History and exam
Key diagnostic factors
common
abdominal pain
Dyspepsia, a chronic or recurrent abdominal pain or discomfort centered in the upper abdomen, is a common clinical feature.[46]
Commonly related to eating and is often nocturnal.
In patients with duodenal ulcers, pain may be severe and radiate through to the back as a result of penetration of the ulcer posteriorly into the pancreas.
uncommon
"pointing sign"
Patient can show site of pain with one finger.
Other diagnostic factors
common
epigastric tenderness
May occur on palpation of the abdomen.
uncommon
nausea or vomiting
Nausea is relieved by eating.
Vomiting occurs after eating.
May indicate pyloric stenosis.
early satiety
May indicate pyloric stenosis.
weight loss or anorexia
Patients may experience weight loss or anorexia.
diarrhea
May indicate Zollinger-Ellison syndrome.
symptoms of anemia
Gastric and duodenal ulcers may cause iron deficiency anemia. Symptoms generally include fatigue, pica (abnormal craving or appetite for nonfood substances such as dirt, ice, paint, or clay), and nail changes.
gastrointestinal (GI) bleeding
Bleeding may be either occult (stool heme test positive) or overt (hematemesis and/or melena). This is a complication of peptic ulcer disease.
hypotensive or septic shock
From GI bleeding or perforation.
succussion splash
Rarely, a succussion splash may be heard in patients with pyloric stenosis (caused by gastric outlet obstruction).
Risk factors
strong
Helicobacter pylori infection
H pylori is known to have a role in the etiology of peptic ulcer disease. If those taking nonsteroidal anti-inflammatory drugs (NSAIDs) are excluded, about 90% of patients with duodenal ulcers and more than 70% with gastric ulcers have H pylori infection.[17][19] Infection increases the lifetime risk of peptic ulcers.[10]
The likely mechanisms are through gastrin and acid hypersecretion (duodenal ulcers) and local mucosal damage (gastric ulcers).
Eradication of infection prevents recurrence of both peptic ulcer disease and bleeding.
nonsteroidal anti-inflammatory drug (NSAID) use
The incidence of ulcers in chronic NSAID users is about 20% compared with about 5% in nonusers.[20] Low-dose aspirin use is also likely to increase the risk, but high-quality trials are lacking.
The risk of NSAID-induced ulcers increases with increasing age (>60 years), a history of peptic ulcer, high doses of NSAIDs and longer duration of use, Helicobacter pylori infection, and concurrent use of corticosteroids, other antithrombotic drugs, and bisphosphonates.[21][22][23][24][25]
NSAIDs more commonly cause gastric ulcers than duodenal ulcers and do so by impairing mucosal defenses, mainly mediated through cyclo-oxygenase (COX)-1. Selective COX-2 inhibitors are less likely to cause peptic ulcers.[26]
In patients using NSAIDs, peptic ulcer disease is more common in H pylori-positive than in H pylori-negative patients.[27]
Stopping NSAID use (and treating H pylori, if present) reduces ulcer recurrence. If NSAID use cannot be stopped, coprescription with a proton-pump inhibitor reduces recurrence.
smoking
increasing age
The incidence of peptic ulcers and associated complications increase with age.
personal history of peptic ulcer disease
Mainly through persistent unrecognized Helicobacter pylori infection.
family history of peptic ulcer disease
patient in intensive care
Prophylactic use of a proton-pump inhibitor is appropriate for patients in intensive care, who are deemed at high risk of GI bleeding due comorbidities such as chronic liver disease, or have coexisting conditions such as coagulopathy, shock, or liver disease.[33][34] The risk lessens as patient status improves.
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