Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Peptic Ulcer Disease Workup

  • Author: BS Anand, MD; Chief Editor: Julian Katz, MD  more...
 
Updated: Jan 09, 2015
 

Approach Considerations

Testing for H pylori infection is essential in all patients with peptic ulcers. In most patients with uncomplicated peptic ulcer disease (PUD), routine laboratory tests usually are not helpful. Documentation of PUD depends on radiographic and endoscopic confirmation.

If the diagnosis of PUD is suspected, obtaining CBC count, liver function tests (LFTs), amylase, and lipase may be useful. CBC count and iron studies can help detect anemia, which is an alarm signal that mandates early endoscopy to rule out other sources of chronic GI blood loss.

H pylori Testing

Testing for H pylori infection is essential in all patients with peptic ulcers.

Endoscopic or invasive tests for H pylori include a rapid urease test, histopathology, and culture. Rapid urease tests are considered the endoscopic diagnostic test of choice. The presence of H pylori in gastric mucosal biopsy specimens is detected by testing for the bacterial product urease. Fecal antigen testing identifies active H pylori infection by detecting the presence of H pylori antigens in stools. This test is more accurate than antibody testing and is less expensive than urea breath tests.

Three kits (ie, CLOtest, Hp-fast, Pyloritek) are commercially available for H pylori testing, and each contains a combination of a urea substrate and a pH sensitive indicator. One or more gastric biopsy specimens are placed in the rapid urease test kit. If H pylori is present, bacterial urease converts urea to ammonia, which changes the pH, resulting in a color change.

Urea breath tests detect active H pylori infection by testing for the enzymatic activity of bacterial urease. In the presence of urease produced by H pylori, labeled carbon dioxide (heavy isotope, carbon-13, or radioactive isotope, carbon-14) is produced in the stomach, absorbed into the bloodstream, diffused into the lungs, and exhaled.

Obtain histopathology, often considered the criterion standard to establish a diagnosis of H pylori infection , if the rapid urease test result is negative and a high suspicion for H pylori persists (presence of a duodenal ulcer).

Antibodies (immunoglobulin G [IgG]) to H pylori can be measured in serum, plasma, or whole blood. Results with whole blood tests obtained from finger sticks are less reliable.

Next

Endoscopy

Upper GI endoscopy is the preferred diagnostic test in the evaluation of patients with suspected PUD. It is highly sensitive for the diagnosis of gastric and duodenal ulcers, allows for biopsies and cytologic brushings in the setting of a gastric ulcer to differentiate a benign ulcer from a malignant lesion, and allows for the detection of H pylori infection with antral biopsies for a rapid urease test and/or histopathology in patients with PUD. (See the images below.)

At endoscopy, gastric ulcers appear as discrete mucosal lesions with a punched-out smooth ulcer base, which often is filled with whitish fibrinoid exudate. Ulcers tend to be solitary and well circumscribed and usually are 0.5-2.5 cm in diameter. Most gastric ulcers tend to occur at the junction of the fundus and antrum, along the lesser curvature. Benign ulcers tend to have a smooth, regular, rounded edge with a flat smooth base and surrounding mucosa that shows radiating folds. Malignant ulcers usually have irregular heaped-up or overhanging margins. The ulcerated mass often protrudes into the lumen, and the folds surrounding the ulcer crater are often nodular and irregular.

Gastric ulcer with punched-out ulcer base with whi Gastric ulcer with punched-out ulcer base with whitish fibrinoid exudates.
Gastric ulcer (lesser curvature) with punched-out Gastric ulcer (lesser curvature) with punched-out ulcer base with whitish exudate.
Gastric cancer. Note the irregular heaped up overh Gastric cancer. Note the irregular heaped up overhanging margins.
Gastric cancer with ulcerated mass. Gastric cancer with ulcerated mass.

More than 95% of duodenal ulcers are found in the first part of the duodenum; most are less than 1 cm in diameter.[24] Duodenal ulcers are characterized by the presence of a well-demarcated break in the mucosa that may extend into the muscularis propria of the duodenum (see the images below).

Gastric cancer with ulcerated mass. Gastric cancer with ulcerated mass.
Endoscope view of an ulcer (at upper center) in th Endoscope view of an ulcer (at upper center) in the wall of the duodenum, the first part of the small intestine. This ulcer is an open sore. Image courtesy of Science Source | Gastrolab.
Duodenal ulcer in a 65-year-old man with osteoarth Duodenal ulcer in a 65-year-old man with osteoarthritis who presented with hematemesis and melena stools. The patient took naproxen on a daily basis.

A meta-analysis has shown that for individuals who undergo endoscopy for dyspepsia, the most common finding is erosive esophagitis (though prevalence was lower when the Rome criteria were used to define dyspepsia) followed by peptic ulcer.[25]

Previous
Next

Radiography

In patients presenting acutely, a chest radiograph may be useful to detect free abdominal air when perforation is suspected. On upper GI contrast study with water-soluble contrast, the extravasation of contrast indicates gastric perforation.

Double-contrast radiography performed by an experienced radiologist may approach the diagnostic accuracy of upper GI endoscopy. However, it has been replaced largely by diagnostic endoscopy, when available. An upper GI series is not as sensitive as endoscopy for establishing a diagnosis of small ulcers (< 0.5 cm). It also does not allow for obtaining a biopsy to rule out malignancy in the setting of a gastric ulcer or to assess for H pylori infection in the setting of a gastroduodenal ulcer.

Previous
Next

Angiography

Angiography may be necessary in patients with a massive GI bleed in whom endoscopy cannot be performed. An ongoing bleeding rate of 0.5 mL/min or more is needed for the angiography to be able to accurately identify the bleeding source. Angiography can depict the source of the bleeding and can help provide needed therapy in the form of a direct injection of vasoconstrictive agents.

Previous
Next

Serum Gastrin Level

A fasting serum gastrin level should be obtained in certain cases to screen for Zollinger-Ellison syndrome. Such cases include the following:

  • Patients with multiple ulcers
  • Ulcers occurring distal to the duodenal bulb
  • Strong family history of PUD
  • Peptic ulcer associated with diarrhea, steatorrhea, or weight loss
  • Peptic ulcer not associated with H pylori infection or NSAID use
  • Peptic ulcer associated with hypercalcemia or renal stones
  • Ulcer refractory to medical therapy
  • Ulcer recurring after surgery
Previous
Next

Secretin Stimulation Test

A secretin stimulation test may be required if the diagnosis of Zollinger-Ellison syndrome cannot be made on the basis of the serum gastrin level alone. This test can distinguish Zollinger-Ellison syndrome from other conditions with a high serum gastrin level, such as use of antisecretory therapy with a proton pump inhibitor, renal failure, or gastric outlet obstruction.

Previous
Next

Biopsy

A single biopsy offers 70% accuracy in diagnosing gastric cancer, but 7 biopsy samples obtained from the base and ulcer margins increase the sensitivity to 99%. Brush cytology has been shown to increase the biopsy yield, and this method may be useful particularly when bleeding is a concern in a patient with coagulopathy.

Previous
Next

Histologic Findings

The histology of gastric ulcer depends on its chronicity. The surface is covered with slough and inflammatory debris. Beneath this neutrophilic infiltration, active granulation with mononuclear leukocytic infiltration and fibrinoid necrosis may be seen. In chronic superficial gastritis, lymphocytes, monocytes, and plasma cells often infiltrate the mucosa and submucosa.

Previous
Next

Emergency Department Workup

The ED workup will vary depending on presentation and includes the following:

  • Complete blood count is used to evaluate acute or chronic blood loss.
  • Electrolytes, BUN, and creatinine levels are useful tests for critical-appearing patients who require fluid resuscitation.
  • Type and screen and crossmatched blood for transfusion is indicated in unstable or potentially critical patients.
  • aPTT, PT, and INR are indicated in patients with active bleeding and those on anticoagulants.
  • Amylase, lipase, and liver transaminase levels can be helpful to rule out other common causes of epigastric pain.
  • Patients younger than 55 years with no alarm features should be referred for noninvasive testing for H pylori infection in the outpatient setting. [1]
Previous
 
 
Contributor Information and Disclosures
Author

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Acknowledgements

Faisal Aziz, MD Assistant Professor of Surgery, Divsion of Vascular and Endovascular Surgery, Department of Surgery, Pennsylvania State University College of Medicine

Faisal Aziz, MD is a member of the following medical societies: American College of Surgeons and American Medical Association

Disclosure: Nothing to disclose.

Simmy Bank, MD Chair, Professor, Department of Internal Medicine, Division of Gastroenterology, Long Island Jewish Hospital, Albert Einstein College of Medicine

Disclosure: Nothing to disclose.

Jeffrey Glenn Bowman, MD, MS Consulting Staff, Highfield MRI

Disclosure: Nothing to disclose.

Carmen Cuffari, MD Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine

Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Brian James Daley, MD, MBA, FACS, FCCP, CNSC Professor and Program Director, Department of Surgery, Chief, Division of Trauma and Critical Care, University of Tennessee Health Science Center College of Medicine

Brian James Daley, MD, MBA, FACS, FCCP, CNSC is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Chest Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Association for Surgical Education, Eastern Association for the Surgery of Trauma, Shock Society, Society of Critical Care Medicine, Southeastern Surgical Congress, and Tennessee Medical Association

Disclosure: Nothing to disclose.

Shane M Devlin, MD, FRCP(C) Clinical Assistant Professor, Department of Internal Medicine, Peter Lougheed Center, University of Calgary, Canada

Shane M Devlin, MD, FRCP(C) is a member of the following medical societies: American Gastroenterological Association, Canadian Association of Gastroenterology, Canadian Medical Association, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Steven C Dronen, MD, FAAEM Chair, Department of Emergency Medicine, LeConte Medical Center

Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

George T Fantry, MD Associate Professor of Medicine, Department of Internal Medicine, Division of Gastroenterology, University of Maryland School of Medicine

George T Fantry, MD is a member of the following medical societies: American College of Gastroenterology and American Gastroenterological Association

Disclosure: Nothing to disclose.

John Geibel, MD, DSc, MA Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital

John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract

Disclosure: AMGEN Royalty Consulting; Ardelyx Ownership interest Board membership

David Greenwald, MD Associate Professor of Clinical Medicine, Fellowship Program Director, Department of Medicine, Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine

David Greenwald, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, and New York Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Harsh Grewal, MD, FACS, FAAP Clinical Professor of Surgery, Temple University School of Medicine; Chief, Division of Pediatric Surgery, Cooper University Hospital

Harsh Grewal, MD, FACS, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Association for Surgical Education, Children's Oncology Group, Eastern Association for the Surgery of Trauma, International Pediatric Endosurgery Group, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons, and SouthwesternSurgical Congress

Disclosure: Nothing to disclose.

Eugene Hardin, MD, FAAEM, FACEP Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center

Disclosure: Nothing to disclose.

Andre Hebra, MD Chief, Division of Pediatric Surgery, Professor of Surgery and Pediatrics, Medical University of South Carolina College of Medicine; Surgeon-in-Chief, Medical University of South Carolina Children's Hospital

Andre Hebra, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Children's Oncology Group, Florida Medical Association, International Pediatric Endosurgery Group, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons,South Carolina Medical Association, Southeastern Surgical Congress, and Southern Medical Association

Disclosure: Nothing to disclose.

Juda Zvi Jona MD, FAAP(s), FACS, EUPSA, Clinical Professor of Surgery, Michigan State University College of Human Medicine; Clinical Professor of Surgery, Northwestern University, The Feinberg School of Medicine; Attending Senior Surgeon, Director of Pediatric Surgery Service, Surgical Executive Committee, Sparrow Hospital

Juda Zvi Jona is a member of the following medical societies: Alpha Omega Alpha, American Bronchoesophagological Association, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Association for Academic Surgery, British Association of Paediatric Surgeons, Central Surgical Association, Children's Oncology Group, and International Pediatric Endosurgery Group

Disclosure: Nothing to disclose.

Daryl Lau, MD, MPH, MSc, FRCP(C) Director of Translational Liver Research, Liver Center, Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center; Associate Professor of Medicine, Harvard Medical School

Daryl Lau, MD, MPH, MSc, FRCP(C) is a member of the following medical societies: American Association for the Study of Liver Diseases and American Gastroenterological Association

Disclosure: Nothing to disclose.

Tri H Le, MD Assistant Professor of Medicine, Division of Gastroenterology and Hepatology, Penn State Milton S Hershey Medical Center

Tri H Le, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, American Society of Gastrointestinal Endoscopy, and Crohns and Colitis Foundation of America

Disclosure: Nothing to disclose.

Terence David Lewis, MBBS, FRACP, FRCPC, FACP Program Director, Internal Medicine Residency, & Assistant Chairman, Associate Professor, Department of Internal Medicine, Division of Gastroenterology, Loma Linda University Medical Center

Terence David Lewis, MBBS, FRACP, FRCPC, FACP is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Medical Association, California Medical Association, Royal College of Physicians and Surgeons of Canada, and Sigma Xi

Disclosure: Nothing to disclose.

B UK Li, MD Professor of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Director, Pediatric Fellowships and Gastroenterology Fellowship, Medical Director, Functional Gastrointestinal Disorders and Cyclic Vomiting Program, Medical College of Wisconsin; Attending Gastroenterologist, Children's Hospital of Wisconsin

B UK Li, MD is a member of the following medical societies: Alpha Omega Alpha, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

Chris A Liacouras MD, Director of Pediatric Endoscopy, Division of Gastroenterology and Nutrition, Children's Hospital of Philadelphia; Associate Professor of Pediatrics, University of Pennsylvania School of Medicine

Chris A Liacouras is a member of the following medical societies: American Gastroenterological Association

Disclosure: Nothing to disclose.

Wendi S Miller, MD Resident Physician, Department of Emergency Medicine, Emory University School of Medicine

Wendi S Miller, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Southern Medical Association

Disclosure: Nothing to disclose.

Robert K Minkes, MD, PhD Professor of Surgery, University of Texas Southwestern Medical Center at Dallas, Southwestern Medical School; Medical Director and Chief of Surgical Services, Children's Medical Center of Dallas-Legacy Campus

Robert K Minkes, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Waqar A Qureshi, MD Associate Professor of Medicine, Chief of Endoscopy, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine and Veterans Affairs Medical Center

Waqar A Qureshi, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Erick F Rivas, MD, PT Resident Physician, Department of Surgery, Michigan State University College of Human Medicine

Erick F Rivas, MD, PT is a member of the following medical societies: American College of Surgeons

Disclosure: Nothing to disclose.

Ameesh Shah, MD Assistant Professor of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Memorial Hospital

Ameesh Shah, MD is a member of the following medical societies: North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

Philip Shayne MD, Associate Professor, Program Director and Vice Chair for Education, Department of Emergency Medicine, Emory University School of Medicine

Philip Shayne is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Sanjeeb Shrestha, MD Consulting Staff, Division of Gastroenterology, Gastroenterology Care Consultants

Sanjeeb Shrestha, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, and American Society of Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Mutaz I Sultan, MBChB Makassed Hospital, Israel

Mutaz I Sultan, MBChB is a member of the following medical societies: American Gastroenterological Association and North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Alan BR Thomson, MD Professor of Medicine, Division of Gastroenterology, University of Alberta, Canada

Alan BR Thomson, MD is a member of the following medical societies: Alberta Medical Association, American College of Gastroenterology, American Gastroenterological Association, Canadian Association of Gastroenterology, Canadian Medical Association, College of Physicians and Surgeons of Alberta, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Noel Williams, MD Professor Emeritus, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Professor, Department of Internal Medicine, Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada

Noel Williams, MD is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Jay A Yelon, DO, FACS Associate Professor of Surgery and Anesthesiology, Program Director, Surgical Critical Care Fellowship, New York Medical College; Chief, Division of Trauma and Surgical Critical Care, Westchester Medical Center

Jay A Yelon, DO, FACS is a member of the following medical societies: American Association for the Surgery of Trauma, American Burn Association, American College of Surgeons, American Trauma Society, Association for Academic Surgery, Eastern Association for the Surgery of Trauma, Pan American Trauma Society, Shock Society, Society of Critical Care Medicine, Southeastern Surgical Congress, and Surgical Infection Society

Disclosure: Nothing to disclose.

References
  1. Chey WD, Wong BC. American College of Gastroenterology guideline on the management of Helicobacter pylori infection. Am J Gastroenterol. 2007 Aug. 102(8):1808-25. [Medline].

  2. Javid G, Zargar SA, U-Saif R, Khan BA, Yatoo GN, Shah AH, et al. Comparison of p.o. or i.v. proton pump inhibitors on 72-h intragastric pH in bleeding peptic ulcer. J Gastroenterol Hepatol. 2009 Jul. 24(7):1236-43. [Medline].

  3. Lai KC, Lam SK, Chu KM, Wong BC, Hui WM, Hu WH, et al. Lansoprazole for the prevention of recurrences of ulcer complications from long-term low-dose aspirin use. N Engl J Med. 2002 Jun 27. 346(26):2033-8. [Medline].

  4. Lai KC, Lam SK, Chu KM, Hui WM, Kwok KF, Wong BC, et al. Lansoprazole reduces ulcer relapse after eradication of Helicobacter pylori in nonsteroidal anti-inflammatory drug users--a randomized trial. Aliment Pharmacol Ther. 2003 Oct 15. 18(8):829-36. [Medline].

  5. Sung JJ, Tsoi KK, Ma TK, Yung MY, Lau JY, Chiu PW. Causes of mortality in patients with peptic ulcer bleeding: a prospective cohort study of 10,428 cases. Am J Gastroenterol. 2010 Jan. 105(1):84-9. [Medline].

  6. Pietroiusti A, Luzzi I, Gomez MJ, Magrini A, Bergamaschi A, Forlini A, et al. Helicobacter pylori duodenal colonization is a strong risk factor for the development of duodenal ulcer. Aliment Pharmacol Ther. 2005 Apr 1. 21(7):909-15. [Medline].

  7. Laine L, Curtis SP, Cryer B, Kaur A, Cannon CP. Risk factors for NSAID-associated upper GI clinical events in a long-term prospective study of 34 701 arthritis patients. Aliment Pharmacol Ther. 2010 Nov. 32(10):1240-8. [Medline].

  8. Ruigomez A, Johansson S, Nagy P, Martín-Perez M, Rodriguez LA. Risk of uncomplicated peptic ulcer disease in a cohort of new users of low-dose acetylsalicylic acid for secondary prevention of cardiovascular events. BMC Gastroenterol. 2014 Dec 10. 14(1):205. [Medline].

  9. Vergara M, Catalán M, Gisbert JP, Calvet X. Meta-analysis: role of Helicobacter pylori eradication in the prevention of peptic ulcer in NSAID users. Aliment Pharmacol Ther. 2005 Jun 15. 21(12):1411-8. [Medline].

  10. Berezin SH, Bostwick HE, Halata MS, Feerick J, Newman LJ, Medow MS. Gastrointestinal bleeding in children following ingestion of low-dose ibuprofen. J Pediatr Gastroenterol Nutr. 2007 Apr. 44(4):506-8. [Medline].

  11. Gulmez SE, Lassen AT, Aalykke C, Dall M, Andries A, Andersen BS, et al. Spironolactone use and the risk of upper gastrointestinal bleeding: a population-based case-control study. Br J Clin Pharmacol. 2008 Aug. 66(2):294-9. [Medline]. [Full Text].

  12. Lewis JD, Strom BL, Localio AR, Metz DC, Farrar JT, Weinrieb RM, et al. Moderate and high affinity serotonin reuptake inhibitors increase the risk of upper gastrointestinal toxicity. Pharmacoepidemiol Drug Saf. 2008 Apr. 17(4):328-35. [Medline].

  13. Aldoori WH, Giovannucci EL, Stampfer MJ, Rimm EB, Wing AL, Willett WC. A prospective study of alcohol, smoking, caffeine, and the risk of duodenal ulcer in men. Epidemiology. 1997 Jul. 8(4):420-4. [Medline].

  14. Sonnenberg A, Müller-Lissner SA, Vogel E, Schmid P, Gonvers JJ, Peter P, et al. Predictors of duodenal ulcer healing and relapse. Gastroenterology. 1981 Dec. 81(6):1061-7. [Medline].

  15. Koivisto TT, Voutilainen ME, Färkkilä MA. Effect of smoking on gastric histology in Helicobacter pylori-positive gastritis. Scand J Gastroenterol. 2008. 43(10):1177-83. [Medline].

  16. Schubert ML, Peura DA. Control of gastric acid secretion in health and disease. Gastroenterology. 2008 Jun. 134(7):1842-60. [Medline].

  17. Yuan XG, Xie C, Chen J, Xie Y, Zhang KH, Lu NH. Seasonal changes in gastric mucosal factors associated with peptic ulcer bleeding. Exp Ther Med. 2015 Jan. 9(1):125-130. [Medline]. [Full Text].

  18. Cai S, García Rodríguez LA, Massó-González EL, Hernández-Díaz S. Uncomplicated peptic ulcer in the UK: trends from 1997 to 2005. Aliment Pharmacol Ther. 2009 Nov 15. 30(10):1039-48. [Medline].

  19. Leontiadis GI, Sreedharan A, Dorward S, Barton P, Delaney B, Howden CW, et al. Systematic reviews of the clinical effectiveness and cost-effectiveness of proton pump inhibitors in acute upper gastrointestinal bleeding. Health Technol Assess. 2007 Dec. 11(51):iii-iv, 1-164. [Medline].

  20. Bardou M, Toubouti Y, Benhaberou-Brun D, Rahme E, Barkun AN. High dose proton pump inhibition decrease both re-bleeding and mortality in high-risk patients with acute peptic ulcer bleeding. Gastroenterology. 2003. 123(suppl 1):A625.

  21. Bardou M, Youssef M, Toubouti Y, et al. Newer endoscopic therapies decrease both re-bleeding and mortality in high risk patients with acute peptic ulcer bleeding: a series of meta-analyses [abstract]. Gastroenterology. 2003. 123:A239.

  22. Gisbert JP, Pajares R, Pajares JM. Evolution of Helicobacter pylori therapy from a meta-analytical perspective. Helicobacter. 2007 Nov. 12 Suppl 2:50-8. [Medline].

  23. Svanes C, Lie RT, Svanes K, Lie SA, Søreide O. Adverse effects of delayed treatment for perforated peptic ulcer. Ann Surg. 1994 Aug. 220(2):168-75. [Medline]. [Full Text].

  24. Ramakrishnan K, Salinas RC. Peptic ulcer disease. Am Fam Physician. 2007 Oct 1. 76(7):1005-12. [Medline].

  25. Ford AC, Marwaha A, Lim A, Moayyedi P. What is the prevalence of clinically significant endoscopic findings in subjects with dyspepsia? Systematic review and meta-analysis. Clin Gastroenterol Hepatol. 2010 Oct. 8(10):830-7, 837.e1-2. [Medline].

  26. Zullo A, Hassan C, Campo SM, Morini S. Bleeding peptic ulcer in the elderly: risk factors and prevention strategies. Drugs Aging. 2007. 24(10):815-28. [Medline].

  27. Udd M, Miettinen P, Palmu A, Heikkinen M, Janatuinen E, Pasanen P, et al. Analysis of the risk factors and their combinations in acute gastroduodenal ulcer bleeding: a case-control study. Scand J Gastroenterol. 2007 Dec. 42(12):1395-403. [Medline].

  28. Wang HM, Hsu PI, Lo GH, Chen TA, Cheng LC, Chen WC, et al. Comparison of hemostatic efficacy for argon plasma coagulation and distilled water injection in treating high-risk bleeding ulcers. J Clin Gastroenterol. 2009 Nov-Dec. 43(10):941-5. [Medline].

  29. Larssen L, Moger T, Bjørnbeth BA, Lygren I, Kløw NE. Transcatheter arterial embolization in the management of bleeding duodenal ulcers: a 5.5-year retrospective study of treatment and outcome. Scand J Gastroenterol. 2008. 43(2):217-22. [Medline].

  30. Travis AC, Wasan SK, Saltzman JR. Model to predict rebleeding following endoscopic therapy for non-variceal upper gastrointestinal hemorrhage. J Gastroenterol Hepatol. 2008 Oct. 23(10):1505-10. [Medline].

  31. Elmunzer BJ, Young SD, Inadomi JM, Schoenfeld P, Laine L. Systematic review of the predictors of recurrent hemorrhage after endoscopic hemostatic therapy for bleeding peptic ulcers. Am J Gastroenterol. 2008 Oct. 103(10):2625-32; quiz 2633. [Medline].

  32. Chiu PW, Ng EK, Cheung FK, Chan FK, Leung WK, Wu JC, et al. Predicting mortality in patients with bleeding peptic ulcers after therapeutic endoscopy. Clin Gastroenterol Hepatol. 2009 Mar. 7(3):311-6; quiz 253. [Medline].

  33. Kikkawa A, Iwakiri R, Ootani H, Ootani A, Fujise T, Sakata Y, et al. Prevention of the rehaemorrhage of bleeding peptic ulcers: effects of Helicobacter pylori eradication and acid suppression. Aliment Pharmacol Ther. 2005 Jun. 21 Suppl 2:79-84. [Medline].

  34. Gisbert JP, Calvet X, Feu F, Bory F, Cosme A, Almela P, et al. Eradication of Helicobacter pylori for the prevention of peptic ulcer rebleeding. Helicobacter. 2007 Aug. 12(4):279-86. [Medline].

  35. Boparai V, Rajagopalan J, Triadafilopoulos G. Guide to the use of proton pump inhibitors in adult patients. Drugs. 2008. 68(7):925-47. [Medline].

  36. Barkun A, Bardou M, Marshall JK. Consensus recommendations for managing patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2003 Nov 18. 139(10):843-57. [Medline].

  37. Coté GA, Howden CW. Potential adverse effects of proton pump inhibitors. Curr Gastroenterol Rep. 2008 Jun. 10(3):208-14. [Medline].

  38. Laine L, Shah A, Bemanian S. Intragastric pH with oral vs intravenous bolus plus infusion proton-pump inhibitor therapy in patients with bleeding ulcers. Gastroenterology. 2008 Jun. 134(7):1836-41. [Medline].

  39. Chan WH, Khin LW, Chung YF, Goh YC, Ong HS, Wong WK. Randomized controlled trial of standard versus high-dose intravenous omeprazole after endoscopic therapy in high-risk patients with acute peptic ulcer bleeding. Br J Surg. 2011 May. 98(5):640-4. [Medline].

  40. Andriulli A, Loperfido S, Focareta R, Leo P, Fornari F, Garripoli A, et al. High- versus low-dose proton pump inhibitors after endoscopic hemostasis in patients with peptic ulcer bleeding: a multicentre, randomized study. Am J Gastroenterol. 2008 Dec. 103(12):3011-8. [Medline].

  41. Sari YS, Can D, Tunali V, Sahin O, Koc O, Bender O. H pylori: Treatment for the patient only or the whole family?. World J Gastroenterol. 2008 Feb 28. 14(8):1244-7. [Medline]. [Full Text].

  42. Konno M, Yokota S, Suga T, Takahashi M, Sato K, Fujii N. Predominance of mother-to-child transmission of Helicobacter pylori infection detected by random amplified polymorphic DNA fingerprinting analysis in Japanese families. Pediatr Infect Dis J. 2008 Nov. 27(11):999-1003. [Medline].

  43. Singh V, Mishra S, Maurya P, Rao G, Jain AK, Dixit VK, et al. Drug resistance pattern and clonality in H. pylori strains. J Infect Dev Ctries. 2009 Mar 1. 3(2):130-6. [Medline].

  44. [Guideline] Lanza FL, Chan FK, Quigley EM. Guidelines for prevention of NSAID-related ulcer complications. Am J Gastroenterol. 2009 Mar. 104(3):728-38. [Medline]. [Full Text].

  45. Chan FK, Hung LC, Suen BY, Wu JC, Lee KC, Leung VK, et al. Celecoxib versus diclofenac and omeprazole in reducing the risk of recurrent ulcer bleeding in patients with arthritis. N Engl J Med. 2002 Dec 26. 347(26):2104-10. [Medline].

  46. Chan KL, Ching YL, Hung CY. Clopidogrel versus aspirin and esomeprazole to prevent ulcer bleeding. N Eng J Med. 2005. 352:238-44. [Medline]. [Full Text].

  47. Lai KC, Chu KM, Hui WM, Wong BC, Hung WK, Loo CK, et al. Esomeprazole with aspirin versus clopidogrel for prevention of recurrent gastrointestinal ulcer complications. Clin Gastroenterol Hepatol. 2006 Jul. 4(7):860-5. [Medline].

  48. Hsu PI, Lai KH, Liu CP. Esomeprazole with clopidogrel reduces peptic ulcer recurrence, compared with clopidogrel alone, in patients with atherosclerosis. Gastroenterology. 2011 Mar. 140(3):791-798.e2. [Medline].

  49. Talley NJ, Vakil N. Guidelines for the management of dyspepsia. Am J Gastroenterol. 2005 Oct. 100(10):2324-37. [Medline].

  50. Tajima A, Koizumi K, Suzuki K, Higashi N, Takahashi M, Shimada T, et al. Proton pump inhibitors and recurrent bleeding in peptic ulcer disease. J Gastroenterol Hepatol. 2008 Dec. 23 Suppl 2:S237-41. [Medline].

  51. McConnell DB, Baba GC, Deveney CW. Changes in surgical treatment of peptic ulcer disease within a veterans hospital in the 1970s and the 1980s. Arch Surg. 1989 Oct. 124(10):1164-7. [Medline].

  52. Gisbert JP, Calvet X, Cosme A, Almela P, Feu F, Bory F, et al. Long-Term Follow-Up of 1,000 Patients Cured of Helicobacter pylori Infection Following an Episode of Peptic Ulcer Bleeding. Am J Gastroenterol. 2012 May 22. [Medline].

  53. Berne TV, Donovan AJ. Nonoperative treatment of perforated duodenal ulcer. Arch Surg. 1989 Jul. 124(7):830-2. [Medline].

  54. Donovan AJ, Berne TV, Donovan JA. Perforated duodenal ulcer: an alternative therapeutic plan. Arch Surg. 1998 Nov. 133(11):1166-71. [Medline].

  55. Lai KC, Lam SK, Chu KM, Wong BC, Hui WM, Hu WH, et al. Lansoprazole for the prevention of recurrences of ulcer complications from long-term low-dose aspirin use. N Engl J Med. 2002 Jun 27. 346(26):2033-8. [Medline].

  56. Wangensteen OH. Non-operative treatment of localized perforations of the duodenum. Proc Minn Acad Med. 1935. 18:477-480.

 
Previous
Next
 
Vagal innervation of stomach.
Gastric ulcer with punched-out ulcer base with whitish fibrinoid exudates.
Gastric ulcer (lesser curvature) with punched-out ulcer base with whitish exudate.
Gastric cancer. Note the irregular heaped up overhanging margins.
Gastric cancer with ulcerated mass.
Gross pathology of a gastric ulcer.
Gastric cancer with ulcerated mass.
Endoscope view of an ulcer (at upper center) in the wall of the duodenum, the first part of the small intestine. This ulcer is an open sore. Image courtesy of Science Source | Gastrolab.
Duodenal ulcer in a 65-year-old man with osteoarthritis who presented with hematemesis and melena stools. The patient took naproxen on a daily basis.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.