High-yield map
Key points before the detail
- 01
H. pylori and NSAIDs are the principal causes.
- 02
Meal timing does not reliably distinguish gastric from duodenal ulcer.
- 03
A gastric ulcer requires adequate biopsy and documented healing.
- 04
Bleeding, perforation and obstruction follow different emergency pathways.
- 05
Conservative treatment of a sealed perforation is exceptional.
1. Aggression versus mucosal defence
| Aggressive factors | Protective factors |
|---|---|
| Acid/pepsin | Mucus-bicarbonate barrier. |
| H. pylori inflammation | Mucosal blood flow and epithelial restitution. |
| NSAID prostaglandin inhibition | Prostaglandin-mediated defence. |
| Smoking, severe physiological stress and rare hypersecretory states | Normal motility and repair. |
2. Presentation and complications
- Epigastric pain, dyspepsia, nausea or early satiety.
- Occult bleeding or iron-deficiency anaemia.
- Haematemesis/melaena suggests bleeding.
- Sudden generalised pain suggests perforation.
- Persistent non-bilious vomiting suggests gastric outlet obstruction.
3. Diagnosis and H. pylori testing
| Situation | Approach |
|---|---|
| Uncomplicated dyspepsia without alarms | H. pylori test-and-treat and/or empirical PPI according to current dyspepsia guidance. |
| Alarm features or diagnostic uncertainty | Upper-GI endoscopy. |
| Gastric ulcer | Multiple biopsies and repeat endoscopy to document healing. |
| Non-invasive H. pylori test | Urea breath or stool antigen after appropriate PPI/antibiotic washout. |
4. Uncomplicated ulcer treatment
- Eradicate H. pylori using the current local antimicrobial regimen.
- Stop NSAIDs where possible and use full-dose PPI therapy.
- If an NSAID must continue, reassess indication and use gastroprotection according to risk.
- Refractory ulcer requires adherence review, repeat/validated H. pylori testing, hidden drug review and malignancy exclusion.
5. Bleeding peptic ulcer
- Use the acute upper-GI bleeding pathway and risk assessment.
- Endoscopic haemostasis should not rely on adrenaline injection alone.
- Use high-dose PPI after treatment of high-risk stigmata according to protocol.
- Rebleeding progresses from repeat endoscopy to transcatheter embolisation, then surgery when necessary.
6. Perforated peptic ulcer
- Resuscitate, keep nil by mouth, give broad-spectrum IV antibiotics and acid suppression.
- Obtain urgent senior surgical and anaesthetic input.
- Prompt source control is standard; small benign-appearing perforations are often closed with an omental patch.
- Biopsy appropriately, especially gastric perforations, and treat H. pylori after recovery.
Active recall
Close the notes and answer these
Try each question from memory before revealing the answer. These public prompts are a small preview of the integrated retrieval system inside SurgAtlas.
01What are the two principal causes of peptic ulcer disease?
Helicobacter pylori and NSAID exposure.
02Does meal timing reliably distinguish gastric from duodenal ulcer?
No.
03What special rule applies to a gastric ulcer?
It should be adequately biopsied to exclude malignancy and re-endoscoped to document healing as appropriate.
04What is the escalation pathway for rebleeding after initial endoscopic haemostasis?
Repeat endoscopic therapy, then transcatheter arterial embolisation, then surgery if bleeding remains life-threatening.
05Is non-operative care standard for perforated peptic ulcer?
No. It is exceptional and requires a proven sealed leak, stability and close specialist monitoring.
Sources & editorial basis
References & editorial basis
- SurgAtlas production source. General Surgery — Peptic Ulcer Disease. Public lesson curated from the corresponding production chapter.
- NICE CG184. GORD and dyspepsia in adults: investigation and management.
- NICE CG141. Acute upper gastrointestinal bleeding in over 16s: management.
This lesson is derived from the corresponding SurgAtlas production teaching material. Where the source makes current management or guideline claims, the public lesson uses the cited contemporary guidance. It is written for education and examination preparation, not as patient-specific clinical advice.
Editorial details
Medical Doctor (MD) · MRCS Part A · Physician · Surgical Educator
SurgAtlas is an educational resource. For patient care, verify current national guidance, local antimicrobial and transfusion policies, specialty pathways and individual patient factors.
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