is:[8]


Users of nonsteroidal anti-inflammatory (NSAID) medications

Patients with a history of bleeding ulcer have a 26% rate of ulcers with NSAIDs.[9] Patients with H. pylori have 2.5 risk of an ulcer on NSAIDs.[10]

For patients starting long-term NSAIDs, screening for H. pylori with a breath test among patients with prior ulcer or dyspepsia and treating positive patients reduced subsequent rate of ulcers.[11] [12]

For patients who must take NSAIDs, proton pump inhibitors may be effective in preventing dyspepsia.[13]


  1. 1.0 1.1 Möllmann KM, Bonnevie O, Gudbrand Höyer E, Wulff HR (1975). "A diagnostic study of patients with upper abdominal pain". Scand. J. Gastroenterol. 10 (8): 805–9. PMID 1202611[e]
  2. 2.0 2.1 Marton KI, Sox HC, Wasson J, Duisenberg CE (1980). "The clinical value of the upper gastrointestinal tract roentgenogram series". Arch. Intern. Med. 140 (2): 191–5. PMID 7352814[e]
  3. Carlsson R, Dent J, Bolling-Sternevald E, et al (1998). "The usefulness of a structured questionnaire in the assessment of symptomatic gastroesophageal reflux disease". Scand. J. Gastroenterol. 33 (10): 1023–9. PMID 9829354[e]
  4. Möllmann KM, Bonnevie O, Gudmand-Höyer E, Wulff HR (1976). "Nosography of X-ray negative dyspepsia". Scand. J. Gastroenterol. 11 (2): 193–7. PMID 1265440[e]
  5. Talley NJ, Weaver AL, Tesmer DL, Zinsmeister AR (1993). "Lack of discriminant value of dyspepsia subgroups in patients referred for upper endoscopy". Gastroenterology 105 (5): 1378–86. PMID 8224642[e]
  6. Johnsen R, Bernersen B, Straume B, Førde OH, Bostad L, Burhol PG (1991). "Prevalences of endoscopic and histological findings in subjects with and without dyspepsia". BMJ 302 (6779): 749–52. PMID 2021764[e] Fulltext
  7. Nardone DA, Roth KM, Mazur DJ, McAfee JH (1990). "Usefulness of physical examination in detecting the presence or absence of anemia". Arch. Intern. Med. 150 (1): 201–4. PMID 2297289[e]
  8. McColl KE, el-Nujumi A, Murray L, et al (1997). "The Helicobacter pylori breath test: a surrogate marker for peptic ulcer disease in dyspeptic patients". Gut 40 (3): 302–6. PMID 9135516[e]
  9. Spiegel BM, Targownik L, Dulai GS, Gralnek IM (2003). "The cost-effectiveness of cyclooxygenase-2 selective inhibitors in the management of chronic arthritis". Ann. Intern. Med. 138 (10): 795–806. PMID 12755551[e]
  10. Huang JQ, Sridhar S, Hunt RH (2002). "Role of Helicobacter pylori infection and non-steroidal anti-inflammatory drugs in peptic-ulcer disease: a meta-analysis". Lancet 359 (9300): 14–22. PMID 11809181[e]
  11. Chan FK, To KF, Wu JC, et al (2002). "Eradication of Helicobacter pylori and risk of peptic ulcers in patients starting long-term treatment with non-steroidal anti-inflammatory drugs: a randomised trial". Lancet 359 (9300): 9–13. PMID 11809180[e]
  12. Chan FK, Sung JJ, Chung SC, et al (1997). "Randomised trial of eradication of Helicobacter pylori before non-steroidal anti-inflammatory drug therapy to prevent peptic ulcers". Lancet 350 (9083): 975–9. PMID 9329511[e]
  13. Spiegel BM, Farid M, Dulai GS, Gralnek IM, Kanwal F (2006). "Comparing rates of dyspepsia with Coxibs vs NSAID+PPI: a meta-analysis". Am. J. Med. 119 (5): 448.e27–36. DOI:10.1016/j.amjmed.2005.11.020. PMID 16651060. Research Blogging.