Study guide
3.2 Stomach & Duodenal Disease and Gastrointestinal Hemorrhage
ABIM Internal Medicine Exam
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1 Chapter 0: The ABIM Exam, Blueprint & Study Strategy
0.1 Exam Format, Question Types & the 2026 Blueprint 0.2 Eligibility, Registration, Fees & Exam-Day Logistics 0.3 Scoring, the Passing Standard & Score Reports 0.4 Building a Blueprint-Weighted Study Plan
2 Chapter 1: Cardiovascular Disease (14% of Exam)
1.1 Ischemic Heart Disease & Acute Coronary Syndromes 1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI 1.3 Atrial Fibrillation, Atrial Flutter & Stroke Prevention 1.4 Supraventricular Tachycardias, Ventricular Arrhythmias & Bradycardias 1.5 Heart Failure: Classification, Staging & Guideline-Directed Medical Therapy 1.6 Device Therapy, HFpEF & the Cardiomyopathies 1.7 Valvular Heart Disease & Endocarditis Prophylaxis 1.8 Pericardial Disease & Acute Aortic Syndromes 1.9 Hypertension: Classification, Diagnosis & Secondary Causes 1.10 Hypertensive Crises & Dyslipidemia 1.11 Adult Congenital Heart Disease & Coarctation of the Aorta 1.12 Syncope: Reflex, Orthostatic & Cardiac Causes 1.13 Cardiac Physical Examination, Murmurs & Antithrombotic Selection
3 Chapter 2: Endocrinology, Diabetes & Metabolism (9% of Exam)
2.1 Diabetes Mellitus: Diagnosis, Glycemic Targets & Pharmacotherapy 2.2 Insulin Therapy, Hyperglycemic Emergencies & Chronic Complications 2.3 Thyroid Function Testing & Hypothyroidism 2.4 Thyrotoxicosis, Thyroid Storm & Thyroid Nodules 2.5 Adrenal & Pituitary Disorders 2.6 Hypercalcemia, Hypocalcemia & Disorders of Mineral Metabolism 2.7 Osteoporosis & Paget Disease of Bone 2.8 Ovarian, Testicular & Reproductive Endocrine Disorders 2.9 Hypoglycemia, Endocrine Tumors, Polyglandular Syndromes & Severe Hypertriglyceridemia
4 Chapter 3: Gastroenterology & Hepatology (9% of Exam)
3.1 Esophageal Disease 3.2 Stomach & Duodenal Disease and Gastrointestinal Hemorrhage 3.3 Inflammatory Bowel Disease 3.4 Celiac Disease & Irritable Bowel Syndrome 3.5 Diverticular Disease & Colorectal Cancer Screening 3.6 Viral Hepatitis, Steatotic & Alcohol-Associated Liver Disease 3.7 Cirrhosis & the Complications of Portal Hypertension 3.8 Acute Pancreatitis 3.9 Chronic Pancreatitis & Biliary Tract Disease 3.10 Inherited, Autoimmune & Drug-Induced Liver Disease 3.11 Small Intestinal Disease, Ischemia & Gastrointestinal Complications of HIV
5 Chapter 4: Infectious Disease (9% of Exam)
4.1 Lower Respiratory Tract Infections & Sepsis Syndromes 4.2 Viral Respiratory Pathogens & Tuberculosis 4.3 Central Nervous System Infections 4.4 Skin, Soft Tissue, Bone & Joint Infections 4.5 Infective Endocarditis & Cardiovascular Infection 4.6 Clostridioides difficile & Catheter-Related Bloodstream Infection 4.7 HIV Diagnosis, Antiretroviral Therapy & Prevention 4.8 Opportunistic Infections & Sexually Transmitted Infections 4.9 Fever of Unknown Origin, Neutropenic Fever & Toxic Shock 4.10 Travel-Related Illness, Vector-Borne Disease & Outbreaks 4.11 Infection Prevention, Nosocomial Infection & Postexposure Prophylaxis 4.12 Rheumatic Fever, Poststreptococcal Disease, Enteric & Hepatic Infections
6 Chapter 5: Pulmonary Disease (9% of Exam)
5.1 COPD: Diagnosis, GOLD Classification & Initial Pharmacotherapy 5.2 Interventions That Reduce COPD Mortality & Exacerbation Management 5.3 Asthma: Diagnosis, Stepwise Therapy & Status Asthmaticus 5.4 Interstitial Lung Disease & Idiopathic Pulmonary Fibrosis 5.5 Sarcoidosis, Hypersensitivity Pneumonitis & Occupational Lung Disease 5.6 Pulmonary Embolism: Diagnosis, Risk Stratification & Anticoagulation 5.7 Pulmonary Hypertension & Sleep-Disordered Breathing 5.8 Acute Respiratory Distress Syndrome & Mechanical Ventilation 5.9 Pleural Disease, Empyema & Pneumothorax 5.10 Bronchiectasis, Cystic Fibrosis & Restrictive Lung Disease 5.11 Evaluation of Cough, Dyspnea, Hemoptysis & the Solitary Pulmonary Nodule
7 Chapter 6: Rheumatology & Orthopedics (9% of Exam)
6.1 Rheumatoid Arthritis: Diagnosis & Systemic Manifestations 6.2 Antirheumatic Pharmacotherapy & the Spondyloarthropathies 6.3 Gout: Pathophysiology & Acute Management 6.4 Urate-Lowering Therapy & Calcium Pyrophosphate Deposition Disease 6.5 Osteoarthritis 6.6 Systemic Lupus Erythematosus 6.7 Systemic Sclerosis, Sjogren Syndrome & Inflammatory Myopathies 6.8 The Vasculitides 6.9 Regional Musculoskeletal Syndromes, Back Pain & Sports Injuries 6.10 Other Primary Rheumatic Disorders & Mixed Connective Tissue Disease 6.11 Osteonecrosis & Metabolic Bone Disease
8 Chapter 7: Hematology (6% of Exam)
7.1 Approach to Anemia & the Microcytic Anemias 7.2 Macrocytic, Normocytic & Hemolytic Anemias 7.3 Hemoglobinopathies, Thalassemias & Paroxysmal Nocturnal Hemoglobinuria 7.4 Platelet Disorders, Thrombocytopenia & the Bleeding Patient 7.5 Coagulation Factor Disorders, Thrombophilia & Anticoagulant Reversal 7.6 Acute Leukemias, Chronic Leukemias & Myeloproliferative Neoplasms 7.7 Lymphomas & Plasma Cell Disorders 7.8 Myelodysplastic Syndrome, Myeloproliferative Neoplasms & Porphyria 7.9 Transfusion Medicine & Late Complications of Transplantation
9 Chapter 8: Medical Oncology (6% of Exam)
8.1 Breast, Lung, Colorectal & Prostate Cancer 8.2 Oncologic Emergencies 8.3 Genitourinary & Gynecologic Malignancies 8.4 Head and Neck, Bone & Soft Tissue Cancer and Cancer of Unknown Primary 8.5 Complications of Cancer & Its Treatment 8.6 Cancer Prevention, Survivorship & Psychosocial Care
10 Chapter 9: Nephrology & Urology (6% of Exam)
9.1 Acute Kidney Injury: Staging, Etiology & Urine Microscopy 9.2 Glomerular Disorders & Nephrotic Syndrome 9.3 Nephritic Syndromes, RPGN & Indications for Renal Replacement Therapy 9.4 Chronic Kidney Disease: Staging & Progression Retardation 9.5 Complications of Chronic Kidney Disease: Anemia, CKD-MBD & Acidosis 9.6 Hyponatremia, Hypernatremia & Water Balance 9.7 Potassium Disorders & Systematic Acid-Base Analysis 9.8 Renal Tubular Acidosis & Nephrolithiasis 9.9 Prostate Disorders, Urinary Incontinence & Other Urologic Conditions 9.10 Cystic Kidney Disease, Obstructive Uropathy, Tubulointerstitial Disease & Hematuria
11 Chapter 10: Neurology (4% of Exam)
10.1 Acute Ischemic Stroke: Syndromes & Reperfusion 10.2 Transient Ischemic Attack, Secondary Prevention & Hemorrhagic Stroke 10.3 Headache & Facial Pain 10.4 Seizures, Epilepsy & Movement Disorders 10.5 Multiple Sclerosis & Neuromuscular Junction Disorders 10.6 Motor Neuron Disease & Acute Peripheral Neuropathy 10.7 Cranial Neuropathies & Neuro-Ophthalmology 10.8 Peripheral Neuropathies, CNS Tumors & Other Neurologic Disorders
12 Chapter 11: Psychiatry & Behavioral Health (4% of Exam)
11.1 Major Depressive Disorder & Medical Mimics 11.2 Antidepressant Pharmacotherapy & Treatment-Resistant Depression 11.3 Bipolar Disorder, Mood Stabilizers & Lithium Toxicity 11.4 Anxiety, Stress-Related & Obsessive-Compulsive Disorders 11.5 Alcohol Use Disorder & Withdrawal 11.6 Pharmacotherapy for Alcohol & Opioid Use Disorder 11.7 Toxidromes, Psychiatric Emergencies & Suicide Risk Assessment 11.8 Psychotic, Somatic Symptom, Factitious & Personality Disorders 11.9 Eating Disorders, Sleep Disorders & Sexual Health
13 Chapter 12: Dermatology (3% of Exam)
12.1 Dermatitis, Papulosquamous & Inflammatory Dermatoses 12.2 Acne, Rosacea & Cutaneous Infections 12.3 Herpes Zoster & Autoimmune Blistering Diseases 12.4 Nodules, Tumors & Cutaneous Oncology 12.5 Dermatologic Emergencies & Severe Cutaneous Adverse Reactions 12.6 Pigment Disorders, Alopecia, Nail Disease & Photosensitivity 12.7 Vascular Dermatoses, Environmental Injury & Cutaneous Signs of Systemic Disease
14 Chapter 13: Obstetrics & Gynecology / Women's Health (3% of Exam)
13.1 Contraception, Preconception Care & Teratogenicity 13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes 13.3 Thyroid Disease & Venous Thromboembolism in Pregnancy 13.4 Menopause & Menopausal Hormone Therapy 13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening 13.6 Breast Disorders & Diseases of the Vulva and Vagina 13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications
15 Chapter 14: Geriatric Syndromes (3% of Exam)
14.1 Comprehensive Geriatric Assessment & Frailty 14.2 Falls, Gait Assessment & Polypharmacy 14.3 Urinary Incontinence & Pressure Injuries in Older Adults 14.4 Mild Cognitive Impairment, Dementia & Its Subtypes 14.5 Delirium & the Pharmacotherapy of Cognitive Disorders 14.6 Palliative Care, Hospice & Advance Care Planning 14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture 14.8 Sensory Impairment, Dizziness, Elder Mistreatment & Care Settings
16 Chapter 15: Allergy & Immunology (2% of Exam)
15.1 Anaphylaxis: Recognition & Emergency Management 15.2 Urticaria & Angioedema 15.3 Drug Allergy, Desensitization & Adult Immunodeficiency 15.4 Food Allergy, Insect Venom Hypersensitivity, Serum Sickness & Contrast Reactions 15.5 Rhinitis, Conjunctivitis, Eosinophilic & Mast Cell Disorders
17 Chapter 16: Preventive Medicine, Immunization & Clinical Epidemiology
16.1 The USPSTF Framework & Evidence-Based Cancer Screening 16.2 Cardiovascular & Metabolic Screening and Primary Prevention 16.3 Adult Immunization & Vaccines in Special Populations 16.4 Clinical Epidemiology, Biostatistics & Study Design
18 Chapter 17: Miscellaneous - Ethics, Patient Safety & Quality Improvement (2% of Exam)
17.1 Principles of Bioethics & Decisional Capacity 17.2 Informed Consent, Treatment Refusal & Special Scenarios 17.3 Surrogate Decision-Making, Advance Directives & Confidentiality 17.4 Patient Safety Science, Medical Error & Diagnostic Reasoning 17.5 Quality Improvement Methods, Health Disparities & Health Equity
19 Chapter 18: Perioperative Medicine & Medical Consultation
18.1 Preoperative Cardiovascular Risk Assessment 18.2 Preoperative Pulmonary Risk & Perioperative Medication Management 18.3 Perioperative Anticoagulation, Bridging & Postoperative Complications
20 Chapter 19: Ophthalmology (1% of Exam)
19.1 The Acute Red Eye & Ophthalmic Emergencies 19.2 Painless Vision Loss & Chronic Ophthalmic Disease 19.3 Uveitis, Scleritis & Orbital Disease
21 Chapter 20: Otolaryngology & Dental Medicine (1% of Exam)
20.1 Dizziness, Vertigo & Epistaxis 20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections 20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders
3.2 Stomach & Duodenal Disease and Gastrointestinal Hemorrhage
Key Takeaways Explain This Topic AI
Stomach and duodenal disease covers Helicobacter pylori infection, peptic ulcer disease from other causes, gastritis and gastropathy, non-ulcer dyspepsia and disorders of gastric emptying.
Gastrointestinal hemorrhage is a separate blueprint subsection divided into upper, lower and obscure-source bleeding.
Eradication of Helicobacter pylori must always be confirmed after treatment using a urea breath test, stool antigen test or biopsy.
Confirmatory testing requires holding proton pump inhibitors for two weeks and antibiotics or bismuth for four weeks to avoid false-negative results.
High-risk endoscopic stigmata such as active bleeding or a non-bleeding visible vessel require endoscopic therapy plus high-dose proton pump inhibition, whereas a clean-based ulcer does not.
Last updated: August 2026
- 1. Peptic Ulcer Disease & Helicobacter pylori
- Peptic Ulcer Disease (PUD)
Peptic Ulcer Disease is characterized by mucosal defects in the stomach or duodenum extending through the muscularis mucosae.
Etiologies:
Helicobacter pylori infection: Responsible for 70–85% of duodenal ulcers and 50–60% of gastric ulcers.
NSAIDs & Aspirin: Inhibit cyclooxygenase-1 (COX-1), depleting mucosal protective prostaglandins (PGE2, PGI2).
Zollinger-Ellison Syndrome (ZES): Gastrin-secreting neuroendocrine tumor (gastrinoma) located in the duodenum or pancreas, causing profound gastric acid hypersecretion, severe refractory peptic ulcers (often post-bulbar or multiple), and secretory diarrhea (check fasting serum gastrin >1,000 pg/mL off PPI, secretin stimulation test).
Stress Ulcers: In critically ill ICU patients with mechanical ventilation >48 hours or coagulopathy (INR >1.5, platelets <50,000/mcL).
Duodenal vs. Gastric Ulcers
Feature Duodenal Ulcer Gastric Ulcer
Pain Timing Occurs 2 to 5 hours postprandially and awakens patient at night (between 11 PM and 2 AM). Occurs immediately after meals (within 15–30 min) .
Effect of Food Relieved by food or antacids. Worsened by food ingestion, leading to anorexia and weight loss.
Malignancy Risk Almost universally benign ; biopsy rarely required. Malignancy risk (3–5%) ; mandatory multiple biopsies at initial EGD and follow-up EGD in 8–12 weeks to confirm healing.
Peak Age Younger patients (30–55 years). Older patients (55–70 years).
Helicobacter pylori Infection: ACG 2024 Guidelines
Helicobacter pylori is a microaerophilic, spiral, gram-negative, urease-producing rod that colonizes gastric mucosa.
Diagnostic Testing Principles
Active Infection Tests:
Urea Breath Test ( 13 C ^{13}\text{C} 13 C or 14 C ^{14}\text{C} 14 C -UBT): High sensitivity and specificity (>95%).
Stool Antigen Test (Monoclonal EIA): High sensitivity and specificity (>95%).
Endoscopic Biopsy: Rapid Urease Test (CLOtest) or histopathology with Giemsa/Warthin-Starry stain.
Crucial Diagnostic Washout Rules:
Must discontinue PPIs for at least 1 to 2 weeks prior to breath, stool, or biopsy testing.
Must discontinue antibiotics and bismuth compounds for at least 4 weeks prior to testing.
Failure to observe washouts causes false-negative test results due to temporary suppression of bacterial load.
Serology (IgG antibodies): NOT recommended because it cannot distinguish active infection from past resolved infection and cannot be used to confirm eradication (antibodies persist for years).
ACG 2024 Eradication Regimens
Important
Due to high worldwide and North American clarithromycin resistance rates (>15–20%), Clarithromycin-based triple therapy is NO LONGER recommended as empiric first-line therapy unless local resistance testing confirms susceptibility.
Regimen Category Medications, Dosages & Duration Clinical Notes & Selection
First-Line Empiric: ; Bismuth Quadruple Therapy • PPI (Standard dose BID, e.g., Omeprazole 20 mg BID); • Bismuth Subsalicylate 524 mg QID (or Bismuth Subcitrate 120–300 mg QID); • Metronidazole 500 mg TID or QID; • Tetracycline 500 mg QID; • Duration: 14 Days Preferred first-line empiric regimen for all patients, including those with penicillin allergy or prior macrolide exposure. Can be prescribed as individual components or combined formulation (Pylera + PPI).
First-Line Alternative: ; Vonoprazan Triple Therapy • Vonoprazan (P-CAB) 20 mg BID; • Amoxicillin 1,000 mg BID; • Clarithromycin 500 mg BID; • Duration: 14 Days Potassium-competitive acid blocker (P-CAB) provides rapid, profound acid suppression. Approved for first-line treatment.
First-Line Alternative: ; Vonoprazan Dual Therapy • Vonoprazan 20 mg BID; • Amoxicillin 1,000 mg TID (or 1,000 mg BID); • Duration: 14 Days Excellent alternative that avoids macrolide/metronidazole resistance in penicillin-tolerant patients.
Alternative / Salvage: ; Rifabutin Triple Therapy • PPI Standard dose BID; • Rifabutin 150 mg BID; • Amoxicillin 1,000 mg BID (or TID); • Duration: 14 Days High efficacy in salvage therapy after failure of bismuth quadruple and clarithromycin regimens. (Talicia is an FDA-approved combined capsule).
Salvage Regimen: ; Levofloxacin Triple Therapy • PPI Standard dose BID; • Levofloxacin 500 mg once daily; • Amoxicillin 1,000 mg BID; • Duration: 14 Days Used only when guided by susceptibility testing due to increasing fluoroquinolone resistance.
Confirmation of Eradication
Eradication testing is mandatory for all treated patients .
Perform Urea Breath Test , Stool Antigen Test , or Endoscopy Biopsy at least 4 weeks after completion of antibiotic therapy AND at least 1 to 2 weeks after stopping PPI therapy .
- 2. Acute Upper Gastrointestinal Bleeding (UGIB)
- Clinical Triage & Risk Stratification
Clinical Presentation: Hematemesis ("coffee-ground" emesis or bright red blood), melena (black, tarry stools; requires ~50–100 mL of blood in upper tract), or hematochezia (massive upper GI hemorrhage with rapid transit, hemodynamic instability).
Glasgow-Blatchford Score (GBS): Triage tool based on admission BUN, hemoglobin, systolic blood pressure, heart rate, melena, syncope, hepatic disease, and heart failure (Scores 0–23).
GBS = 0–1: Extremely low risk (<1% intervention rate). Suitable for outpatient management without emergency endoscopy.
GBS ≥ 2 \ge 2 ≥ 2 : High risk. Requires inpatient admission, active resuscitation, and early endoscopic evaluation.
Acute Resuscitation Protocol
Hemodynamic Stabilization & Access: Secure airway in patients with active hematemesis or altered mental status. Place two large-bore peripheral IV lines (16- or 18-gauge) or a large-bore central line.
Restrictive Transfusion Strategy (TRICC & Villanueva Guidelines):
Target Hemoglobin: 7.0 to 8.0 g/dL .
Transfusion threshold: Transfuse Packed Red Blood Cells ( PRBCs ) when Hb < 7.0 g/dL \text{Hb} < 7.0\text{ g/dL} Hb < 7.0 g/dL (reduces rebleeding rates, fluid overload, and overall mortality compared to liberal transfusion threshold of > 9.0 g/dL >9.0\text{ g/dL} > 9.0 g/dL ).
Exception: Patients with active acute coronary syndrome, severe symptomatic coronary artery disease, or ongoing hemodynamic instability (target Hb ≥ 8.0 − 9.0 g/dL \text{Hb} \ge 8.0-9.0\text{ g/dL} Hb ≥ 8.0 − 9.0 g/dL ).
Pharmacotherapy:
Intravenous PPI: High-dose IV PPI (e.g., Pantoprazole 80 mg IV bolus followed by 8 mg/hour continuous IV infusion, or 40 mg IV BID) to maintain intragastric pH > 6.0 \text{pH} > 6.0 pH > 6.0 , promoting platelet aggregation and clot stability.
Prokinetic Agent: Erythromycin 250 mg IV infused 30–60 minutes prior to endoscopy promotes gastric motility, clears blood and clots from the gastric fundus, and significantly improves endoscopic visualization.
Endoscopic Timing: Perform EGD within 24 hours of presentation following adequate hemodynamic resuscitation.
Peptic Ulcer Forrest Classification & Endoscopic Hemostasis
Forrest Class Endoscopic Description Risk of Rebleeding Endoscopic Intervention Protocol
Ia Active Arterial Spurting 90% Dual Endoscopic Therapy (Epinephrine injection + Coaptive Thermal coagulation OR Through-the-scope / Over-the-scope Mechanical Hemoclip) + IV PPI continuous infusion for 72 hours.
Ib Active Oozing Hemorrhage 50% Dual Endoscopic Therapy + IV PPI continuous infusion for 72 hours.
IIa Non-Bleeding Visible Vessel 40–50% Dual Endoscopic Therapy + IV PPI continuous infusion for 72 hours.
IIb Adherent Clot 20–30% Consider targeted irrigation and gentle clot removal; if underlying visible vessel or active bleeding is exposed, apply endoscopic hemostasis.
IIc Flat Pigmented Spot 5–10% No endoscopic intervention . Oral PPI once daily; early discharge.
III Clean-Based Ulcer <3% No endoscopic intervention . Oral PPI once daily; outpatient discharge.
Caution
Epinephrine injection monotherapy is INSUFFICIENT because it achieves only transient local tamponade and vasoconstriction. It must ALWAYS be combined with a second mechanical (clips) or thermal modality to prevent early rebleeding.