Intended for healthcare professionals

Practice Clinical Update

Peptic ulcer disease

BMJ 2019; 367 doi: (Published 02 October 2019) Cite this as: BMJ 2019;367:l5495
  1. Emma Sverdén, upper gastrointestinal surgeon1 2,
  2. Lars Agréus, general practitioner, professor3 4,
  3. Jason M Dunn, gastroenterologist5,
  4. Jesper Lagergren, upper gastrointestinal surgeon, professor1 5
  1. 1Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
  2. 2Department of Upper Gastrointestinal Surgery, South Hospital, Stockholm, Sweden
  3. 3Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
  4. 4The University of Newcastle, Australia
  5. 5School of Cancer and Pharmaceutical Sciences, King’s College London, and Guy’s and St Thomas’ NHS Foundation Trust, UK
  1. Correspondence to emma.s.eklund{at}

What you need to know

  • More than 90% of duodenal ulcers are linked to H pylori infection; eradication therapy with antibiotics and proton pump inhibitors is the mainstay of treatment

  • A “test and treat” strategy for H pylori infection is appropriate in patients under 60 with suspected peptic ulcer disease who have no complications

  • Proton pump inhibitors are important in the prevention and treatment of peptic ulcer disease, but avoid their use without clear indications, and re-evaluate patients on long-term treatment

  • Gastric ulcers are followed up with endoscopy until healed to rule out malignancy

  • Urgently refer patients with complications such as bleeding, perforation, or penetration to an emergency unit

Peptic ulcer disease presents with gastrointestinal symptoms similar to dyspepsia and can be difficult to distinguish clinically. It can have potentially serious complications such as bleeding or perforation, with a high risk of mortality.1 Optimal treatment with proton pump inhibitors (PPIs) facilitates healing and can prevent complications and recurrence.

Observational studies and surveys among healthcare providers report that adherence to evidence based treatment guidelines is often poor.23456789 This results in inadequate treatment and overuse of PPIs. Increasingly, antibiotic resistance has affected the choice of eradication regimen for Helicobacter pylori infection, the main risk factor. In this Clinical Update, we review the epidemiology and management of peptic ulcer disease for non-specialists to guide prompt diagnosis and appropriate treatment.

What is peptic ulcer disease?

Peptic ulcer disease is often defined as a mucosal break greater than 3-5 mm in the stomach or duodenum with a visible depth. It is therefore an endoscopic diagnosis in contrast to dyspepsia, which is a clinical diagnosis based on symptoms alone. Peptic ulcer disease results from an imbalance between factors that protect the mucosa of the stomach and duodenum, and factors that cause damage to it (fig 1). …

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