Gastrointestinal & Hepatic · Topic 20 of 26

Peptic Ulcer Disease & Stress Ulcer Prophylaxis

Gastrointestinal · acid-peptic disease

Peptic Ulcer Disease & Stress Ulcer Prophylaxis

Most ulcers come from H. pylori or NSAIDs — test every ulcer and eradicate H. pylori. In the ICU, give prophylaxis only for coagulopathy, shock or chronic liver disease.

Key numbers

Bismuth quadruple therapy for 14 days14 days

Confirm eradication 4 weeks after therapy≥ 4 weeks

01 · DoTest every ulcer for H. pylori

Test every patient with a peptic ulcer for H. pylori (biopsy urease test at endoscopy, or urea breath or stool antigen test) and eradicate it if present; eradication cuts recurrence and gastric cancer risk.

02 · Defined byICU prophylaxis: coagulopathy, shock or liver disease

Give stress ulcer prophylaxis to critically ill adults with risk factors for clinically important stress-related upper GI bleeding — coagulopathy, shock or chronic liver disease — not to every ICU patient.

03 · FirstPerforated ulcer: free air, then emergency surgery

Confirm perforation by free air on upright or lateral chest film or CT (absence does not exclude it); place an NG tube, give IV antibiotics covering gut flora, and send for immediate surgery.

Causes & risk factors

Why it happens

H. pylori and NSAIDs cause most ulcers must knowH. pylori infection and NSAIDs (including aspirin) cause most peptic ulcers — NSAIDs now account for over half; smoking adds risk and impairs healing, and gastrinoma is a rare cause.

Presentation

What you'll see

Sudden severe pain, rigid abdomen: perforationFree perforation causes sudden, intense epigastric pain spreading across the abdomen, sometimes to the shoulders, with a rigid board-like abdomen and rebound; signs are blunted in older or steroid-treated patients.

Duodenal pain: relieved by food, wakes at nightDuodenal ulcer pain is relieved by food but returns 2–3 hours after meals and often wakes the patient at night; gastric ulcer pain is less predictable and eating may worsen it.

Diagnosis & monitoring

Work-up

Confirm eradication 4 weeks after therapyTest every treated patient for cure (ACG 2024) by urea breath test, stool antigen or endoscopy at least 4 weeks after antibiotics and 1 week off the PPI; serology cannot show cure.

Do right now

In this order

First moves

Sudden severe pain, rigid abdomen: perforation

→

Perforated ulcer: free air, then emergency surgery

Why each step

Perforated ulcer: free air, then emergency surgeryConfirm perforation by free air on upright or lateral chest film or CT (absence does not exclude it); place an NG tube, give IV antibiotics covering gut flora, and send for immediate surgery.

Management

Orders

Bismuth quadruple therapy for 14 days must knowWhen antibiotic susceptibility is unknown, give bismuth quadruple therapy for 14 days: a PPI twice daily plus bismuth, tetracycline and metronidazole.

Alternatives: rifabutin triple or vonoprazan-amoxicillin dualRifabutin triple therapy or potassium-competitive acid blocker (vonoprazan) plus amoxicillin for 14 days are empiric alternatives in patients without penicillin allergy; clarithromycin or levofloxacin regimens only when susceptibility is confirmed.

Use a low-dose PPI or H2 blockerFor stress ulcer prophylaxis use a low-dose PPI or H2-receptor antagonist, by mouth, tube or IV, rather than sucralfate — low-dose, not high-dose, regimens.

Biopsy gastric ulcers to exclude cancerEndoscopy confirms the ulcer; biopsy gastric ulcers to exclude ulcerating gastric cancer, especially in patients over 60, with weight loss or refractory symptoms. Duodenal ulcers are rarely malignant and not routinely biopsied.

Continued NSAIDs after ulcer: long-term acid suppressionStop NSAIDs when possible; patients who must stay on NSAIDs after an ulcer, or who had a perforation or bleed, are candidates for long-term PPI, H2-blocker or misoprostol therapy.

Red flags & don'ts

Avoid harm

Bleeding is the most common complication complicationGI hemorrhage (hematemesis, melena or hematochezia, orthostasis) is the most common ulcer complication; manage it per Upper GI Bleeding.

Gastric outlet obstruction: decompress and suppress acid complicationUlcer-related gastric outlet obstruction causes late large-volume vomiting, a succussion splash, dehydration and alkalosis; treat with NG decompression, IV PPI or H2 blocker and fluid-electrolyte repair — it usually resolves in 2–5 days.

The rules

Know these

Ventilation alone is not an indicationMechanical ventilation alone is not firmly established as a risk factor, and enteral nutrition probably lowers bleeding risk; do not give prophylaxis to low-risk patients, especially those who are enterally fed.

Stop prophylaxis before ICU transferStop stress ulcer prophylaxis when critical illness or the risk factor resolves, and before transfer out of the ICU, to prevent inappropriate long-term acid suppression.

Gastric or duodenal ulcer?

Commonly confused

Pain and meals	Eating may worsen pain
Night pain	Less typical
Biopsy	Biopsy to exclude cancer
H. pylori	30–50% of cases

More detail

Reference

Show 6 reference facts

Suspect gastrinoma (Zollinger-Ellison) with multiple ulcers, postbulbar or refractory ulcers, or ulcers with prominent diarrhea or weight loss; measure serum gastrin.

Three-year ulcer recurrence is under 10% when H. pylori is eradicated versus over 50% when it is not; retest and retreat patients with recurrent ulcers.

Patients with an H. pylori–associated gastric or duodenal ulcer continue acid suppression for at least 4 weeks alongside eradication therapy.

A posterior duodenal ulcer penetrating into the pancreas causes intense, persistent pain referred to the back and changed by position; CT or MRI confirms it.

Ulcer surgery is now reserved for perforation, obstruction, uncontrolled or recurrent bleeding and rare medically refractory disease.

H. pylori is present in over 50% of duodenal ulcers and 30–50% of gastric ulcers.

Pearl

Every ulcer gets an H. pylori test; every ICU patient gets a risk check before a PPI — and loses it when the risk is gone.

Sources · Merck Manual Professional — Peptic Ulcer Disease · Merck Manual Professional — Helicobacter pylori Infection (cites ACG 2024) · Chey WD et al. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol 2024;119:1730–1753 (abstract via Europe PMC) · SCCM/ASHP Guideline for the Prevention of Stress-Related Gastrointestinal Bleeding in Critically Ill Adults. Crit Care Med 2024 (abstract via Europe PMC) · Saudi Critical Care Society / SSAI contextualized SUP guideline adopted from SCCM/ASHP 2024. Acta Anaesthesiol Scand 2026 · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).