FFinalistSouthampton · 2027
Gastroenterology
AKT · Gastroenterology/Oesophagus & stomach

Peptic ulcer disease & gastritis

Mucosal ulceration of stomach/duodenum (Helicobacter pylori or NSAIDs; rarely Zollinger-Ellison)

Overview

Ulceration of the gastric or duodenal mucosa, driven by Helicobacter pylori infection or NSAIDs (the two big causes). Epigastric pain (duodenal classically relieved by food/worse at night; gastric worse with food). Complications: bleeding (commonest), perforation, gastric outlet obstruction. Test-and-treat H. pylori; stop NSAIDs; PPI healing. Refractory/multiple ulcers → think Zollinger-Ellison.

Recognise

  • Epigastric pain/dyspepsia; DUODENAL ulcer classically relieved by eating and worse at night; GASTRIC ulcer worse with food (weight loss)
  • Causes: H. pylori (majority), NSAIDs/aspirin, smoking, alcohol; gastritis = mucosal inflammation on the same spectrum
  • Complications: upper GI bleed (haematemesis/melaena), perforation (peritonitis), gastric outlet obstruction

Red flags

  • ALARM features (dysphagia, weight loss, anaemia, GI bleeding, age ≥55 new dyspepsia) → urgent endoscopy
  • Perforation (sudden severe epigastric pain, peritonitis, free air) or major bleed → emergency
  • A GASTRIC ulcer needs repeat endoscopy + biopsy to confirm healing and exclude malignancy

Differentials & how to tell them apart

GORDheartburn/regurgitation rather than epigastric ulcer pain
Gastric cancerweight loss, anorexia, persistent gastric ulcer — biopsy mandatory
Functional dyspepsiadyspepsia with normal endoscopy and no H. pylori
Zollinger-Ellison syndromemultiple/refractory/atypical-site ulcers + diarrhoea, high gastrin (see endocrine/paraneoplastic)

Investigations

H. pylori testing (C13-urea breath test or stool antigen — off PPI 2 weeks, antibiotics 4 weeks). Endoscopy for ALARM features/gastric ulcers (biopsy to exclude cancer). FBC (anaemia). Fasting gastrin if Zollinger-Ellison suspected.

Management

Test-and-treat H. pylori (7-day triple therapy) / stop NSAIDs + PPI

  1. 1Test for H. pylori; if positive give 7-day triple eradication (PPI + amoxicillin + clarithromycin/metronidazole). If NSAID-related, stop the NSAID and heal with a full-dose PPI.Gate: Re-test (urea breath test) to confirm eradication after treatment; a GASTRIC ulcer requires repeat endoscopy + BIOPSY to confirm healing and EXCLUDE malignancy (duodenal ulcers do not); ALARM features → urgent endoscopy
  2. 2Refractory → endoscopy, recheck adherence/second-line eradication, consider Zollinger-Ellison (gastrin). Complications (bleed/perforation) → emergency management.
H. pylori eradication — 7-day triple therapy — PPI BD + amoxicillin 1 g BD + clarithromycin 500 mg BD (or metronidazole); penicillin allergy → PPI + clarithromycin + metronidazole
Stop NSAIDs/aspirin; full-dose PPI — NSAID-related ulcers — stop the drug and heal with a PPI
PPI co-prescription — gastroprotection if NSAIDs must continue

Key points

Epigastric pain → test-and-treat H. pylori or stop the NSAID + PPI. Duodenal = relieved by food; gastric = worse with food + needs biopsy/repeat scope to exclude cancer. Multiple refractory ulcers + diarrhoea = Zollinger-Ellison.

Monitor & prognosis

Eradication re-test; gastric ulcer healing on repeat endoscopy.

Excellent with eradication/NSAID withdrawal.

Source: NICE NG/CKS Dyspepsia; BSG