2. Gastro-intestinal Ulcer Disease (GUD)

📄Definition

Mucosal ulceration in the stomach (gastric ulcer) or proximal duodenum (duodenal ulcer), due to imbalance between mucosal defences and acid/pepsin exposure.

🛡️ Aetiology / Risk Factors – Mnemonic: SHADE

  • Smoking

  • Helicobacter pylori infection

  • Anti-inflammatory drugs (NSAIDs, aspirin)

  • Duodenal acid hypersecretion

  • Excess alcohol / emotional stress (less common)

High-risk groups:

  • Elderly on NSAIDs ± steroids

  • Previous ulcer/bleed

  • Chronic anticoagulant use

🤒 Clinical Features (Mnemonic: DUPE)

    • Dyspepsia:

      • Duodenal ulcer: pain relieved by food, worse at night

      • Gastric ulcer: pain worsened by food

    • Ulcer complications: bleeding, perforation, obstruction

    • Post-prandial fullness / bloating

    • Epigastric tenderness on palpation

🚩 OGD Referral Criteria:

Refer for urgent endoscopy if:

1️⃣ Urgent – 2 Week Wait (ALARM55)

  • Anaemia (iron deficiency)

  • Loss of weight (unintentional)

  • Anorexia

  • Recent-onset progressive dysphagia

  • Melaena / haematemesis

  • 55 – Age ≥55 with new-onset symptoms

2️⃣ Non-Urgent OGD – Without ALARM Features

  • Age ≥55 with unexplained, persistent dyspepsia

  • Persistent symptoms after 4–8 week PPI trial + negative H. pylori

  • Unexplained iron-deficiency anaemia without obvious source

🔬 Investigations

If NO red flags →

  • Test for H. pylori before OGD in most cases

    • 1st-line: Urea breath test or stool antigen

    • Stop PPI ≥2 weeks before testing

  • Consider FBC (anaemia), LFTs/amylase (differentials)

If red flags present →

  • Urgent OGD

    • Gastric ulcer → biopsy to exclude malignancy

    • CLO test or histology for H. pylori

Follow-up OGD

    • Gastric ulcer – always re-scope at 6–8 weeks to confirm healing

    • Duodenal ulcer – no routine re-scope if H. pylori eradicated & symptoms resolved

💊 Management (Mnemonic: HOPER)

1️⃣ H. pylori eradication (if positive)

  • Triple therapy × 7 days:

    • PPI + clarithromycin + amoxicillin

    • Metronidazole if penicillin-allergic

  • Confirm eradication ≥4 weeks post-treatment (off PPI ≥2 weeks)

2️⃣ Omeprazole (PPI) – healing therapy

  • Omeprazole 20–40 mg OD × 4–8 weeks

3️⃣ Prevention (NSAID users)

  • Stop NSAIDs if possible

  • If unavoidable: co-prescribe PPI, eradicate H. pylori first

4️⃣ Endoscopy follow-up

  • As above – re-scope gastric ulcers, not routine for duodenal ulcers

5️⃣ Risk factor modification

  • Stop smoking

  • Limit alcohol/caffeine/spicy foods

⚠️Complications (Mnemonic: BAPH)

  • Bleeding – may present with haematemesis or melaena

  • Anaemia – iron deficiency from chronic blood loss

  • Perforation – presents with acute abdomen

  • Hourglass deformity – from fibrosis/scarring (rare)

💡Key Exam Traps for PARA MCQs

  • Gastric ulcer pain worse with food, duodenal relieved by food

  • Always biopsy gastric ulcers to exclude cancer

  • Stop PPIs 2 weeks before H. pylori testing — common MCQ distractor

  • NSAID use + ulcer → stop NSAID, treat H. pylori, give PPI

  • Only gastric ulcers need repeat OGD

  • Bleeding risk rises with SSRIs, steroids, anticoagulants

🔬 Differentiating Gastric vs Duodenal Ulcers

Feature Gastric Ulcer Duodenal Ulcer
Pain Worsened by food Relieved by food
Risk of malignancy Yes (requires biopsy) Rare
Common in Older adults Younger patients
Location Lesser curvature of stomach First part of duodenum

Last updated in line with NICE CG184 (Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management)
Published: November 2014 • Last updated: October 2019
Last reviewed: July 2025
PASSMAP ensures all content is NICE-aligned and reviewed for Physician Associate Registration Assessment (PARA) success.

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