What are the symptoms and treatment of gastric ulcers?

Symptoms and Treatment of Gastric Ulcers

The most common symptoms of gastric ulcers include epigastric pain that is often relieved by food, antacids, or proton pump inhibitors, along with possible nausea, bloating, early satiety, and weight loss. 1

Symptoms of Gastric Ulcers

Gastric ulcers present with a characteristic symptom profile that helps differentiate them from other gastrointestinal conditions:

Primary Symptoms

• Epigastric discomfort/pain: Typically described as burning or gnawing
  • Often relieved by food intake or antacids
  • May awaken patients at night
  • Occurs between meals when stomach is empty 1
• Loss of appetite
• Weight loss
• Nausea and vomiting
• Bloating and feeling of fullness

Warning Signs (Alarm Symptoms)

• Hematemesis (vomiting blood)
• Melena (black, tarry stools)
• Unexplained weight loss
• Persistent vomiting
• Dysphagia (difficulty swallowing)
• Anemia

Diagnosis

The gold standard for diagnosis is endoscopy, which allows direct visualization and biopsy to exclude malignancy 2. Other diagnostic approaches include:

• H. pylori testing: Urea breath test (95-100% sensitivity) or stool antigen testing (92% sensitivity) 2
• Gastric emptying studies: May be used in certain cases, though they have low sensitivity and specificity 2

Treatment of Gastric Ulcers

First-Line Treatment

1. Proton Pump Inhibitors (PPIs):

   • First choice for treatment of gastric ulcers 2, 3
   • Omeprazole 20mg twice daily for 4-8 weeks 3
   • PPIs are more effective than H2 receptor antagonists or antacids 2

2. H. pylori Eradication (if positive):

   • Standard triple therapy (if low clarithromycin resistance) 2:
     • PPI standard dose twice daily
     • Clarithromycin 500mg twice daily
     • Amoxicillin 1000mg twice daily
   • Treatment duration: 14 days 2
   • Sequential therapy (if high clarithromycin resistance) 2:
     • PPI + amoxicillin for first 5 days
     • PPI + clarithromycin + metronidazole for next 5 days

3. Risk Factor Modification:

   • Discontinuation of NSAIDs 2
   • Smoking cessation 2
   • Alcohol reduction
   • Avoidance of steroids if possible 2

Second-Line Treatment

• For H. pylori treatment failures, 10-day levofloxacin-amoxicillin triple therapy 2:
  • PPI standard dose twice daily
  • Levofloxacin 500mg once daily or 250mg twice daily
  • Amoxicillin 1000mg twice daily

Management of Complications

Bleeding

• Endoscopic evaluation and treatment for stable patients
• Angiography with transcatheter angioembolization for refractory bleeding
• Surgical intervention for recurrent bleeding from ulcers >2cm 2

Perforation

• Laparoscopic primary suture with omental patch for perforations <1cm in stable patients
• Open surgery for unstable patients or complex cases 2

Treatment Duration and Follow-up

• Standard treatment duration: 4-8 weeks 3
• For benign gastric ulcers: 12 weeks of therapy may be required 4
• Follow-up endoscopy is recommended to confirm healing and rule out malignancy, especially in older patients or those with persistent symptoms 1

Pitfalls and Caveats

1. Symptom resolution does not guarantee ulcer healing:

   • Studies show poor correlation between symptom relief and actual ulcer healing 4
   • Follow-up endoscopy is essential, especially for gastric ulcers

2. Misdiagnosis risks:

   • Gastric cancer can mimic ulcer symptoms
   • Always biopsy gastric ulcers to exclude malignancy 2

3. Treatment failures:

   • Any gastric ulcer that fails to heal within 12-15 weeks should be carefully examined to exclude malignancy 5
   • Consider surgical intervention for non-healing ulcers

4. Medication adherence:

   • Poor compliance with gastroprotective agents increases risk of NSAID-induced upper GI adverse events 4-6 times 2
   • Emphasize the importance of completing the full course of treatment

By following this structured approach to diagnosis and treatment, most patients with gastric ulcers can achieve complete healing and symptom resolution.