PassFinals
Gastroenterology & Nutrition

Peptic Ulcer Disease

A gastric or duodenal mucosal breach occurs when H. pylori, NSAIDs or another insult overwhelms mucosal defence; the high-yield priorities are cause-directed treatment and early recognition of bleeding, perforation, obstruction and gastric malignancy.

In a nutshell

Think defence failure from H. pylori or NSAIDs, but first look for bleeding, perforation, obstruction or malignancy. Eradicate H. pylori, stop ulcerogenic medicines, heal with a PPI, biopsy and follow gastric ulcers, and use the acute upper-GI-bleed pathway when complications occur.

Classic presentation

Epigastric burning or gnawing pain with dyspepsia, nausea or early satiety, often with NSAID or aspirin exposure or known H. pylori; meal timing is a clue, not a reliable site diagnosis.

Key points

  • The common causes are H. pylori and NSAIDs: treatment must remove the cause as well as suppress acid.
  • A bleeding ulcer may present with haematemesis, coffee-ground vomit, melaena, collapse or anaemia.
  • Perforation causes sudden severe pain and peritonism; gastric outlet obstruction causes persistent vomiting, early satiety and distension.
  • Gastric ulcers require biopsy and documented healing follow-up because malignancy cannot be excluded by appearance alone.
  • Use a urea breath test or stool-antigen test appropriately, with the PPI and antibiotic washout before testing.
  • For acute upper-GI bleeding, use Blatchford before endoscopy and Rockall after endoscopy; endoscopy timing follows stability and resuscitation.
  • Do not use adrenaline alone for non-variceal ulcer bleeding, and do not give pre-endoscopy acid suppression in the NICE suspected non-variceal pathway.

First-line investigation

Assess cause and alarm features, test for H. pylori when appropriate, and arrange OGD with biopsy for gastric ulcer, bleeding or concerning symptoms.

Management

Recognise and stabilise complications

  • Treat haematemesis, melaena with instability, collapse, perforation or gastric outlet obstruction as emergencies; resuscitate and use the acute upper-GI-bleed pathway, with endoscopy immediately after resuscitation when severe and unstable or within 24 hours for other admitted bleeds.4,3

Find the cause

  • Review NSAIDs, aspirin, anticoagulants and other ulcerogenic medicines; test for H. pylori with an appropriate breath, stool or endoscopic pathway and observe the required medication washout.1,5,2

Treat the ulcer and its trigger

  • Eradicate confirmed H. pylori using the current NICE/UKHSA and BNF regimen, stop NSAIDs where possible, and give full-dose PPI treatment for the guideline duration according to the cause and ulcer context.1,5,8,9,10,11

Prevent recurrence and treatment failure

  • Protect people who must continue NSAIDs with the appropriate specialist or NICE pathway, confirm H. pylori eradication after treatment, and refer for gastroenterology or microbiology advice after failed or complex eradication.1,5,2

Control bleeding and manage structural complications

  • After endoscopy, treat high-risk non-variceal bleeding with an appropriate endoscopic method and PPI; never use adrenaline alone. Repeat endoscopy for re-bleeding, then use interventional radiology or urgent surgery when required.4,8
  • Perforation, peritonitis or gastric outlet obstruction needs urgent surgical or gastroenterology assessment and appropriate imaging or intervention rather than outpatient ulcer treatment.4,2,3

Prove healing and exclude malignancy

  • Biopsy and follow gastric ulcers through repeat endoscopy. The current BSG/JAG pathway uses repeat assessment within 12 weeks of diagnosis; NICE CG184 retains a 6 to 8 week recommendation, which is recorded as a labelled source divergence.6,1,2

Exam traps

  • Meal-related pain is not reliable enough to diagnose gastric versus duodenal ulcer without objective assessment.
  • A negative H. pylori test while taking a PPI or soon after antibiotics may be false negative.
  • A gastric ulcer is not automatically benign: biopsy and healing follow-up are required.
  • Adrenaline is not monotherapy for non-variceal upper-GI bleeding.
  • Vomiting blood or melaena is an emergency, not a routine outpatient dyspepsia presentation.

Illustrations

Mucosal defence versus aggressive factorsDiagram balancing acid and pepsin against mucus-bicarbonate protection and prostaglandin-dependent repair, with H. pylori and NSAIDs weakening the defence side.PassFinals · original
Endoscopic appearance of a peptic ulcerEndoscopic image of a gastric ulcer showing a discrete mucosal defect with a visible base; diagnosis and malignancy exclusion require endoscopic assessment and biopsy.Wikimedia Commons contributor · CC0
Posterior duodenal ulcer and gastroduodenal arteryDiagram showing how a deep posterior duodenal ulcer can erode an adjacent artery and cause major upper-GI bleeding.PassFinals · original

Key sources

  1. NICE CG184, Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and managementUpdated 18 Oct 2019
  2. NICE CKS, dyspepsia and proven peptic ulcer disease
  3. NHS, stomach ulcerUpdated 12 Aug 2025
  4. NICE CG141, Acute upper gastrointestinal bleeding in over 16s: managementUpdated 1 Mar 2025
  5. UKHSA, Helicobacter pylori in dyspepsia: test and treatUpdated 22 May 2025
  6. BSG/AUGIS/RCP, best practice for upper-GI endoscopy
  7. NICE NG12, Suspected cancer: recognition and referralUpdated 15 Apr 2026
  8. BNF, omeprazole
  9. BNF, amoxicillin
  10. BNF, clarithromycin
  11. BNF, metronidazole

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.