Peptic ulcer

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Peptic ulcer

Gastrointestinal system

Peritoneum and peritoneal cavity disorders




Peptic ulcer


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USMLE® Step 1 questions

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High Yield Notes

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Peptic ulcer

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USMLE® Step 1 style questions USMLE

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A 62-year-old man presents to the emergency department with severe abdominal pain and vomiting this morning. He states he has had abdominal pain for the past several weeks, with the pain acutely worsening today with radiation to the left shoulder. He reports the vomit was dark brown and had a granular consistency. Past medical history is significant for hypertension and hypercholesterolemia. He was also admitted for alcoholic pancreatitis approximately six weeks ago.The patient has smoked 1 pack of cigarettes daily for 30 years. He reports drinking 3-4 beers daily. Temperature is 37°C (98.6 °F), pulse is 111/min, respirations are 24/min, and blood pressure is 92/62 mmHg. Physical examination shows a pale man in acute distress. Abdominal examination is notable for diffuse tenderness to palpation, with rebound and rigidity. Laboratory results are shown below:

Laboratory value  Result
 CBC, Serum 
 Hemoglobin  10.1  g/dL 
 Hematocrit  30% 
 Leukocyte count  14,000 /mm3 
 Platelet count  160,000/mm3 
               Sodium  132 mEq/L 
           Potassium  4.2 mEq/L 
              Chloride  95 mEq/L 
                 BUN                    67 mg/dL  
             Creatinine  2.6 mg/dL 
              Albumin  3.7  g/dL 
                 AST  60 U/L 
                 ALT  30 U/L 
    Alkaline Phosphatase  110 U/L 
           Bilirubin, total  .7 mg/dL 
              Lipase  100 U/L 
Abdominal imaging is most likely to reveal which of the following findings?    

External References

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peptic ulcer disease p. 389


acute gastric ulcer p. 729

Gastric ulcers p. 389

NSAID toxicity p. 499

Nonsteroidal anti-inflammatory drugs (NSAIDs) p. 499

gastric ulcers from p. 389

peptic ulcer disease and p. 389

Peptic ulcer disease p. 389

associations p. 727

glycopyrrolate for p. 242

H2 blockers for p. 407

Helicobacter pylori p. , 144

misoprostol for p. 408

proton pump inhibitors for p. 407

Zollinger-Ellison syndrome p. 359

Perforation (GI) p. 389

duodenal ulcer p. 373

Weight loss

gastric ulcers p. 389


Peptic refers to the stomach, and an ulcer is a sore or break in a membrane, so peptic ulcer disease describes having one or more sores in the stomach - called gastric ulcers - or duodenum - called duodenal ulcers- which are actually more common.

Normally, the inner wall of the entire gastrointestinal tract is lined with mucosa, which has three cell layers.

The innermost layer is the epithelial layer and it absorbs and secretes mucus and digestive enzymes.

The middle layer is the lamina propria and it contains blood and lymph vessels.

Then there’s the outermost layer which is the muscularis mucosa, and it’s a layer of smooth muscle that contracts and helps break down food.

In the stomach, there are four regions - the cardia, the fundus, the body, and the antrum.

So the epithelial layer in different parts of the stomach contains different proportions of gastric glands which secrete various substances.

Having said that, the cardia contains mostly foveolar cells that secrete mucus which is a mix of water and glycoproteins.

The fundus and the body have mostly parietal cells that secrete hydrochloric acid and chief cells that secrete pepsinogen, an enzyme that digests protein.

Finally, the antrum has mostly G cells that secrete gastrin in response to food entering the stomach. These G cells are also found in the duodenum and the pancreas, which is an accessory organ of the gastrointestinal tract.

Gastrin stimulates the parietal cells to secrete hydrochloric acid, and more broadly stimulates the growth of glands throughout the stomach.

In addition, the duodenum contains Brunner glands which secrete mucus rich in bicarbonate ions.

In fact, with all of the digestive enzymes and hydrochloric acid floating around, the stomach and duodenal mucosa would get digested if not for the mucus coating the walls and bicarbonate ions secreted by the duodenum which neutralizes the acid.


A peptic ulcer is an erosion or a break in gastric or/and duodenal mucosa. The most common causes of peptic ulcers are infection with a bacterium called Helicobacter pylori (H. pylori) and long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen. Symptoms of a peptic ulcer include abdominal pain, usually felt in the upper middle or upper left part of the abdomen, bloating, vomiting, nausea, and loss of appetite. In severe cases, a peptic ulcer can cause bleeding or a perforation in the mucosa of the stomach or duodenum. Treatment includes a combination of medications called triple therapy to kill the H. pylori bacteria and reduce acid production in the stomach. Surgery is the last optional treatment to repair the ulcer if drugs are unsuccessful.


  1. "Robbins Basic Pathology" Elsevier (2017)
  2. "Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2)" McGraw-Hill Education / Medical (2018)
  3. "Pathophysiology of Disease: An Introduction to Clinical Medicine 8E" McGraw-Hill Education / Medical (2018)
  4. "Peptic ulcer disease" The Lancet (2017)
  5. "The ulcer sleuths: The search for the cause of peptic ulcers" Journal of Gastroenterology and Hepatology (2011)

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