Key points in the history

Symptoms of PUD are non-specific and have limited predictive value.
Elderly patients with PUD are frequently asymptomatic or have minor symptoms [6].
NSAID-induced ulcers are more likely to be asymptomatic [13].
Patients with gastric ulcers may have postprandial abdominal pain, nausea and weight loss.
Patients with duodenal ulcers typically feel hungry or have nocturnal abdominal pain.
Patients may present with complications such as bleeding, perforation or gastric outlet obstruction.
Patients should be specifically asked whether there has been a change in bowel habit, melaena or rectal bleeding, and whether there has been any coffee-ground or fresh haematemesis. Patients may not always volunteer such information due to fear or embarrassment.
Ask about features suggesting malignancy:
- dysphagia
- unintentional weight loss
- persistent vomiting
- epigastric mass
- altered stools

Red-Flag Features

Signs of acute bleeding
- Melaena
- Haematemesis
- Tachycardia or hypotension
- Signs of severe anaemia
Signs of perforation
- Severe abdominal pain
- Peritonitis
Symptoms suggesting malignancy
- New dyspepsia and > 60 years
- Dysphagia
- Unexplained weight loss
- Loss of appetite
- Recurrent vomiting
Symptoms persist despite successful eradication
Second line eradication therapy fails

Learning Bite

Patients with NSAID-induced ulcers are the most likely to have minimal preceding symptoms and present with complications.