1. Definition, types, and pathophysiology
2. Symptoms, examination, and differential diagnosis
3. ECG and troponin-based diagnosis
4. Immediate emergency management and reperfusion
5. NSTEMI/unstable-angina risk stratification and invasive management
6. Medications and secondary prevention
7. Complications and prognosis

1. Definition, types, and pathophysiology
2. Symptoms, examination, and differential diagnosis
3. ECG and troponin-based diagnosis
4. Immediate emergency management and reperfusion
5. NSTEMI/unstable-angina risk stratification and invasive management
6. Medications and secondary prevention
7. Complications and prognosis

Peptic ulcer disease (PUD): topic map

1. Definition and types
   • Gastric ulcer versus duodenal ulcer
   • Acute versus chronic ulcers
2. Causes and risk factors
   • Helicobacter pylori
   • NSAIDs and aspirin
   • Smoking, severe physiological stress, hypersecretory states
   • Less common causes such as malignancy or Crohn disease
3. Pathogenesis
   • Imbalance between acid-pepsin injury and mucosal defenses
   • How H. pylori and NSAIDs produce ulcers
4. Clinical features
   • Epigastric pain patterns
   • Nausea, bloating, early satiety
   • Silent ulcers, particularly with NSAID use
5. Diagnosis
   • Alarm features
   • Upper GI endoscopy and biopsy
   • Tests for H. pylori
   • When imaging or laboratory tests are useful
6. Treatment
   • Proton-pump inhibitors
   • H. pylori eradication regimens
   • Management when NSAIDs or antiplatelet drugs are necessary
   • Confirmation of eradication and follow-up endoscopy
7. Complications
   • Upper GI bleeding
   • Perforation
   • Gastric outlet obstruction
   • Penetration and malignancy consideration in gastric ulcers
8. Prevention and prognosis
   • NSAID gastroprotection
   • Lifestyle measures
   • Recurrence prevention

Evidence-based diagnostic approach to suspected peptic ulcer disease

1. First, identify emergencies

• Hematemesis, coffee-ground vomit, melena, syncope, hypotension, or tachycardia: possible upper GI bleeding
• Sudden severe generalized abdominal pain, guarding, rigidity, fever, or shock: possible perforation
• Persistent vomiting, dehydration, early satiety with weight loss: possible gastric outlet obstruction

2. Establish the pretest probability

• Epigastric burning, gnawing, or aching pain
• Nocturnal pain or pain related to meals
• Nausea or bloating
• A past ulcer or H. pylori infection

• NSAIDs, including over-the-counter ibuprofen, naproxen, diclofenac, and high-dose aspirin
• Antiplatelet agents, anticoagulants, corticosteroids, SSRIs, bisphosphonates
• Prior H. pylori treatment or eradication testing
• Smoking, alcohol, cocaine or other ulcerogenic exposures
• Family history of gastric cancer
• Prior gastric surgery
• Immunosuppression

• Epigastric tenderness
• Pallor, orthostatic hypotension or tachycardia
• Weight loss, lymphadenopathy, abdominal mass
• Peritoneal signs

3. Decide: endoscopy now or noninvasive testing first?

A. Upper endoscopy with biopsy is preferred when there is high risk

• Overt GI bleeding or iron-deficiency anemia
• Persistent vomiting or suspected obstruction
• Unintentional weight loss
• Dysphagia or odynophagia
• Palpable mass, lymphadenopathy, or concerning systemic features
• New dyspepsia in an older adult, commonly age 60 years or above in North American guidance
• Increased gastric-cancer risk, such as a first-degree family history or immigration from a high-incidence region
• Persistent symptoms despite appropriate initial management
• Long-term NSAID use, especially with additional bleeding risks

1. Confirm ulcer location, size, depth, bleeding stigmata, and obstruction.
2. Take gastric biopsies from a gastric ulcer and suspicious mucosa to exclude malignancy.
3. Obtain gastric biopsies for H. pylori testing, typically with histology and/or rapid urease testing.

B. Noninvasive “test-and-treat” is appropriate for lower-risk dyspepsia

4. Test for H. pylori correctly

Avoid false-negative tests

• Stop PPIs or potassium-competitive acid blockers for 2 weeks if clinically safe.
• Stop antibiotics and bismuth for at least 4 weeks.
• H2 blockers may sometimes be used temporarily, but local testing instructions should be followed.

5. If an ulcer is found

1. Test for H. pylori.
2. Review NSAID, aspirin, and other relevant drug exposure.
3. If both are absent, confirm true negativity, including whether PPIs, antibiotics, or bismuth could have caused a false-negative result.
4. Consider uncommon etiologies in refractory, multiple, distal, recurrent, or atypical ulcers:
   • Hypersecretory state such as Zollinger-Ellison syndrome
   • Crohn disease
   • Malignancy
   • CMV or other infection in immunocompromised people
   • Ischemia or substance-related injury

• Gastric ulcer: repeat EGD is generally used to document healing and exclude missed malignancy, especially if biopsy was limited, symptoms persist, the ulcer appears suspicious, or risk is high.
• Uncomplicated duodenal ulcer: routine repeat endoscopy is usually unnecessary if symptoms resolve and H. pylori eradication is documented, unless symptoms, bleeding, obstruction, or diagnostic uncertainty persists.

Practical algorithm

Suspected PUD / dyspepsia
        |
        |-- Bleeding, perforation, obstruction, instability?
        |       |-- Yes: resuscitate + urgent imaging/endoscopy or surgery as appropriate
        |       '-- No
        |
        |-- Alarm features, age ≥60, high gastric-cancer risk, persistent/refractory symptoms?
        |       |-- Yes: EGD + gastric and ulcer biopsies + H. pylori testing
        |       '-- No
        |
        '-- Age <60, no alarm features:
                Urea breath test or stool antigen test
                    |
                    |-- Positive: diagnose active H. pylori infection, treat, confirm eradication
                    '-- Negative: assess NSAID exposure and alternative diagnoses;
                                 consider PPI trial or EGD if symptoms persist

Evidence-based diagnostic approach to suspected peptic ulcer disease

1. Triage first: rule out a complication

• Hematemesis, coffee-ground vomiting, melena, syncope, hypotension, or tachycardia: possible upper GI bleed
• Sudden severe abdominal pain with guarding, rigidity, or shock: possible perforation
• Persistent vomiting, dehydration, early satiety, or marked weight loss: possible gastric outlet obstruction

• CBC, urea/creatinine and electrolytes, liver tests, coagulation tests, blood group and crossmatch as indicated
• Urgent upper endoscopy for suspected upper GI bleeding after resuscitation
• CT abdomen/pelvis for suspected perforation if stable. Avoid routine endoscopy when perforation is suspected because insufflation may worsen it. Sleisenger and Fordtran's Gastrointestinal and Liver Disease, p. 11.7.

2. Assess likelihood and alternative diagnoses

• NSAIDs, aspirin, corticosteroids, anticoagulants, antiplatelets, SSRIs
• Previous ulcer or H. pylori infection/treatment
• Smoking and alcohol
• Family history of gastric cancer
• Unintentional weight loss, dysphagia, vomiting, GI bleeding, anemia
• Immunosuppression and prior gastric surgery

3. Select endoscopy or noninvasive H. pylori testing

Perform upper GI endoscopy with biopsy if:

• Overt GI bleeding or iron-deficiency anemia
• Persistent vomiting or possible obstruction
• Unintentional weight loss
• Dysphagia or odynophagia
• Palpable mass or suspicious examination findings
• New dyspepsia at age 60 years or older
• Strong family history of gastric cancer or other increased gastric-cancer risk
• Persistent/recurrent symptoms despite appropriate initial management
• Suspected gastric ulcer or long-term NSAID exposure with concerning symptoms

• Biopsies from any gastric ulcer to exclude malignancy
• Gastric biopsies for H. pylori testing, using histology and/or rapid urease testing

Use noninvasive H. pylori test-and-treat if:

• Age below 60 years
• Dyspepsia without alarm features
• No high gastric-cancer-risk features
• No immediate reason for endoscopy

4. Test accurately for Helicobacter pylori

• Stop PPIs or PCABs for 2 weeks before testing, if safe.
• Stop antibiotics and bismuth for 4 weeks before testing.

5. If an ulcer is demonstrated

1. Test for H. pylori.
2. Review NSAID/aspirin and other ulcerogenic medication exposure.
3. If H. pylori negative and no NSAID exposure, verify that medication-related false-negative testing has not occurred.
4. Investigate atypical, multiple, recurrent, refractory, or distal ulcers for:
   • Zollinger-Ellison syndrome
   • Malignancy
   • Crohn disease
   • CMV or other infection in immunocompromised patients
   • Ischemia or drug-induced injury

6. Follow-up

• Gastric ulcer: repeat endoscopy is commonly required to document healing and exclude malignancy, particularly if appearance or histology is concerning.
• Duodenal ulcer: routine repeat endoscopy is usually unnecessary if symptoms resolve and H. pylori eradication has been confirmed, unless there is bleeding, obstruction, recurrent symptoms, or diagnostic uncertainty.

One-line algorithm

Suspected PUD
  → unstable / bleed / perforation / obstruction? urgent resuscitation and targeted endoscopy or CT
  → otherwise alarm feature, age ≥60, high cancer risk, or persistent symptoms? EGD plus biopsy
  → otherwise: urea breath or stool antigen test for H. pylori
  → if positive: treat and confirm eradication
  → if negative or symptoms persist: review NSAIDs and alternative diagnoses; consider EGD