What is the difference between peptic ulcer disease (PUD) and an active ulcer in a patient with a history of chronic alcohol use and suspected bleeding peptic ulcer?

Difference Between Peptic Ulcer Disease and Active Ulcer

Peptic ulcer disease (PUD) is the broad diagnostic term encompassing all peptic ulcers regardless of their current activity status, while an "active ulcer" specifically refers to an ulcer that is currently present and demonstrable on endoscopy or imaging, often with ongoing complications such as bleeding or perforation. 1

Key Conceptual Distinctions

Peptic Ulcer Disease (PUD)

• PUD represents the overall disease entity that includes both current ulcers and a history of ulceration, encompassing all stages from active disease to healed ulcers 1, 2
• Patients may carry a diagnosis of PUD even when no active ulcer is present at a given time 2
• The term encompasses the full spectrum of disease complications including bleeding, perforation, penetration, and obstruction 2

Active Ulcer

• An active ulcer is an endoscopically or radiologically confirmed ulcer crater that is currently present in the gastric or duodenal mucosa 1
• Active ulcers are characterized by specific endoscopic findings and may demonstrate stigmata of recent hemorrhage, which predict risk of further bleeding 1
• The presence of an active ulcer requires immediate therapeutic consideration, particularly when complicated by bleeding or perforation 1

Clinical Significance in Bleeding Presentations

Why This Distinction Matters in Your Patient with Chronic Alcohol Use

In patients with suspected bleeding peptic ulcer and chronic alcohol use, identifying an active ulcer versus simply having PUD fundamentally changes management urgency and prognosis. 3

• Patients with advanced alcoholic liver disease and active peptic ulcer bleeding have significantly worse outcomes than other patients with peptic ulcer bleeding, including higher rates of uncontrolled bleeding, rebleeding, and mortality 3
• Active ulcers in cirrhotic patients require more aggressive initial management compared to patients with a history of PUD but no current active ulcer 3
• The frequency of bleeding from active ulcers is markedly increased in patients with alcoholic liver disease, and these patients experience more severe bleeding episodes 3, 4

Endoscopic Differentiation

Early endoscopy within 24 hours is essential to distinguish between active ulceration and healed PUD, as this provides both effective therapy and critical prognostic information based on endoscopic stigmata 1

• Endoscopic stigmata of hemorrhage in active ulcers predict risk of further bleeding and guide management decisions (strong recommendation) 1
• Patients with active bleeding at endoscopy (Forrest Ia), visible vessels (Forrest IIa), or adherent clot have significantly higher mortality risk compared to those without stigmata 5
• Patients without endoscopic stigmata of hemorrhage had zero deaths in one study, compared to 12% mortality in those with stigmata (p<0.02) 5

Active-Stage Ulcers and Symptomatology

• Active-stage ulcers are significantly more likely to be symptomatic compared to healing or healed ulcers (p=0.002) 4
• In patients with chronic alcohol use, excessive alcohol consumption is independently associated with symptomatic active ulcers rather than asymptomatic disease (p=0.005) 4
• NSAID use is a risk factor specifically for symptomatic active PUD, not asymptomatic disease (p=0.040) 4

Management Implications

For Active Bleeding Ulcers

Rapid surgical/medical evaluation is mandatory to prevent further bleeding and reduce mortality (strong recommendation) 1

• Blood-typing, hemoglobin, hematocrit, electrolytes, and coagulation assessment should be performed immediately 1
• INR greater than 1.5 is associated with increased mortality risk in active bleeding 1
• Rockall and Glasgow-Blatchford scoring systems should be used to assess severity and guide therapy 1

For Suspected Active Ulcer Without Confirmed Bleeding

• When endoscopy is not immediately available, contrast-enhanced CT scan should be performed (weak recommendation) 1
• CT can detect complications including perforation, unexplained intraperitoneal fluid, pneumoperitoneum, and bowel wall thickening 6

Common Pitfalls to Avoid

• Do not assume a patient with known PUD has an active ulcer without endoscopic confirmation, as this distinction fundamentally alters management intensity 1, 2
• Do not underestimate bleeding severity in patients with alcoholic liver disease and active ulcers, as they have markedly worse outcomes than the general population 3
• Do not delay endoscopy beyond 24 hours in suspected active bleeding, as early endoscopy reduces rebleeding, need for surgery, and mortality 1
• Physical examination findings may be equivocal, and peritonitis may be present in only two-thirds of patients with perforated active ulcers 7, 6