In uncomplicated cases of peptic ulcer disease, the clinical findings are few and non-specific with the following often recorded:

• Succussion splash as a result of partial or complete gastric outlet obstruction
• Mild epigastric tenderness 
• Right upper quadrant tenderness which may suggest a biliary etiolog
• Guaiac-positive stool as a result of occult blood loss
• Melena as a result of acute or subacute gastrointestinal bleeding

In patients with perforated peptic ulcer disease, onset of severe, sharp, abdominal pain is a common presentation [7]. In some other patients, generalised pain is described while epigastric pain is seen in rare cases. Since slight movement can bring about worsening of pains, a common presentation among peptic ulcer patients is the assumption of fetal position most of the time.

Abdominal examination also shows general tenderness, rigidity, rebound tenderness and guarding.

• Anemia

  A bleeding ulcer can cause symptoms of anemia (you become faint, pale and dizzy). About one out of four will experience complications caused by peptic ulcers. Elderly and people that frequently use NSAIDs are at larger risk of this. [nhi.no]

  Sepper Roxadustat Treatment for Anemia in Patients Undergoing Long-Term Dialysis N. Chen et al. Roxadustat and Anemia of Chronic Kidney Disease J. Kaplan Roxadustat for Anemia in Patients with Kidney Disease Not Receiving Dialysis N. Chen et al. [nejm.org]

  Other similar signs and symptoms of stomach cancer and stomach ulcers include weight loss and anemia. [emedicinehealth.com]

  A blood test for anemia may be done, and a stool sample may be checked for the presence of blood. Both of these tests can indicate a bleeding ulcer. [health.harvard.edu]

• Fatigue

  The pain: Starts between meals or during the night Briefly stops if you eat or take antacids Lasts for minutes to hours Comes and goes for several days or weeks Other possible symptoms include: Bloody or dark tarry stools Chest pain Fatigue Vomiting, [wexnermedical.osu.edu]

  Additional symptoms may include the following: Nausea Vomiting Lack of appetite Fullness and bloating Unexplained weight loss Fatigue Blood in the stool or vomit DIAGNOSING PEPTIC ULCERS The gastroenterologist may use the following tests to diagnose a [barnesjewish.org]

  […] away if any of these occur: Fever of 100.4°F (38°C) or higher, or as directed by your healthcare provider Stomach pain that worsens or moves to the lower right part of abdomen Continued weight loss Pale skin Fast heartbeat Weakness or dizziness Extreme fatigue [fairview.org]

  […] fullness Difficulty drinking as much liquid as usual Hunger or an empty feeling in your stomach after you eat Mild nausea Stomach pain that wakes you up at night Less common symptoms include: Bloating Burping Poor appetite Bloody or dark stools Chest pain Fatigue [familydoctor.org]

• Pseudotumor

  Sealed perforated ulcer with pseudotumor formation is very rarely encountered. Here we present a case of gastric pseudotumor induced by perforation of a peptic ulcer. [ncbi.nlm.nih.gov]

• Non-Cardiac Chest Pain

  Other PUD symptoms include the following: Heartburn (acid reflux) Indigestion (dyspepsia) Nausea and vomiting Non-cardiac chest pain Weight loss In patients who have peptic ulcer disease, stress, diet (e.g., spicy foods, foods that are high in fat), alcohol [healthcommunities.com]

• Nausea

  Nausea- The symptoms of peptic ulcers may include nausea. Nausea is a feeling of sickness with an inclination to vomit. Nausea has many possible causes. [alaskagi.com]

  Drugs Used to Treat Peptic Ulcer Disease Drug Type Some Side Effects Comments Antacids Aluminum hydroxide Calcium carbonate Magnesium hydroxide Sodium bicarbonate Aluminum hydroxide: Nausea, headache, weakness, loss of appetite, and constipation Magnesium [merckmanuals.com]

  Older adults (>80 years old) with PUD often do not present with abdominal pain; instead, epigastric pain, nausea and vomiting are among their most common presenting symptoms. [ncbi.nlm.nih.gov]

  Antibiotics Diarrhea ( amoxicillin, clarithromycin, or tetracycline ), altered taste, and nausea These drugs are effective for treating peptic ulcers caused by Helicobacter pylori infection. [web.archive.org]

• Abdominal Pain

  Abdominal pain (classically epigastric) that is eased by eating or antacids is the most common complaint. Almost half of the patients that have this condition deny any correlation between the pain and meals. [nhi.no]

  Older adults (>80 years old) with PUD often do not present with abdominal pain; instead, epigastric pain, nausea and vomiting are among their most common presenting symptoms. [ncbi.nlm.nih.gov]

  Plain radiograph Abdominal films have little role in the setting of vague/chronic upper abdominal pain, and have a very low yield. [radiopaedia.org]

  Seek urgent medical attention if you experience the following symptoms: sudden, sharp abdominal pain fainting, excessive sweating, or confusion, as these may be signs of shock blood in vomit or stool abdomen that’s hard to the touch abdominal pain that [healthline.com]

• Loss of Appetite

  Drugs Used to Treat Peptic Ulcer Disease Drug Type Some Side Effects Comments Antacids Aluminum hydroxide Calcium carbonate Magnesium hydroxide Sodium bicarbonate Aluminum hydroxide: Nausea, headache, weakness, loss of appetite, and constipation Magnesium [merckmanuals.com]

  Other peptic ulcer symptoms include bloating, weight loss, vomiting, loss of appetite, or bleeding. Bleeding caused by ulcers is especially dangerous. If you notice blood in your stool or vomit, contact a medical professional immediately. [mana.md]

  In some cases, especially if you’re older and your symptoms include things like weight loss or loss of appetite, he might use a long, flexible tube called an endoscope to look down your throat and into your stomach for signs of an ulcer. [webmd.com]

  Loss of appetite, belching and bloating. Chest discomfort. Unexplained weight loss. When there is bleeding from the peptic ulcer, the patient may have coffee-ground vomitus and/or black tarry stool. [chp.gov.hk]

• Dyspepsia

  Peptic ulcer disease — for further information, see the CKS topic on Dyspepsia - proven... Dyspepsia Dyspepsia describes pain or discomfort in the upper abdomen. [evidence.nhs.uk]

  METHODS: Patients with dyspepsia were selected and divided into three groups of non-ulcer dyspepsia (NUD, n=22), peptic ulcer disease (PUD, n=25), and gastric cancer (GC, n=27) according to their endoscopic and histopathological examinations. [ncbi.nlm.nih.gov]

  The most common symptom in patients with peptic ulcer disease is dyspepsia, which is a technical term for indigestion. [courses.washington.edu]

• Melena

  RESULTS: Of all patients admitted for endoscopy, 147/649 (23%) had PUD with the main symptom of melena. Of these PUD patients, 35% had major stigmata of bleeding (Forrest Ia-IIb) in endoscopy. [ncbi.nlm.nih.gov]

  / hematochezia (20%) hematemesis (30%) both melena and hematemesis (50%) perforation affects up to 6% of ulcer patients 1 generalized acute abdominal pain, peritonism and shock 2 pain may radiate to the right shoulder and back 2 pain may prominently [radiopaedia.org]

  Melena – black very sticky stool, often compared to roof tar. This is a common symptom of a bleeding ulcer. Black stool that looks like melena can be caused by taking iron medications and by drugs like Pepto-Bismol ®. [patients.gi.org]

  Melena – black very sticky stool, often compared to roof tar. This is a common symptom of a bleeding ulcer. Black stool that looks like melena can be caused by taking iron medications and by drugs like Pepto-Bismol®. [gi.org]

• Halitosis

  All was well for 5 days, but then he developed halitosis, morning nausea, and recurrent vomiting of acid-free gastric juice. A gastric biopsy on Day 10 showed severe acute gastritis and many H. pylori ( Box 3 ). [web.archive.org]

  His symptoms disappeared after two weeks, but he took antibiotics to kill the remaining bacteria at the urging of his wife, since halitosis is one of the symptoms of infection.[38] This experiment was published in 1984 in the Australian Medical Journal [en.wikipedia.org]

• Chest Pain

  Other PUD symptoms include the following: Heartburn (acid reflux) Indigestion (dyspepsia) Nausea and vomiting Non-cardiac chest pain Weight loss In patients who have peptic ulcer disease, stress, diet (e.g., spicy foods, foods that are high in fat), alcohol [healthcommunities.com]

  The pain: Starts between meals or during the night Briefly stops if you eat or take antacids Lasts for minutes to hours Comes and goes for several days or weeks Other possible symptoms include: Bloody or dark tarry stools Chest pain Fatigue Vomiting, [wexnermedical.osu.edu]

  Symptoms may include: burning pain in the stomach nausea vomiting chest pain loss of appetite weight loss difficulty feeding blood in the stools or vomit (may be red or black) unger pain a few hours after eating (pain often goes away after eating something [virtualpediatrichospital.org]

  […] in the stomach region Stomach becomes rigid Low body temperature Unusually fast heart rate Chest pain appears or worsens, or spreads to the back, neck, shoulder, or arm Trouble breathing or swallowing Confusion Extreme drowsiness or trouble waking up [fairview.org]

  Chest pain include:Gastroenterological causes, such as acute pancreatitis, oesophageal rupture, peptic ulcer disease,... Crohn's disease surfaces of the legs or arms. [evidence.nhs.uk]

In diagnosis of ulcers, patients are subjected to diagnostic tests such as:

• Tests for Helicobacter pylori (stool, blood or breath depending on condition)
• Endoscopy (biopsy used in identification of Helicobacter pylori in the stomach lining)
• X-ray of the upper digestive system 

• Pneumoperitoneum

  The study showed pneumoperitoneum, contrast stasis in heart with decreased caliber of vessels below the abdominal aortic level, and diffuse lymphedema at the abdominal walls. Emergent laparotomy was performed. [ncbi.nlm.nih.gov]

  Perforation is usually a straightforward diagnosis, often with abundant pneumoperitoneum visible. The site of perforation is sometimes visible as a region of discontinuity in the stomach or duodenal wall. [radiopaedia.org]

  Recently, Computerized tomography (CT) scans with oral contrast are now considered the reliable method of detecting small pneumoperitoneum before surgery and the gold standard for the diagnosis of a perforation [12,54,81-83]. [oatext.com]

  Upright or lateral decubitus abdominal radiography or erect chest radiography may demonstrate pneumoperitoneum; however, the absence of this finding does not rule out perforation. 17 Sonography, computed tomography, and gastroduodenography are confirmatory [aafp.org]

• Helicobacter Pylori

  Its impact is seen in 'idiopathic' and Helicobacter pylori-associated ulcers, and in acute surgical cases. [ncbi.nlm.nih.gov]

  Again, Helicobacter pylori colonisation often results in inflammation. To reduce the risk of peptic ulcer, the following is advised: Protect yourself from Helicobacter pylori infection. [symptoma.com]

  Helicobacter pylori in peptic ulcer disease. NIH Consensus Development Panel on Helicobacter pylori in Peptic Ulcer Disease. JAMA 1994; 272: 65-9. JAMA Hopkins RJ, Girardi LS, Turney EA. [web.archive.org]

  As with adults, use of nonsteroidal anti-inflammatory drugs (NSAIDs) and infection with Helicobacter pylori bacteria can lead to the formation of peptic ulcers. In children, Helicobacter pylori is not as common a cause as in adults. [merckmanuals.com]

• Occult Blood Positive

  blood positive test acute presentation: melena / hematochezia (20%) hematemesis (30%) both melena and hematemesis (50%) perforation affects up to 6% of ulcer patients 1 generalized acute abdominal pain, peritonism and shock 2 pain may radiate to the [radiopaedia.org]

Treatment for peptic ulcers is dependent on the cause of the condition. Antibiotic medications taken over a period of two weeks can eradicate Helicobacter pylori [8]. Antibiotics are often used with additional medications to reduce stomach acid.

In the case of excessive acid production, protein pump inhibitors that block the production and promote healing can be used. Other treatment agents are histamine blockers, and antacids. Antacids are used to provide relief but they do not heal ulcers [9].

As long as the underlying cause is addressed, prognosis is positive. Majority of patients are successfully treated with eradication of Helicobacter pylori, adequate use of antisecretory therapy and the avoidance of drugs that are etiologic factors [6]. When Helicobacter pylori is eradicated, the natural history of the disease is altered and this leads to reduction of the recurrence rate from 60-90% to around 10-20%.

Mortality rate for peptic ulcer disease has decreased a great deal over the last three decades to approximately 1 death for every 100,000 cases.

Ulcers are caused by a variety of factors but in most cases, they arise as a result of Helicobacter pylori infection [3]. Other main causes of ulcer are drug use, unfavourable life style choices, severe physiologic stress, hypersecretory states and genetics.

Other lesser etiologic factors include:

• Hepatic cirrhosis
• Bile gastropathy
• Chronic obstructive pulmonary disease
• Graft versus host disease 
• Cytomegalovirus infection
• Allergic gastritis and eosinophilic gastritis
• Uremic gastropathy
• Celiac disease
• Henoch-Schönlein gastritis
• Corrosive gastropathy
• Crohn disease
• Autoimmune disease
• Other granulomatous gastritides such as sarcoidosis, histiocytosis X, tuberculosis
• Phlegmonous gastritis and emphysematous gastritis
• Use of crack cocaine, which causes localized vasoconstriction, resulting in reduced blood flow and may also lead to mucosal damage.
• Infections such as Epstein-Barr virus, HIV, Helicobacter heilmannii, herpes simplex, influenza, syphilis, Candida albicans, histoplasmosis, mucormycosis, and anisakiasis.
• Local radiation resulting in mucosal damage, which may lead to the development of duodenal ulcers.
• Chemotherapeutic agents

Peptic ulcer affects around 4.5 million people each year in the US. In other countries, the figures are variable and incidence is determined majorly on association with the major causes of peptic ulcer [4].

In the past, peptic ulcer was seen more in males than in females but now it occurs similarly in both males and females. Age statistics show that ulcer occurrence is declining in younger men especially for duodenal ulcer, while rates continue to increase in older women.

Peptic ulcers signify a defect in the gastric or duodenal mucosa which extends through the muscularis mucosa [5]. In a healthy individual, there is a physiologic balance between gastric acid secretion and gastroduodenal mucosal defense.

Mucosal injury and peptic ulcer set in when the balance between the aggressive factors and defensive mechanisms of the stomach become disrupted. Aggressive factors like Helicobacter pylori infection, alcohol pepsin and bile salts can alter the mucosal defense by allowing hydrogen ion diffusion and ensuing injury to the epithelial cell. Again, Helicobacter pylori colonisation often results in inflammation.

To reduce the risk of peptic ulcer, the following is advised [10]:

• Protect yourself from Helicobacter pylori infection. There is no definite path on how it spreads but evidence suggest that it can be transmitted from person to person and via food and water. Prevention can therefore be achieved by adequate hygiene and consistent washing of hands with soap and water and also eating properly cooked foods.
• Exercise caution when using pain relievers as regular use only increases the risk of peptic ulcer. It is also advisable to take medications with meals at all times.

Peptic ulcer refers to the condition that arises when there is a clear breach in the mucosal lining of the stomach or the first part of the small intestine [1]. The former is known as gastric ulcer while the latter is known as duodenal ulcer. Peptic ulcers arise following the caustic effects of acid and pepsin in the lumen.

Peptic ulcer is defined histologically as a necrosis of the mucosa that leads to the production of lesions that are equal to or greater than 0.5 cm. It is also the most common ulcer of the gastrointestinal tract. The very painful nature of the condition is a result of the acidic nature of the gastrointestinal tract. Ulcers are often worsened by drugs like aspirin or ibuprofen.

Peptic ulcers occur four times more in the duodenum than in the stomach. 4% of gastric ulcers are as a result of a malignant tumor [2]. This is why biopsies are used in most cases to exclude the possibility of cancer. Duodenal ulcers are benign generally.

Peptic ulcers are sores that develop on the lining of the esophagus, stomach, and upper part of the small intestine. In patients with peptic ulcer the most common symptom is abdominal pain.

Ulcers that occur inside the stomach are known as gastric ulcers while those that occur in the throat and in the upper part of the small intestine are known as esophageal and duodenal ulcers respectively.

Treatment of ulcers in most cases is with the aid of antibiotics and medication to help reduce the pain and other symptoms that arise from it. Contrary to common opinion, eating spicy meals or working a stressful shift does not cause ulcer.

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3. Lai KC, Lam SK, Chu KM, Wong BC, Hui WM, Hu WH, et al. Lansoprazole for the prevention of recurrences of ulcer complications from long-term low-dose aspirin use. N Engl J Med. Jun 27 2002;346(26):2033-8.
4. Lai KC, Lam SK, Chu KM, Hui WM, Kwok KF, Wong BC, et al. Lansoprazole reduces ulcer relapse after eradication of Helicobacter pylori in nonsteroidal anti-inflammatory drug users--a randomized trial. Aliment Pharmacol Ther. Oct 15 2003;18(8):829-36.
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7. Gudmand-Høyer E, Jensen KB, Krag E, et al. Prophylactic effect of cimetidine in duodenal ulcer disease. Br Med J 1978; 1:1095.
8. Current status of maintenance therapy in peptic ulcer disease. The ACG Committee on FDA-Related Matters. Am J Gastroenterol 1988; 83:607.
9. Jorde R, Bostad L, Burhol PG. Asymptomatic gastric ulcer: a follow-up study in patients with previous gastric ulcer disease. Lancet 1986; 1:119.
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