Peptic Ulcer Disease (PUD)

Mucosal break ≥5 mm in stomach or duodenum extending through muscularis mucosae

Symptoms / Associated Sx

  • Epigastric pain — burning or gnawing; duodenal ulcer classically relieved by food; gastric ulcer worsened by food

  • Nausea, early satiety, bloating

  • Hematemesis or melena if complicated by bleeding

  • Weight loss if malignant gastric ulcer

Denies

  • Jaundice (rules out biliary or hepatic etiology)

  • Dysphagia (rules out esophageal malignancy)

  • RLQ pain (rules out appendicitis or Crohn's)

  • Peritoneal signs — guarding, rigidity, rebound (rules out perforation if truly absent)

Social History (SHx)

NSAID/aspirin use, smoking, alcohol, steroid use, ICU stress, prior PUD or H. pylori history.

Main Etiology

  • H. pylori infection (~70% duodenal, ~50% gastric ulcers)

  • NSAID/aspirin use (COX-1 inhibition → decreased mucosal prostaglandins)

  • Stress ulcers (Curling's — burns; Cushing's — head trauma)

  • Zollinger-Ellison syndrome (gastrinoma — recurrent, refractory)

  • Idiopathic (H. pylori negative, NSAID negative)

Most Common DDx

  • GERD / erosive esophagitis (burning pain but substernal, not epigastric; relieved by antacids; no melena; EGD shows esophagitis not ulcer)

  • Gastritis (no discrete ulcer on EGD; diffuse mucosal erythema/erosion; same risk factors but milder presentation)

  • Functional dyspepsia (chronic epigastric discomfort; normal EGD; no ulcer, no H. pylori; diagnosis of exclusion)

  • Biliary colic (RUQ pain, postprandial, radiates to right shoulder; gallstones on ultrasound; no melena)

  • Acute pancreatitis (epigastric pain radiating to back; lipase >3× ULN; no melena; imaging confirms)

  • Gastric cancer (weight loss, early satiety, ulcer with irregular margins on EGD; biopsy shows malignancy)

  • Perforated ulcer (sudden-onset severe pain, rigid abdomen, free air on imaging — rules in perforation)

DATA

  • CBC (anemia from chronic/acute blood loss)

  • BMP (BUN elevation if bleeding; renal function)

  • H. pylori: urea breath test or stool antigen (non-invasive); rapid urease test/biopsy at EGD

  • EGD — diagnostic and therapeutic; biopsy gastric ulcers to rule out malignancy

  • PT/INR (coagulopathy if anticoagulated)

  • Fasting serum gastrin (if recurrent/refractory — screen for ZE syndrome)

Home Meds

  • NSAIDs / aspirin / COX-2 inhibitors (hold; reassess indication)

  • Corticosteroids (additive mucosal injury)

  • Anticoagulants (increase bleeding risk)

  • PPIs at home (partial protection — upgrade to IV if actively bleeding)

  • Clopidogrel (discuss hold vs. continue with cardiology if recent stent)

Plan

  • PPI therapy:

    • Active bleed: Pantoprazole 80 mg IV bolus → 8 mg/hr infusion × 72h post-EGD (high-risk lesion)

    • Non-bleeding: Pantoprazole 40 mg IV/PO q12–24h

    • Step-down: Pantoprazole 40 mg PO daily × 4–8 weeks (duodenal); 8–12 weeks (gastric)

  • H. pylori eradication (if positive):

    • Bismuth quadruple (preferred): Bismuth subsalicylate 525 mg QID + Metronidazole 250 mg QID + Tetracycline 500 mg QID + PPI BID × 14 days

    • Clarithromycin triple (if resistance <15%): Omeprazole 20 mg BID + Clarithromycin 500 mg BID + Amoxicillin 1 g BID × 14 days

    • Confirm eradication: urea breath test or stool antigen ≥4 weeks after completion

  • Hold NSAIDs; if essential → add PPI, use lowest dose

  • ZE suspected: fasting gastrin, secretin stimulation test; GI/surgery referral

  • Repeat EGD 8–12 weeks for all gastric ulcers (rule out malignancy)

  • Trend CBC, BMP daily while admitted

  • PT/OT if deconditioned or prolonged admission

  • Discharge: PPI daily (4–8 weeks duodenal; 8–12 weeks gastric), H. pylori treatment completion, NSAID avoidance, GI follow-up 4 weeks, repeat EGD for gastric ulcer at 8–12 weeks

Red Flags

  • Peritoneal signs → perforated ulcer → emergent surgery

  • Hemodynamic instability + melena/hematemesis → resuscitate + urgent EGD

  • Recurrent ulcers despite PPI + H. pylori eradication → ZE syndrome (fasting gastrin)

  • Weight loss + gastric ulcer → malignancy until proven otherwise → biopsy at EGD

Senior IM Resident Pearls

  • Forrest classification: Ia (active spurting ~90% rebleed) → Ib (oozing) → IIa (visible vessel ~50%) → IIb (adherent clot ~25%) → IIc/III (flat spot/clean base <5%) — drives PPI infusion vs. PO strategy

  • BUN:Cr >20 suggests upper GI bleeding source — useful when source uncertain

  • Test-and-treat appropriate for H. pylori in young (<60), uncomplicated dyspepsia without alarm features

  • Always biopsy gastric ulcers — duodenal ulcers are almost never malignant; gastric ulcers must be biopsied

  • Common mistake: Stopping PPI too early — 4 weeks minimum duodenal, 8–12 weeks gastric; extend if H. pylori positive

ORDERS

Labs

Admission Labs

  • CBC with diff

  • BMP (BUN/Cr)

  • CMP if liver disease suspected

  • PT/INR

  • PTT if anticoagulated

  • Type & Screen if concern for bleeding

  • H. pylori stool antigen OR urea breath test (if not currently on PPI/antibiotics)

  • Lipase (rule out pancreatitis if diagnostic uncertainty)

  • Iron studies if chronic blood loss anemia

Additional Labs

  • Fasting serum gastrin (recurrent/refractory ulcers, multiple ulcers, young patient, diarrhea, severe GERD)

  • Secretin stimulation test (if gastrin elevated)

  • Hgb/Hct q6–8 hr if active bleed

Trending Labs

  • CBC daily

  • BMP daily

  • PT/INR daily if anticoagulated or bleeding

Imaging

Usually Not Needed

PUD is primarily an endoscopic diagnosis.

If Perforation Suspected

  • Upright CXR (free air under diaphragm)

  • CT Abdomen/Pelvis with IV contrast

  • CT Abdomen/Pelvis with oral contrast if requested by surgery

If Alternative Diagnosis Suspected

  • RUQ Ultrasound (biliary disease)

  • CT Abdomen/Pelvis (pancreatitis, malignancy, perforation)

Procedures

Definitive Diagnostic Procedure

  • EGD with biopsy

During EGD

  • Gastric ulcer biopsy (mandatory)

  • H. pylori biopsy/rapid urease testing

  • Endoscopic hemostasis if bleeding ulcer

If Active Bleeding

  • Two large-bore IVs

  • Telemetry

  • NPO

Medications

PPI Therapy

Active Bleeding Ulcer

  • Pantoprazole 80 mg IV bolus

  • Then Pantoprazole infusion 8 mg/hr x72 hr

Non-Bleeding Ulcer

  • Pantoprazole 40 mg IV BID
    OR

  • Pantoprazole 40 mg PO BID

Step-Down

  • Pantoprazole 40 mg PO daily

H. pylori Treatment (if positive)

Preferred Bismuth Quadruple Therapy x14 days

  • Pantoprazole 40 mg PO BID

  • Bismuth subsalicylate 525 mg PO QID

  • Tetracycline 500 mg PO QID

  • Metronidazole 250–500 mg PO QID

Alternative Clarithromycin Triple Therapy x14 days

  • Omeprazole 20 mg PO BID

  • Clarithromycin 500 mg PO BID

  • Amoxicillin 1 g PO BID

Hold Medications

  • NSAIDs

  • Aspirin (unless strong indication)

  • Steroids if possible

  • Anticoagulants if actively bleeding

  • Clopidogrel (discuss with cardiology if recent PCI)

Consults

Gastroenterology

  • EGD

  • Bleeding ulcer

  • Gastric ulcer

  • Refractory symptoms

General Surgery

  • Perforation

  • Failed endoscopic hemostasis

  • Free air

Cardiology

  • Recent PCI/stent requiring antiplatelet decisions

PT/OT

  • Deconditioning

  • Prolonged admission

Nursing Orders

Monitoring

  • Vital signs q4 hr

  • Monitor stool color

  • Monitor melena/hematemesis

  • Strict I&O if bleeding

  • Daily weights if prolonged stay

Diet

  • NPO before EGD

  • Advance diet after endoscopy

  • Avoid alcohol

  • Avoid NSAIDs

Follow-Up Studies

  • Follow H. pylori testing

  • Follow pathology from gastric ulcer biopsy

  • Follow gastrin level if obtained

  • Repeat EGD in 8–12 weeks for gastric ulcers

Escalation Criteria

Urgent GI

  • Hematemesis

  • Melena with Hgb drop

  • Active bleeding ulcer

ICU

  • Hemodynamic instability

  • Massive UGIB

  • Multiple transfusions

  • Vasopressor requirement

Surgery

  • Perforation

  • Peritonitis

  • Failed endoscopic treatment