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.

• Pain

  The daily pattern of pain is related to the secretion of acid and the presence of food in the stomach to act as a buffer. This pain is diminished in the morning when secretion is low and after meals when food is present. [medical-dictionary.thefreedictionary.com]

  Duodenal ulcers tend to cause more consistent pain. Pain is absent when the patient awakens but appears in mid-morning and is relieved by food but recurs 2 to 3 h after a meal. [merckmanuals.com]

  The pain of ulcer disease correlates poorly with the presence or severity of active ulceration. Some individuals have persistent pain even after an ulcer is almost completely healed by medication. Others experience no pain at all. [medicinenet.com]

  […] and upper abdominal pain that improves with eating.[1] With a gastric ulcer, the pain may worsen with eating.[8] The pain is often described as a burning or dull ache.[1] Other symptoms include belching, vomiting, weight loss, or poor appetite.[1] About [en.wikipedia.org]

  Sometimes the pain can be localized to left upper quadrant (proximal stomach ulcers) or right upper quadrant (duodenal ulcers). The pain is described as “burning” or “gnawing” though some patients present with a vague, diffuse abdominal pain. [clinicaladvisor.com]

• Anemia

  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]

  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]

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

  Other tests you may have include: Hemoglobin blood test to check for anemia Stool occult blood test to test for blood in your stool Sometimes, you may need a test called an upper GI series. [nlm.nih.gov]

• Fatigue

  […] include: Nausea and vomiting Poor appetite Weight loss Bloating Burping Symptoms that require immediate medical attention are associated with bleeding and they include: Sudden sharp abdominal pain Blood in the stool or vomit Dark-colored stool or vomit Fatigue [innerbody.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]

  […] 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]

• 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]

  The side effects of these antibiotic are usually mild and include: nausea, vomiting, diarrhoea, and a metallic taste in the mouth. [hse.ie]

  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 [msdmanuals.com]

  It is characterized by epigastric fullness or pain, cramps, nausea, palpitations, vertigo, extreme weakness, hot sensations, and cold sweats occurring immediately after eating. [veterans.gc.ca]

• Abdominal Pain

  Symptoms Symptoms include: Upper abdominal pain Pain on hunger Pain at night Pain relieved by food Nausea, loss of appetite, fullness after eating can occur. [singhealth.com.sg]

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

  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]

• Dyspepsia

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

  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]

• 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 [msdmanuals.com]

  Symptoms Symptoms include: Upper abdominal pain Pain on hunger Pain at night Pain relieved by food Nausea, loss of appetite, fullness after eating can occur. [singhealth.com.sg]

  Gastritis and an ulcer are conditions that affect the stomach and small intestine, and they share many symptoms, such as abdominal pain, nausea, vomiting, loss of appetite and weight loss. There are many differences, though. [tmphysiciannetwork.org]

  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]

• 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 right shoulder and back 2 pain may prominently [radiopaedia.org]

  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]

  Rectal exam should be done to rule out melena and get a sample for fecal occult blood. C. Laboratory Tests to Monitor Response To, and Adjustments in, Management. The response has to be monitored clinically. [clinicaladvisor.com]

  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]

• 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]

  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]

  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]

  […] 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]

• 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 ). [mja.com.au]

  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]

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

  H. pylori testing and treatment, avoiding use of NSAIDs. "Helicobacter pylori in peptic ulcer disease. NIH Consensus Development Panel on Helicobacter pylori in peptic ulcer disease". JAMA. vol. 272. 1994. pp. 65. [clinicaladvisor.com]

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

  pylori Peptic ulcer, MALT lymphoma, Gastric cancer Helicobacter cinaedi Helicobacter cellulitis [en.wikipedia.org]

  If Helicobacter pylori is found in the ulcer, the patient is treated with antibiotics. [medical-dictionary.thefreedictionary.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.

1. Chey WD, Wong BC. American College of Gastroenterology guideline on the management of Helicobacter pylori infection. Am J Gastroenterol. Aug 2007;102(8):1808-25.
2. Javid G, Zargar SA, U-Saif R, Khan BA, Yatoo GN, Shah AH, et al. Comparison of p.o. or i.v. proton pump inhibitors on 72-h intragastric pH in bleeding peptic ulcer. J Gastroenterol Hepatol. Jul 2009;24(7):1236-43.
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.
5. Sung JJ, Tsoi KK, Ma TK, Yung MY, Lau JY, Chiu PW. Causes of mortality in patients with peptic ulcer bleeding: a prospective cohort study of 10,428 cases. Am J Gastroenterol. Jan 2010;105(1):84-9. 
6. Bardhan KD, Cole DS, Hawkins BW, Franks CR. Does treatment with cimetidine extended beyond initial healing of duodenal ulcer reduce the subsequent relapse rate? Br Med J (Clin Res Ed) 1982; 284:621.
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.
10. Howden CW, Hunt RH. The relationship between suppression of acidity and gastric ulcer healing rates. Aliment Pharmacol Ther 1990; 4:25.