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usmle step 2 ck

Peptic Ulcer Disease

Mucosal ulceration of the stomach or duodenum, most often from Helicobacter pylori infection or NSAID exposure, presenting with epigastric pain or bleeding

Review date
reviewed 2026-05-04
Reading time
8 min read
Author
Dr Kola Tytler MBBS CertHE MBA MSt MRCGP
Gastroenterology & Hepatologycommonacute
On this page
Condition details
Gastroenterology & Hepatology
common
8 min read
reviewed 2026-05-04
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About This Page

This is a clinician-written, evidence-based summary aligned to the USMLE Step 2 CK Content Outline. It is intended for medical students preparing for USMLE Step 2 CK. Management reflects current ACC/AHA, USPSTF, and APA guidelines. Always cross-reference with UpToDate, institutional protocols, and clinical judgment.

Key points

  • Most PUD is caused by H pylori or NSAIDs; smoking impairs healing and increases recurrence
  • Duodenal ulcer pain classically improves with meals; gastric ulcer pain worsens with meals and may cause weight loss
  • Alarm features or age >=60 with new dyspepsia require upper endoscopy
  • Test for H pylori and confirm eradication at least 4 weeks after antibiotics and after holding PPI for 2 weeks
  • Bleeding ulcer after endoscopic hemostasis: high-dose PPI for 72 hours, then oral PPI

Overview

Peptic ulcer disease is a break in gastric or duodenal mucosa extending through the muscularis mucosae. H pylori weakens mucosal defense and increases acid injury; NSAIDs inhibit prostaglandin-mediated mucus and bicarbonate secretion. Gastric ulcers require careful evaluation because malignancy can mimic benign ulcer disease.

Epidemiology

Lifetime risk is approximately 5-10%. NSAID ulcer risk rises with age, prior ulcer, high-dose NSAIDs, aspirin, anticoagulants, antiplatelets, corticosteroids, and SSRIs. Complicated PUD remains a major cause of non-variceal upper GI bleeding.

Clinical Features

Symptoms
Burning or gnawing epigastric pain
Duodenal ulcer: pain 2-5 hours after meals or at night, relieved by food or antacids
Gastric ulcer: pain shortly after eating, nausea, early satiety, weight loss
Melena, hematemesis, syncope, or fatigue from anemia
Sudden severe generalized abdominal pain suggests perforation
Signs
Epigastric tenderness without peritonitis in uncomplicated disease
Orthostatic hypotension or tachycardia with bleeding
Rigid abdomen, rebound, guarding, absent bowel sounds with perforation
Succussion splash if gastric outlet obstruction

Investigations

First-line
H pylori testingUrea breath test or stool antigen preferred for active infection; serology remains positive after eradication
CBC and iron studiesAssess anemia in suspected bleeding or chronic occult blood loss
Second-line
Upper endoscopyAlarm features, age >=60 with new dyspepsia, suspected bleeding, obstruction, perforation, or refractory symptoms; biopsy gastric ulcers
CT abdomen or upright chest/abdominal X-rayFree air under diaphragm suggests perforated ulcer
Specialist
Fasting serum gastrinMultiple/refractory ulcers, ulcers distal to duodenal bulb, or diarrhea suggesting Zollinger-Ellison syndrome
Repeat EGDUsually performed to document healing of gastric ulcers or if symptoms persist

Management

ACG H pylori Treatment Guideline 2024 and ACG Upper GI Bleeding Guideline 2021
1
Uncomplicated ulcer
  • Stop NSAIDs if possible; if required, use lowest dose plus PPI
  • PPI for 4 weeks for duodenal ulcer and 8 weeks for gastric ulcer
  • Avoid smoking and test all PUD patients for H pylori
2
H pylori eradication
  • Preferred empiric regimen when susceptibility unknown: 14-day bismuth quadruple therapy
  • Avoid clarithromycin triple therapy unless susceptibility confirms sensitivity and macrolide exposure is absent
  • Confirm eradication with urea breath test or stool antigen
3
Complicated ulcer
  • Bleeding: resuscitate, transfuse if Hgb <7 g/dL in most patients, EGD within 24 h, high-dose PPI after hemostasis
  • Perforation: NPO, IV fluids, broad-spectrum antibiotics, IV PPI, urgent surgical consultation
  • Gastric outlet obstruction: NG decompression, fluids, electrolytes, endoscopic or surgical therapy if persistent

Complications

  • Upper GI bleeding: Most common complication.
  • Perforation: Sudden severe pain, peritonitis, free air under diaphragm.
  • Penetration: Posterior duodenal ulcer can penetrate pancreas causing back pain.
  • Gastric outlet obstruction: Early satiety, vomiting, hypochloremic metabolic alkalosis.
  • Gastric cancer mimic: Gastric ulcers require biopsy when suspicious.
USMLE Step 2 CK Exam Tips
  • 1Duodenal ulcer improves with meals; gastric ulcer worsens with meals
  • 2All ulcers should be assessed for H pylori and NSAID exposure
  • 3Never use H pylori serology to confirm eradication
  • 4Perforated ulcer = acute abdomen + free air; urgent surgery after resuscitation
  • 5Posterior duodenal ulcer bleeding often involves the gastroduodenal artery
  • 6Refractory/multiple distal ulcers + diarrhea = Zollinger-Ellison syndrome
  • 7Gastric ulcer needs biopsy because cancer can mimic an ulcer

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Verified Sources & References

ACG Clinical Guideline: H pylori Treatment 2024
ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding 2021
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