Synopsis
Identify gastric and duodenal ulcer disease, address Helicobacter pylori and ulcerogenic medicines, recognise bleeding, perforation and obstruction early, and prove healing where a gastric lesion could conceal malignancy.
- Peptic ulcer is a mucosal break extending beyond the muscularis mucosae, most commonly driven by H. pylori infection or exposure to NSAIDs and aspirin.
- Epigastric pain patterns around meals are not sufficiently accurate to distinguish gastric from duodenal ulcer or to exclude cancer.
- Ask about prescribed and non-prescribed ibuprofen, naproxen, aspirin and combination remedies; corticosteroids, anticoagulants and antiplatelets amplify bleeding risk in combination.
- Test for active H. pylori with valid preparation and eradicate confirmed infection using the current resistance-aware regimen, then demonstrate cure when an ulcer was present.
- Stop the NSAID where possible; if it must continue after healing, reassess indication and dose and co-prescribe appropriate gastroprotection according to risk.
- Gastric ulcers require adequate biopsy and planned repeat endoscopy, commonly at 6–8 weeks, because benign appearance and symptom improvement do not reliably exclude malignancy.
- Duodenal ulcers are very rarely malignant, but persistent or recurrent disease still requires confirmation of eradication, medicine review and consideration of hypersecretory or inflammatory causes.
- Major complications are upper-GI bleeding, free or contained perforation, penetration into an adjacent organ and chronic scarring that produces gastric outlet obstruction.
Key red flags
Haematemesis, coffee-ground vomit, melaena, postural symptoms or shock requires acute upper-GI bleeding assessment. Bright rectal blood can occur with a brisk proximal bleed.
Abrupt severe pain with guarding suggests free perforation; pain radiating to the back or persistent focal pain may reflect posterior penetration. Both require urgent imaging and surgical review.
Investigation priorities
Confirm ulcer site, describe bleeding stigmata and obtain appropriate tissue.
Management branches
Endoscopy demonstrates a peptic ulcer without active major bleeding, perforation or fixed outlet obstruction.
- Identify active H. pylori and every ulcerogenic medicine, including over-the-counter NSAIDs, low-dose aspirin, steroids, anticoagulants and antiplatelets, then assess tobacco exposure and cancer features.
- Eradicate confirmed H. pylori and prescribe a defined acid-suppression course appropriate to ulcer site and cause; discontinue the offending NSAID where clinically possible.
- Arrange proof of eradication and, for a gastric ulcer, repeat endoscopy at the planned healing interval with review of biopsy adequacy and any residual lesion.