Peptic ulcer disease (PUD)


Peptic ulcer disease is caused by peptic ulceration that involves the stomach, duodenum and lower oesophagus.

It is an increasingly common problem in developing countries.

Most ulcers are duodenal

Causes and Predisposing factors of Peptic Ulcer Disease

  • H. pylori gut infection
  • Use of NSAIDs
  • Smoking

Symptoms or Clinical features of Peptic Ulcer Disease

  • Recurrent epigastric pain often radiating to the back, worse at night and improved by antacids

Complications of Peptic Ulcer Disease

  • Upper gastrointestinal bleeding
  • Perforation/Penetration
  • Gastric outlet obstruction
  • Gastric cancer


  • Full Blood Count
  • Liver Function Tests
  • Urea, Electrolytes and Creatinine
  • Occult blood test.
  • Stool microscopy
  • Endoscopy,
  • Double contrast barium meal
  • Direct/indirect detection of H. pylori (by CLO test or by CO, breath test)

Differential diagnoses

  • Gastritis
  • Duodenitis
  • Non-Ulcer dyspepsia
  • Gastro-duodenal malignancy
  • Oesophagitis
  • Gall bladder diseases

Treatment objectives

  • Relieve pain
  • Promote healing of ulcers.
  • Eradicate H.pylori
  • Prevent/reduce recurrence

Drug treatment

  • Symptomatic treatment with antacids may be used prior to confirming the diagnosis of peptic ulcer disease
  • H.pylori eradication using triple therapy.


Omeprazole PO: 20 mg once daily in the morning for 7 to 10 days. In severe or recurrent cases, dose can be increased to 40 mg once daily and the treatment can be prolonged for up to 2 months.

Oral Omeprazole is to be taken in an empty stomach, at least 30 minutes before meal.

Other PPIs other than Omeprazole can be used too.


  • Consider perforation
  • Treat acute pain
  • Administer IV Omeprazole 40 mg once daily over 20 to 30 minutes
  • Refer to a surgeon

Triple therapy with:

Clarithromycin 500 mg orally every 12 hours for 7 days


Amoxicillin 1g orally every 12 hours for 7 days


Omeprazole 20 mg orally every 12 hours for 7 days

In penicillin-allergic patients, amoxicillin PO can be substituted with metronidazole PO 500 mg 2 times daily.

Adjunct therapy

Magnesium trisilicate suspension 15 mL. orally three times daily as required.

Treatment of complications

1. Mild upper gastrointestinal bleeding:

  • Intravenous omeprazole 20 mg 12 hourly for 5 days then standard triple therapy. 

2. Severe upper gastrointestinal bleeding:  

  • Interventional endoscopic treatment
  • Blood transfusion
  • Surgery

3. Perforation

  • Surgery

4. Gastric outlet obstruction

  • Rest the gut
  • Surgery

Supportive therapy

  • Regular meals
  • Avoidance of provocative factors (NSAIDs, alcohol, spicy foods etc.)

Notable adverse drug reactions

  • Gastric irritation
  • Diarrhoea from triple therapy
  • Diarrhoea/constipation from adjunct therapy

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