Abstract: The incidence of peptic ulcer disease has dramatically decreased in the last recent years, mainly due to the knowledge of Helicobacter pylori role in the pathogenesis and the eradication treatments. Also, effective acid-decreasing drugs have contributed to the healing of most ulcers. As a result, indications for elective surgery have also dramatically decreased. However, there are some indications for elective surgery such as refractory ulcers and cases of uncertain diagnosis. Also, developing of alternative therapeutic methods such as endoscopy or angioembolization has reduced the need for surgery. Endoscopic therapy is used in the treatment of bleeding ulcers with high rates of success and in cases of gastric outlet obstruction. Angioembolization is used in selected cases of bleeding ulcers. Surgery is today indicated when these procedures fail in hemorrhages of peptic origin. Other indication for surgery is perforated peptic ulcer, since non-operative treatment cannot be considered standard of care. Considerable debate exists concerning the need of adding acid-decreasing procedures to techniques of bleeding control alone in case of hemorrhage. Although the latter are associated with less side effects, the former are associated with lower rates of rebleeding. Simple closure of a perforation, however, appears enough if followed by Helicobacter pylori eradication and avoidance of NSAIDs. Importantly, any gastric ulcer must be biopsied to rule out malignancy, before deciding any conservative treatment.
