nursing case study on peptic ulcer

4 Peptic Ulcer Disease Nursing Care Plans

Use this nursing care plan and management guide to help care for patients with peptic ulcer disease. Enhance your understanding of nursing assessment , interventions, goals, and nursing diagnosis , all specifically tailored to address the unique needs of individuals facing peptic ulcer disease. This guide equips you with the necessary information to provide effective and specialized care to patients dealing with peptic ulcer disease.

Table of Contents

What is peptic ulcer, nursing assessment, nursing diagnosis, nursing goals, 1. providing pain relief and comfort, 2. improving nutritional and fluid balance, 3. reducing anxiety, 4. initiating patient education and health teachings, recommended resources.

A peptic ulcer is ulceration in the mucosal wall of the lower esophagus, stomach , pylorus, or duodenum. The ulcer may be referred to as duodenal, gastric, or esophageal, depending on its location. The most common symptom of both gastric and duodenal ulcers is epigastric pain . It is characterized by a burning sensation and usually occurs shortly after meals with gastric ulcer and 2-3 hours afterward with duodenal ulcer.

Predisposing factors of peptic ulcer include infection with the gram-negative bacteria Helicobacter pylori which may be acquired through the ingestion of food and water, excessive HCL secretion in the stomach, chronic use of non-steroidal anti-inflammatory drugs ( NSAIDs ) which weakens the lining of the GI tract by reducing the protective function of the mucosal layer, increased stress associated with illness and surgery , alcohol ingestion and excessive cigarette smoking.

Nursing Care Plans and Management

Assess for the following subjective and objective data:

• Early satiety
• Nausea and vomiting
• Pain relieved by food or antacid
• Weight loss

Following a thorough assessment , a nursing diagnosis is formulated to specifically address the challenges associated with peptic ulcer disease based on the nurse ’s clinical judgement and understanding of the patient’s unique health condition. While nursing diagnoses serve as a framework for organizing care, their usefulness may vary in different clinical situations. In real-life clinical settings, it is important to note that the use of specific nursing diagnostic labels may not be as prominent or commonly utilized as other components of the care plan. It is ultimately the nurse’s clinical expertise and judgment that shape the care plan to meet the unique needs of each patient, prioritizing their health concerns and priorities.

Goals and expected outcomes may include:

• The client will report satisfactory pain control at a level of less than 2 to 4 on a scale of 0 to 10.
• The client uses pharmacological and nonpharmacological pain relief measures.
• The client will exhibit increased comfort such as baseline levels for HR, BP, and respirations, and relaxed muscle tone for body posture.
• The client will be normovolemic as evidenced by systolic BP greater than or equal to 90 mm Hg (or client’s baseline), absence of orthostasis, HR 60 to 100 beats/minute, urine output greater than 30 ml/hr, and normal skin turgor .

Nursing Interventions and Actions

Therapeutic interventions and nursing actions for patients with peptic ulcer disease may include:

Assess the client’s pain, including the location, characteristics, precipitating factors, onset, duration, frequency, quality, intensity, and severity. Clients with gastric ulcers typically demonstrate pain 1 to 2 hours after eating. The client with duodenal ulcers demonstrates pain 2 to 4 hours after eating or in the middle of the night. With both gastric and duodenal ulcers, the pain is located in the upper abdomen and is intermittent. The client may report relief after eating or taking an antacid.

Encourage the use of nonpharmacological pain relief measures such as acupressure, biofeedback, distraction, guided imagery, massage, and music therapy. Nonpharmacological relaxation techniques will decrease the production of gastric acid, which in turn will reduce pain.

Instruct the client to avoid NSAIDs such as aspirin . These medications may cause irritation of the gastric mucosa.

Instruct the client that meals should be eaten at regularly paced intervals in a relaxed setting. An irregular schedule of meals may interfere with the regular administration of medications.

Encourage the importance of smoking cessation. Smoking decreases the secretion of bicarbonate from the pancreas into the duodenum, resulting in increased acidity of the duodenum.

Administer the prescribed drug therapy:

• Antacids Antacids buffer gastric acid and prevent the formation of peptin. This mechanism of action promotes of healing of the ulcer.
• Antibiotics such as amoxicillin, clarithromycin, metronidazole , tetracycline Antibiotics treat the Helicobacter pylori infection and promote the healing of the ulcer. As the ulcer heals, the client experience less pain.
• Histamine receptor antagonists H2 receptor antagonists block the secretion of gastric acid. Prostaglandin analogue reduces acid secretion and enhances the integrity of the gastric mucosa to resist injury .
• Proton pump inhibitor Proton pump inhibitors block the production and secretion of gastric acid and thereby reduce gastric pain.
• Sucralfate Sucralfate forms a barrier at the base of the ulcer crater to protect the healing ulcer from gastric acid.

Obtain a nutritional history. Clients may often overestimate the amount of food eaten. The client may not eat sufficient calories or essential nutrients as a way to reduce pain episodes with peptic ulcer disease. Because of this, clients are at high risk for malnutrition .

Assess for body weight changes. Weight loss is an indication of inadequate nutritional intake. Gastric ulcers are more likely to be associated with vomiting , loss of appetite, and weight loss than duodenal ulcers.

Monitor laboratory values for serum albumin. This test indicates the degree of protein depletion (2.5 g/dL indicates severe depletion; 3.8 to 4.5 g/dL is normal).

Assist the client with identifying foods that cause gastric irritation. Clients need to learn what foods they can tolerate without gastric pain. Soft, bland, non-acidic foods cause less gastric irritation. The client is more likely to increase food intake if the foods are not associated with pain. Foods that may contribute to mucosal irritation include spicy foods, pepper, aNd raw fruits and vegetables.

Instruct on the importance of abstaining from excessive alcohol. Alcohol causes gastric irritation and increases gastric pain.

Encourage the client to limit the intake of caffeinated beverages such as tea and coffee. Caffeine stimulates the secretion of gastric acid. Coffee, even if decaffeinated, contains a peptide that stimulates the release of gastrin and increases acid production.

Teach about the importance of eating a balanced diet with meals at regular intervals. Specific dietary restrictions are no longer part of the treatment for PUD. During the symptomatic phase of an ulcer, the client may find benefit from eating small meals at more frequent intervals.

Assess for the signs of hematemesis or melena. The client with a bleeding ulcer may vomit bright red blood or coffee grounds emesis. Melena occurs when there is bleeding in the upper GI tract.

Monitor the client’s fluid intake and urine output. The kidney will reabsorb water into circulation to support a decrease in blood volume. This compensatory mechanism results in decreased urine output. A decrease in circulatory blood volume leads to decreased renal perfusion and decreased urine output

Monitor the client’s vital signs, and observes BP and HR for signs of orthostatic changes. The erosion of an ulcer through the gastric or duodenal mucosal layer may cause GI bleeding. The client may develop anemia . If bleeding is brisk, changes in vital signs and physical symptoms of hypovolemia may develop rapidly. A decrease in BP and an increase in HR with changes in position is an early indicators of decreased circulatory volume.

Monitor hemoglobin and hematocrit levels. Erosion of the gastric mucosa by an ulcer results in GI bleeding. A decrease in hemoglobin and hematocrit occurs with bleeding.

Instruct the client to immediately report symptoms of nausea, vomiting, dizziness, shortness of breath , or dark tarry stools. These assessment findings are signs of GI bleeding and should be reported immediately.

Administer IV fluids , volume expanders, and blood products as ordered. Isotonic fluids, volume expanders, and blood products can restore or expand intravascular volume.

Assess the client’s level of anxiety . Clients with peptic ulcers are anxious, but their anxiety level is not visible.

Acknowledge awareness of the client’s anxiety. Acknowledgment of the client’s feelings validates the feelings and communicates the acceptance of those feelings.

Encourage to express fears openly Open communication enables the client to develop a trusting relationship that aids in reducing anxiety and stress.

Use simple language and brief statements when giving instructions to the client. When experiencing moderate to severe anxiety, clients may be unable to comprehend anything more than simple, clear, and brief instructions.

Decrease sensory stimuli by maintaining a quiet environment. Anxiety may escalate to a panic state with the excessive conversation, noise, and equipment around the client.

Provide emotional support to the client. Providing emotional support will give a client calming and relaxing mood that will lower anxiety and stress related to the condition.

Assist the client in developing anxiety-reducing measures such as biofeedback, positive imagery, and behavior modification. Learning these methods provides the client with a variety of ways to manage anxiety.

Assess the client’s knowledge and misconceptions regarding peptic ulcer disease, lifestyle behaviors, and the treatment regimen. Clients may have inaccurate information about how lifestyle behaviors contribute to peptic ulcer disease. The client needs accurate knowledge to make informed decisions about taking prescribed medications and modifying behaviors that contribute to peptic ulcer disease or GI bleeding.

Explain the pathophysiology of the disease and how it relates to the functioning of the body. An understanding of the disease process helps to foster the willingness to follow the recommended treatment plan and modify behaviors to prevent recurrent episodes or related complications.

Instruct the client on what signs and symptoms to report to the health care provider. Recognizing the signs and symptoms can help ensure the early initiation of treatment.

Discuss the therapy options and the rationales for using these options. The correct use of antibiotics and acid suppression medications can promote rapid healing of an ulcer.

Discuss the lifestyle changes required to prevent further complications or episodes of peptic ulcer disease. The modifications of lifestyle behaviors such as alcohol use, coffee, and other caffeinated beverages, and the overuse of aspirin or other nonsteroidal anti-inflammatory drugs is necessary to prevent recurrent ulcer development and prevent complications during the healing phase.

Recommended nursing diagnosis and nursing care plan books and resources.

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy .

Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.

Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition) Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.

Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.

Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care  Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!

All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health   Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.

Other recommended site resources for this nursing care plan:

• Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ! Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
• Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.

More nursing care plans related to gastrointestinal disorders:

• Appendectomy
• Bowel Incontinence (Fecal Incontinence)
• Cholecystectomy
• Constipation
• Diarrhea Nursing Care Plan and Management
• Cholecystitis and Cholelithiasis
• Gastroenteritis
• Gastroesophageal Reflux Disease (GERD)
• Hemorrhoids
• Ileostomy & Colostomy
• Inflammatory Bowel Disease (IBD)
• Intussusception
• Liver Cirrhosis
• Nausea & Vomiting
• Pancreatitis
• Peritonitis
• Peptic Ulcer Disease
• Subtotal Gastrectomy

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Peptic Ulcer

Case Presentation

Harold, a fifty-eight year old grocery store manager, had recently been waking up in the middle of the night with abdominal pain. This was happening several nights a week. He was also experiencing occasional discomfort in the middle of the afternoon. Harold decided to schedule an appointment with his physician.

The doctor listened as Harold described his symptoms and then asked Harold some questions. He noted that Harold's appetite had suffered as a result of the pain he was experiencing and as a result of the fear that what he was eating may be responsible for the pain. Otherwise, Harold seemed fine.

The doctor referred Harold to a physician that specialized in internal medicine and had Harold make an appointment for a procedure called an endoscopy. The endoscopy was performed at a hospital later that week. During the procedure, a long, thin tube was inserted into Harold's mouth and directed into his digestive tract. The end of the tube was equipped with a light source and a small camera which allowed the doctor to observe the interior of Harold's stomach. The endoscope was also equipped with a small claw-like structure that the doctor could use in order to obtain a small tissue sample from the lining of Harold's stomach, if required.

The endoscopy revealed that Harold had a peptic ulcer. Analysis of a tissue sample taken from the site showed that Harold also had an infection that was caused by Helicobacter pylori bacteria. The doctor who performed the endoscopy gave Harold prescriptions for two different antibiotics and a medication that would decrease the secretion of stomach acid. The doctor also instructed Harold to schedule an appointment for another endoscopy procedure in 6 months.

Case Background

A peptic ulcer is a sore that occurs in the lining of a part of the gastrointestinal tract that is exposed to pepsin and acid secretions. Most peptic ulcers occur in the lining of the stomach or duodenum. 90% of all duodenal ulcers and 80% of all gastric ulcers are caused by H. pylori infection. Most of the remaining peptic ulcers are caused by long-term usage of certain anti-inflammatory medications like aspirin.

There is still some question as to how H. pylori is spread. However, H. pylori has been identified in the saliva of infected individuals and may be spread via this fluid. H. pylori bacteria have the ability to survive the acid environment in the stomach because they produce enzymes that neutralize stomach acids. They also have the ability to move through the mucous membrane lining the stomach or duodenum and take up residence in the underlying connective tissue. The damage to the mucous membrane that results from a H. pylori infection allows pepsin and hydrochloric acid to further damage the wall of the stomach or duodenum. The sore that results is the peptic ulcer.

Describe the functions of the following components of gastric juice.

Nursing Care of Peptic Ulcers

A peptic ulcer is a legion in the mucosa lining of the stomach or small intestine, allowing gastric juices to come into contact with, and damage underlying tissues. Untreated or severe peptic ulcers may lead to perforation of the stomach and spilling of gastric juices into the abdominal cavity.

Peptic Ulcers are prevalent in approximately 4% of the population 1 , with an estimated 10% of the population experiencing a peptic ulcer at some point in their life. In 2015 alone, over 87 million new cases were reported, resulting in a reported 267,500 deaths.

Signs and Symptoms

Patients may present with a variety of abdominal complaints, typically relating to pain and discomfort, or they be asymptomatic. In more severe cases they may present with bleeding.

• Abdominal pain strongly correlated with mealtimes.
• Bloating or abdominal fullness.
• Distension of the abdominal wall.
• Nausea or excessive vomiting.
• Loss of appetite.
• Haematemesis (blood in vomit)
• Melana (tarry foul smelling faeces) 2 .

Pathophysiology

A peptic ulcer can form through a variety of physiological processes such as stress (stress ulcer), NSAIDs and colonisation by Helicobacter pylori.

The majority of ulcers have been attributed to colonisation of the antral mucosa by H. pylori, causing chronic inflammation. Due in part its location and the harsh environment of the stomach and duodenum, the body is unable to effectively respond to the infection, thus the bacterium can cause chronic active gastritis, eventually leading to the breakdown of the gastric lining.

Non-steroidal Anti-inflammatory Drugs (NSAIDs) have also been identified as another major cause of ulcers. This is due to a secondary action of many NSAIDs blocking the function of cyclooxygenase 1 (COX-1) which is essential for the production of prostaglandins which stimulate the secretion of a protective mucus. Without this mucus, the gastric mucosa is allowed to come into direct contact with the harsh gastric acids.

Dietary factors such as consumption of spices, coffee, caffeine 4 5 , and alcohol have been shown to be of relatively minor importance in the formation of peptic ulcers 6 7 .

Medical Management

Treatment typically focusses on lifestyle changes and administration of antibiotics in the case of H. pylori infections 8 . Cessation of smoking and alcohol consumption are typical lifestyle changes, while medications may be altered to reduce the consumption of NSAIDs. Alternatively, drugs may be prescribed to reduce the potency of gastric acids, such as proton pump inhibitors or H2 blockers 1 .

A bleeding ulcer may require surgery, such as an endoscopy 9 , while a perforation or heavily bleeding ulcer requires immediate surgical intervention to repair the site and minimise further damage by gastric juices.

Diet is not considered to play an important role in causing or preventing peptic ulcers. It is possible to minimise discomfort by avoiding foods that aggravate the ulcer.

Classification

Peptic ulcers can be categorised by either their location or by the modified Johnson scale.

By Location

Modified johnson scale, nursing diagnosis & care plan, acute pain r/t chemical burn of gastric mucosa.

Nursing Interventions

– Record reports of pain including severity, location and duration. – Review factors that aggravate or alleviate pain. – Identify and limit foods that aggravate condition or cause increased discomfort. – Encourage small frequent meals. – Encourage patient to assume a comfortable position. – Instruct patient to avoid NSAIDs.

Nutrition Imbalance

Nursing Interventions: – Assess and record body weight & Changes – Calculate Basal metabolic needs and ensure the patient is not in a caloric deficit. – Assist the patient in identifying foods which may irritate the ulcer, and advise them to avoid – Educate the patient on the importance of a balanced diet. – Assess the patient for metabolic deficits and dehydration.

Deficit Knowledge

Nursing Interventions – Educate the patient or carer on the causes and processes of peptic ulcers. – Discuss therapy options – Instruct the patient on identifying and responding to signs and symptoms, including when and what to report. – Explain the pathophysiology of the disease.

Dehydration

Nursing Interventions – Monitor the fluid intake and output (fluid balance chart) – Monitor the patients vital signs. Administer IV fluids as ordered.

Anaemia Due to Loss of Red Blood Cells

Nursing Interventions – Monitor the patient for signs of Hematemesis ○ Sudden or excessively large volume of blood is a medical emergency. – Instruct the patient to report any dark or tarry stools. Monitor vital signs.

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GI Lecture: What is Peptic Ulcer Disease?

Welcome to another round of nursing lectures, featuring the gastrointestinal system. Right now, we will be focusing on peptic ulcer disease (PUD).

So, what is peptic ulcer disease and what does it do to the body? To adequately explain what PUD is, we’ll review its pathophysiology then delve into the nursing process of the disease.

Study Technique

An effective method when studying any subject, especially those that are within the scope of Medical-Surgical Nursing subject, is that, aside from knowing the keywords, you should also summarize the condition by following the nursing process. In this way, you will be able to gather the necessary keywords just by taking note of the D-A-R, which means:

• D ata – signs and symptoms, laboratory results, vital signs, and any form of physical assessment findings.
• A ction – drugs and client education (two most common nursing interventions)
• R esponse – how the client reacts or feels after the interventions were given

Peptic Ulcer Disease: An Overview

A peptic ulcer is an ulcer inside the gastrointestinal tract. It is named as such because of the presence of an acid known as pepsin lingering inside the stomach. An overproduction of pepsin will result in deterioration of the gastrointestinal lining. Ulcers can happen either inside the stomach or in the duodenum.

Aside from that, we’ll also talk about how the bacteria, Helicobacter pylori (H. pylori), contributes to the occurrence of peptic ulcer disease.

Inside the Stomach

The stomach has a mucosal lining that protects itself from hydrochloric acid, pepsin, and other enzymes that can break down food into chyme. After food is converted into chyme, it will pass the duodenum (the first portion of the small intestine), then go into the jejunum, ileum, and large intestine. And finally, once chyme is transformed into feces, it will be excreted by defecation through the anus. So, this is what happens typically inside the gastrointestinal tract.

How Peptic Ulcer Occurs

The moment the mucosal membranes become eroded to the point wherein the epithelial cells are exposed, that’s the time the gastric juices start to “eat up” the epithelial cells. The epithelial cells are considered as the stomach’s skin. Continuous “eating up” of the epithelial cells will result in peptic ulcer and can lead to a perforated bowel.

Perforation of bowel means that there is a gaping hole or an opening where the nutrients and toxic wastes can leak and go into the peritoneal cavity. The peritoneal cavity is the space inside the abdomen that keeps the liver, stomach, and intestines intact.

The Peritoneal Cavity

In general, all the organs inside the body are covered with thin membranes that compartmentalize them and keep them safe within their specified location. The heart has a pericardium that protects it from trauma caused by collision against the ribcage or any event similar to that.  

The peritoneum or peritoneal cavity is the stomach’s protective covering just in case there will be direct blows or trauma happening around that area. The peritoneal cavity will prevent the bursting of bowels and other forms of internal conditions.

Peritonitis

If there’s bowel perforation, it can lead to infection. However, the entire body will not get infected immediately because the peritoneal cavity prevents it from spreading. On the other hand, since the infection is confined within the peritoneal cavity, a condition known as peritonitis will occur. Infection of the peritoneum is called peritonitis.

What happens when there’s peritonitis? The peritoneum is filled up and will manifest as distention. Peritonitis is just one of the primary complications of peptic ulcer.

Now that we’ve appropriately discussed what peptic ulcer disease is and its pathophysiology, we’ll proceed to the assessment findings regarding the data collection, whether the peptic ulcer occurs in the stomach or duodenum. Check it out on our succeeding videos via our SimpleNursing YouTube channel.

For more nursing-related topics that will surely come out of major school exams and the NCLEX ® , drop by our SimpleNursing website.

Until next time!

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Peptic Ulcer Case Study

Nursing 7450 Pathophysiology of Altered Health States

Dr. Amy Mackos, Dr. Kelly Casler, and Dr. Lee Cordell

• Hsiaochi (Chi) Chang
• Stephine Burrows

Our rationale for choosing this condition

We chose Peptic Ulcer disease due to the fact that it’s commonly seen among the patients taking NSAIDs and Aspirin; therefore, we anticipate seeing this condition frequently.

(Picture retrieved from https://www.webmd.com/digestive-disorders/ss/slideshow-visual-guide-to-stomach-ulcers)

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Peptic ulcer disease

• Related content
• Peer review
• Emma Sverdén , upper gastrointestinal surgeon 1 2 ,
• Lars Agréus , general practitioner , professor 3 4 ,
• Jason M Dunn , gastroenterologist 5 ,
• Jesper Lagergren , upper gastrointestinal surgeon, professor 1 5
• 1 Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
• 2 Department of Upper Gastrointestinal Surgery, South Hospital, Stockholm, Sweden
• 3 Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
• 4 The University of Newcastle, Australia
• 5 School of Cancer and Pharmaceutical Sciences, King’s College London, and Guy’s and St Thomas’ NHS Foundation Trust, UK
• Correspondence to emma.s.eklund{at}gmail.com

What you need to know

More than 90% of duodenal ulcers are linked to H pylori infection; eradication therapy with antibiotics and proton pump inhibitors is the mainstay of treatment

A “test and treat” strategy for H pylori infection is appropriate in patients under 60 with suspected peptic ulcer disease who have no complications

Proton pump inhibitors are important in the prevention and treatment of peptic ulcer disease, but avoid their use without clear indications, and re-evaluate patients on long-term treatment

Gastric ulcers are followed up with endoscopy until healed to rule out malignancy

Urgently refer patients with complications such as bleeding, perforation, or penetration to an emergency unit

Peptic ulcer disease presents with gastrointestinal symptoms similar to dyspepsia and can be difficult to distinguish clinically. It can have potentially serious complications such as bleeding or perforation, with a high risk of mortality. 1 Optimal treatment with proton pump inhibitors (PPIs) facilitates healing and can prevent complications and recurrence.

Observational studies and surveys among healthcare providers report that adherence to evidence based treatment guidelines is often poor. 2 3 4 5 6 7 8 9 This results in inadequate treatment and overuse of PPIs. Increasingly, antibiotic resistance has affected the choice of eradication regimen for Helicobacter pylori infection, the main risk factor. In this Clinical Update, we review the epidemiology and management of peptic ulcer disease for non-specialists to guide prompt diagnosis and appropriate treatment.

What is peptic ulcer disease?

Peptic ulcer disease is often defined as a mucosal break greater than 3-5 mm in the stomach or duodenum with a visible depth. It is therefore an endoscopic diagnosis in contrast to dyspepsia, which is a clinical diagnosis based on symptoms alone. Peptic ulcer disease results from an imbalance between factors that protect the mucosa of the stomach and duodenum, and factors that cause damage to it ( fig 1 ).

Factors that protect or harm the gastroduodenal mucosa

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Patients with gastric and duodenal ulcers present similarly. They may report epigastric or retrosternal pain, early satiety, nausea, bloating, belching, or postprandial distress. These symptoms are non-specific and may be difficult to distinguish clinically from functional dyspepsia. Studies have shown low correlation between symptoms and endoscopic findings. 10 Conversely, patients may be asymptomatic until a complication occurs, or an ulcer may be diagnosed incidentally during endoscopy performed for other reasons.

How common is it?

Peptic ulcer disease affects 1-2 per 1000 people annually as per a systematic review with data from the USA, UK, and Europe. 1 11 12 The incidence is declining, possibly due to decreasing prevalence of H pylori infection. 1 13 A time trend study from Asia (12 612 patients) showed similar incidence and declining trend. 14

Complications from peptic ulcer disease have not fallen, however, according to a systematic review and meta-analysis (18 studies from Europe, USA, and Israel, more than 1000 individuals per study). 1 An ageing population that has more comorbidities and more frequently uses ulcerogenic medications may be contributing to this.

What are the risk factors?

Previous studies suggest that 90% of duodenal ulcers and 70% of gastric ulcers are associated with H pylori infection. 15 16 Although these percentages are now considered to be lower, H pylori is also an important risk factor for gastric cancer, which further emphasises the importance of its eradication. 17 18

Medications such as aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) cause approximately 10% of peptic ulcers. NSAIDs are more strongly linked to gastric ulcers than duodenal ulcers. 19 20 21 22 The combination of aspirin with NSAIDs further increases the risk. 23 Use of these drugs has increased over the last few decades. In the USA, self-reported use of aspirin and NSAIDs increased by 57% and 43%, respectively, between 2005 and 2010. Nearly 46% of all people over 70 were regular aspirin users in 2010, according to a national survey (27 157 people). 24 Selective COX-2 (cyclo-oxygenase-2) inhibitors have a lower risk of peptic ulcer disease compared with non-selective NSAIDs. 25

Marginal ulcer is seen in approximately 5% of patients who have undergone gastric bypass surgery for obesity. 26 The incidence can be as high as 27-36% in patients with upper gastrointestinal symptoms after gastric bypass surgery. 27

Box 1 lists other risk factors for peptic ulcer disease. The proportion of idiopathic ulcers has been increasing in recent years. 36 A multicentre study based in France (713 patients) found that 22% of patients with duodenal or gastric ulcer were neither infected by H pylori , nor using ulcerogenic drugs. 37 Between 20% and 50% of duodenal ulcers in the USA and 3-12% in Europe are negative for H pylori . 38 Before defining an ulcer as idiopathic, all other risk factors ( box 1 ) should be excluded.

Risk factors and causes of ulcers in the stomach and duodenum

• Gastric bypass surgery

Cigarette smoking 28

Selective serotonin reuptake inhibitors 29 30

Zollinger-Ellison syndrome (uncommon, gastrin producing tumour usually located in the pancreas)

Physiological stress associated with serious trauma and critical illness 31 (eg, septicaemia)

Gastric tumours mistaken for peptic ulcers

Autoimmune diseases, eg, vasculitis, sarcoidosis, and Crohn’s disease

Infections, mainly in immunocompromised patients, eg, cytomegalovirus, tuberculosis, and syphilis 32

Psychological stress is not an established risk factor for peptic ulcer disease, although some research has suggested an association 33

Consumption of alcohol or coffee does not seem to increase the risk of peptic ulcer disease 34 35

What are the complications?

Bleeding, perforation, penetration to a surrounding organ, and obstruction from fibrotic stricturing (usually in the pyloric region) are important complications. Box 2 lists signs suggestive of acute bleeding. Perforation usually presents with acute onset of severe abdominal pain. Penetration can cause secondary pancreatitis if the pancreas is involved. Obstruction causes nausea and vomiting.

Red flags for referral to a specialist

Signs of acute bleeding 39 40 :

Melaena, self-reported or found on digital rectal examination

Blood in vomit (haematemesis)

Abnormally high pulse or low blood pressure

Severe anaemia

Signs of perforation or penetration such as severe abdominal pain and peritonitis

Symptoms suggestive of malignancy in patients over 50:

o Dysphagia 41

o Unexplained weight loss with upper abdominal pain or gastro-oesophageal reflux

o Loss of appetite

o Recurrent vomiting

Second line eradication therapy fails

Symptoms persist despite successful eradication

Bleeding peptic ulcer occurs in 19 to 57 per 100 000 individuals each year, as per a systematic review (93 studies). Perforation or penetration is relatively less common, occurring in 4 to 14 per 100 000 individuals each year. 42 The risk of recurrence and complications from idiopathic ulcers is higher than for ulcers with known aetiology, as reported in prospective cohort studies. 43 44 Mortality is high with these complications. About 8.6% of patients with peptic ulcer bleeding and 23.5% of patients with perforation die within 30 days. 42

What to cover on initial assessment?

Ask about the nature of symptoms and risk factors such as previous ulcer disease, other medical conditions, medications, and smoking. Inquire about symptoms suggestive of complications listed in box 2 .

On examination, record pulse and blood pressure. Severe peptic ulcer bleeding may affect the patient’s haemodynamic status. Palpate the abdomen. Pronounced tenderness may suggest perforation or penetration, indicating the need for emergency referral. Assess for any palpable mass which may represent malignancy. Digital rectal examination is useful to detect melaena when bleeding from a peptic ulcer is suspected.

When to refer?

Box 2 lists features that prompt referral. Immediately transfer patients with signs of bleeding or perforation to an emergency unit. Refer patients with symptoms suggestive of malignancy to a specialist gastroenterology unit for urgent endoscopy within two weeks.

What investigations can be done?

Request a blood test to detect anaemia. Endoscopy is required to confirm ulcer diagnosis, but may be avoided in patients under 55 with no complications.

Testing for H pylori

Current guidelines recommend a “test and treat” strategy for H pylori in patients with symptoms suggestive of peptic ulcer disease and ≤55 years (National Institute for Health and Care Excellence) 39 or ≤60 years (American College of Gastroenterology). 45 46 Non-invasive tests include urea breath test, stool antigen test, or serology. The urea breath test delivers an immediate result and can be performed at home with the necessary equipment. A stool antigen test is equally reliable, and the stool sample can be collected at home. Serology testing for antibodies has high sensitivity but low specificity, ie, a negative test excludes infection, but a positive result needs to be confirmed by another test. It cannot be used to confirm eradication.

Unlike the serology test, a single negative urea breath test or stool antigen test does not exclude H pylori infection. Bleeding or use of PPIs and antibiotics might cause false negative results. Discontinue PPIs for two weeks 47 and antibiotics for at least four weeks before testing. 48 If no other probable cause of the ulcer is identified, repeat testing a few weeks later.

Endoscopy is advised in older people with dyspepsia, in patients with red flag symptoms ( box 2 ), 39 and in patients whose dyspeptic symptoms do not resolve after 4-8 weeks of PPI. Whether endoscopy should be used more liberally in patients with diffuse upper gastrointestinal symptoms is debated. 49 At endoscopy, H pylori can be diagnosed by rapid urease test or on histology, both of which are invasive tests.

Additional specialist tests can include platelet cyclo-oxygenase activity or blood salicylic acid to establish any link to the use of NSAIDs or aspirin, and fasting gastrin to exclude Zollinger-Ellison syndrome, before determining an ulcer as idiopathic.

How is it managed?

The initial management is usually acid suppressing treatment along with elimination of risk factors.

Acid suppression

Endoscopically confirmed peptic ulcers without H pylori infection are treated with a PPI until healed, along with elimination of any other known risk factors. Systematic reviews have shown that PPIs accelerate the healing process and facilitate eradication of H pylori . 50 51 52 The odds of ulcer healing were three times higher with PPIs compared with control group (odds ratio 3.49, 95% confidence interval 3.28 to 3.72) in a recent meta-analysis (847 randomised trials, 142 485 participants). 50 For duodenal ulcers, when H pylori is the predominant cause, acid suppression included in the eradication therapy for 7-14 days is usually sufficient for healing. Gastric ulcers are treated with acid suppression until healing is confirmed on repeat endoscopy.

The duration of acid suppression for the test and treat recommendation (without prior endoscopy) differs between guidelines, but no more than eight weeks is recommended. Reassess the patient after 4-8 weeks for resolution of symptoms. 45

We advise caution against overuse of PPIs. Ensure that the treatment is clearly indicated with adequate dosage. Re-evaluate the indication for any continued treatment. Observational studies in different settings suggest that between 27 and 81% of PPI use in primary care and 36-63% of use in hospitals could be inappropriate, 2 53 54 ie, having no documented indication for its use or prescribed without re-evaluation. Approximately half of older patients in primary care using NSAIDs were prescribed higher than therapeutic doses or double dose regimens of PPIs in a national audit in Bahrain. 55 This overuse results in unnecessary healthcare costs and an increased risk of adverse effects, such as hip fracture, 56 cardiovascular events, 57 Clostridium difficile infection, pneumonia, dementia, 58 and gastric cancer in long term users. 59 60 The evidence regarding these side effects is largely derived from observational studies, with a risk of confounding, 61 but the potential harms need to be considered in the scenario of overuse and long term use.

Consider alternatives such as histamine 2 receptor antagonists if patients experience side effects. Misoprostol, a prostaglandin analogue, is effective in treating and preventing ulcer recurrence, but compliance is poor owing to side effects such as diarrhoea, nausea, and abdominal pain. 62

H pylori eradication

Patients testing positive for H pylori should receive eradication therapy. 39 45 63 64 The choice of antibiotics is determined by antibiotic resistance patterns in any geographical region. Figure 2 describes typical eradication regimens. Patients can find eradication regimens challenging to follow because they involve talking multiple drugs at the same time. Offer clear written explanation if they would prefer.

Regimens for eradicating H pylori

Regimens with eradication rates of ≥90% are recommended. In northern Europe, which has a low prevalence of clarithromycin resistant H pylori , “triple therapy” is recommended. This is a combination of two antibiotics and a PPI twice daily for 7-14 days depending on empirical efficacy in the region. In many regions, for example Italy, Japan, Turkey, and China, this provides an unacceptably low eradication rate, often <80%. 65 In populations with higher prevalence of antibiotic resistance, expert consensus suggests that a “quadruple therapy” is appropriate. This can be concomitant (14 days) or sequential (7+7 days) ( fig 2 ). 66 67 Bismuth is a bactericidal salt that can be added to the quadruple regimen. Prolonged triple therapy in higher doses is an alternative to quadruple regimens. 65

Medication related peptic ulcer disease

Along with prescribing PPIs, consider whether NSAIDs can be discontinued in the patient. A COX 2-selective NSAID in combination with a PPI may be preferred in these patients. The risk of cardiovascular complications has long been considered to be more pronounced with the COX-2 selective NSAID, but a recent review reports similar cardiovascular risk across NSAIDs. 25 68 Use of low dose aspirin for prevention of cardiovascular events can be continued in combination with a PPI. 69 70

Some patients may require long term acid suppression if using ulcerogenic drugs for a longer duration ( box 3 ). Patients are often uncertain of the reason for long term treatment with PPIs and may not be aware that NSAIDs and aspirin can cause peptic ulcer disease. Educate patients about these risks so they are compliant with the treatment.

Indications for long term therapy with a PPI in long term users of aspirin or NSAIDs 71

Age >65 years

A history of peptic ulcer disease, especially with complications

NSAID use at high doses or in combination with certain other drugs, ie, aspirin, steroids, selective serotonin reuptake inhibitors, or anticoagulants

Aspirin use, even at low dosage in elderly patients, particularly in combination with drugs listed above

Histamine 2 receptor antagonists are effective in preventing duodenal ulcers among NSAID users, but not gastric ulcers. 72 These have a shorter duration of action and do not completely suppress postprandial secretion of gastric acid, 73 which requires at least twice-daily dosage. Randomised trials and cohort studies have shown that high doses of famotidine (80 g daily) prevent gastric ulcers, although not as effectively as PPIs. 74

Marginal ulcer

There is no evidence based treatment of marginal ulcers, and they are often difficult to heal. 26 Eliminate any risk factor and consider a high dose PPI regimen. 75 Follow up with endoscopy until the ulcer is healed.

Managing complications

In patients with peptic ulcer bleeding, endoscopic treatment reduces the risk of re-bleeding, the need for surgery, and mortality. 40 76 Approximately 10% of patients require urgent angiographic embolisation or surgery for bleeding despite endoscopic intervention. 77

The gold standard treatment of ulcer perforation is surgery. Endoscopic stenting plus drainage is a less invasive alternative, but its role is debated. 78 Pyloric obstruction is typically managed endoscopically with dilatation, although surgery is sometimes required. 79

What to cover at follow-up visits?

Ask the patient about improvement in symptoms. Assess outcome of eradication therapy, preferably non-invasively, eg, by a urea breath test or a stool antigen test, at least 2 weeks after finishing the PPI therapy. More than 85% of patients experience eradication with good compliance to treatment when the prescription is appropriate for the local resistance pattern. Discuss elimination of other risk factors—mainly NSAIDS and smoking.

Patients with a confirmed endoscopic diagnosis of duodenal ulcer do not require follow-up after eradication. Patients with gastric ulcers will need repeat endoscopies and biopsies until confirmed healed, mainly because such ulcers are slower to heal and some may actually be gastric cancers misdiagnosed as an ulcer. Continue PPI treatment after eradication for up to 8 weeks in total or until healing is endoscopically confirmed. 80 Of note, a malignant ulcer can also temporarily heal with PPI treatment, so biopsies must also be sampled from any visible scar tissue. 81 H pylori eradication may not completely eliminate the risk of gastric cancer. Expert consensus is to offer endoscopic and histological surveillance in patients at risk—as defined by the extent and severity of mucosal atrophy on endoscopy. 82

If eradication fails, second line therapy should be tried ( fig 2 ). If there is no response on second line therapy, or if symptoms persist despite successful eradication, refer the patient to a specialist. Culture from a biopsy of the gastric mucosa can determine potential antibiotic resistance.

Education into practice

Think about a patient with dyspeptic symptoms you have seen in your practice recently. How would you alter your management approach based on reading this article?

How many patients at your practice are on long term treatment with NSAIDs or aspirin and PPIs? When has their indication for continued treatment been evaluated?

Questions for future research

What strategies are effective in treating patients with H pylori antibiotic resistance?

What are the adverse effects of PPI, especially potential cancer risk, with long term use or higher doses?

Which is the ideal long term strategy to prevent recurrence of peptic ulcer disease in high-risk individuals?

How can marginal ulcers occurring after gastric bypass surgery for obesity be prevented and treated?

Additional educational resources

The American College of Gastroenterology https://gi.org/guideline/management-of-dyspepsia-2/

The European Society of Gastrointestinal Endoscopy https://www.esge.com/assets/downloads/pdfs/guidelines/2015_s_0034_1393172.pdf

The National Institute for Health and Care Excellence (NICE)

https://www.nice.org.uk/guidance/cg184 https://www.nice.org.uk/guidance/ng12/chapter/1-Recommendations-organised-by-site-of-cancer#upper-gastrointestinal-tract-cancers

Information resources for patients

National Institute for Health and Care Excellence (NICE) public information. https://www.nice.org.uk/guidance/cg141/ifp/chapter/About-this-information

How patients were involved in the creation of this article

No patients were involved in the creation of this article.

How this article was created

We searched PubMed using the term “peptic ulcer.” We prioritised systematic reviews and high quality and recently published original studies on the topic. We excluded animal and paediatric studies. We also reviewed clinical guidelines from the American College of Gastroenterology, the European Society of Gastrointestinal Endoscopy, the National Institute for Health and Care Excellence, and the Japanese Society of Gastroenterology.

Competing interests The BMJ has judged that there are no disqualifying financial ties to commercial companies. The authors declare the following other interests: none.

Further details of The BMJ policy on financial interests is here: https://www.bmj.com/about-bmj/resources-authors/forms-policies-and-checklists/declaration-competing-interests

Provenance and peer review: commissioned; externally peer reviewed.

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