Medically Fit For Exams
Medically Fit For Exams

Peptic Ulcer


  • Ulcer in the stomach or duodenum
    • Duodenal ulcers are more common, ratio of 4:1


Risk factors

  • H. pylori
  • High acid secretion
  • Alcohol intake
  • Smoking (especially if have H. pylori)
  • NSAIDs
  • Previous ulcers
  • Family history


Differential diagnosis

  • Malignancy
  • Hypersecretory disorder (too much stomach acid)
  • GORD
  • Crohn’s disease
  • Gallstones



  • Slightly more common in men
  • H. pylori infection in high percentage
  • 80% risk of recurrence of duodenal ulcer if H. pylori eradication fails
  • 10% of US population have evidence of peptic ulcer at some point in their life
  • Rates are declining recently, perhaps due to H. pylori eradication and reduction in smoking



  • Increased acid production (H. pylori, smoking, genetic pre-disposition)
  • Increase pepsin, which may start to digest gastric mucosa if over production of acid (inactive pepsinogen only activated to pepsin in acidic environment)
  • Impaired mucosal defence (NSAIDs, smoking, genetics)
  • H. pylori – sequence of events causing duodenal infection and ulceration
    • Gastritis
    • Increased gastrin (hormone secreted in response to food, so increased H+ and stomach motility) and acid secretion
    • Gastric acid hypersecretion à gastric ulcers
    • Increased duodenal acid load
    • Gastric metaplasia in duodenal bulb
    • Duodenal H. pylori
    • Resulting high acidity causes duodenal ulcers




Clinical features

  • Gastric ulcer
    • Upper abdominal pain (epigastric) - dyspepsia
    • Eating makes the pain worse
    • Anorexia
    • Weight loss
    • Anaemia
  • Duodenal ulcer
    • Epigastric pain - dyspepsia
    • Relieved by eating
      • Milk
    • Weight gain
    • Relieved by antacids
    • Relieved by rest



  • Increased acid and pepsin production leads to ulceration of gastric or duodenal mucosa



  • Dyspepsia
    • Two week wait gastroscopy (weight loss, >55, with any of: dyspepsia, reflux, upper abdominal pain. OR refer in new onset dysphagia (difficulty swallowing))
  • OGD: (gastroscopy)
  • Test for H. pylori
    • Urea breath test – H. pylori makes urease
  • FBC – anaemia if losing blood
  • Ultrasound to rule out gallstones



  • PPIs – inhibit stomach acid production, inhibit the proton pump from secreting H+
    • Omeprazole, lansoprazole
    • Are pro-drugs, but are converted to active sulfenamide
    • Bind irreversibly (non-competitive antagonist), to regain proton pump function, new ones must be made
    • Reduce acid by 90%
    • Means that pH may rise above 4, resulting in bacterial infection
    • Inhibit cytochrome P450, so may increase effect of other drugs including warfarin
    • Can mask gastric cancer
  • Histamine 2 receptor antagonists – these receptors signal proton pumps to secrete acid, so inhibiting the histamine receptors reduces acid secretion
    • Cimetidine, ranitidine
    • Reduce acid secretion by 60%
    • Cimetidine also inhibits cytochrome P450
    • Also can mask gastric cancer
  • Antacids
    • Aluminium hydroxide, magnesium trisilicate, calcium, sodium bicarbonate
    • Are bases, so neutralise acid
    • Are fast acting, but work for longer after food, because slower gastric emptying
    • High doses needed for ulcer healing
    • Constipation with aluminium, diarrhoea with magnesium, so often given together
  • Mucosa-protecting drugs
    • Prostoglandin analogues – increase mucus secretion and blood flow (increased buffering)
      • Misoprostol
    • Gel formers – forms gel at low pH and provides physical barrier protecting gut wall
      • Sucralfate
  • Treat H. pylori infection
    • Triple therapy
      • Omeprazole
      • Amoxicillin
      • Clarithromycin or Metronidazole
    • Can do all 4
    • 7-14 days on triple therapy
    • Re-test



  • Gastric ulcers can progress to malignancy
  • Duodenal ulcers are less likely to become malignant
  • Persistent H. pylori infection is likely to lead to recurrence of ulcer
Peptic ulcer.docx
Microsoft Word document [15.7 KB]

Get social with us.

Print Print | Sitemap