What are the diagnosis and management options for gastric ulceration?

Diagnosis and Management of Gastric Ulceration

Endoscopy is the first-line diagnostic approach for gastric ulceration, followed by testing for H. pylori infection and implementation of appropriate medical therapy including proton pump inhibitors and H. pylori eradication when indicated. 1

Diagnosis

Clinical Presentation

• Typical symptoms include epigastric pain, which may be associated with dyspepsia, bloating, abdominal fullness, nausea, or early satiety 2
• Approximately two-thirds of patients with peptic ulcer disease are asymptomatic 3
• Physical examination findings may be equivocal in uncomplicated cases 4

Diagnostic Algorithm

1. Endoscopy: Gold standard for diagnosis of gastric ulceration 1

   • Allows direct visualization of ulcers and collection of biopsies
   • Risk stratification using Blatchford score is recommended to determine timing of endoscopy 1:
     • Very low-risk: Outpatient endoscopy 1
     • Low-risk: Early inpatient endoscopy (≤24h of admission) 1
     • High-risk: Urgent inpatient endoscopy (≤12h of admission) 1

2. H. pylori Testing: Multiple methods available 1, 5

   • Invasive tests (require endoscopy):

     • Rapid urease test (RUT): Quick, reliable, and cost-effective 1, 6
     • Histology: Considered gold standard, also evaluates gastric inflammatory changes 5
     • Culture: Helpful for determining antimicrobial resistance patterns 5

   • Non-invasive tests:

     • Urea breath test: Most accurate non-invasive method 5
     • Stool antigen test: High accuracy, approaching that of breath test 5
     • Serology: Convenient but less accurate, cannot confirm cure 2

3. Imaging Studies:

   • CT scan is recommended as first radiological examination in suspected perforated ulcers 4
   • Chest/abdominal X-ray should be performed when CT is not immediately available 4

Management

Non-Operative Management

1. Initial Resuscitation (for bleeding ulcers) 1:

   • Maintain hemoglobin >7 g/dL
   • Target systolic blood pressure 90-100 mmHg until major bleeding stops
   • Normalize lactate and base deficit
   • Correct/prevent coagulopathy

2. Pharmacological Therapy:

   • Proton Pump Inhibitors (PPIs):

     • First-line therapy for gastric ulcers 7
     • Omeprazole 20-40mg daily has shown significant healing rates (74.8-82.7% at 8 weeks) compared to placebo (48.1%) 7
     • Recommended for 6-8 weeks following endoscopic treatment of bleeding ulcers 1

   • H. pylori Eradication (if positive):

     • Triple therapy: PPI + clarithromycin + amoxicillin for 10-14 days 7
     • Quadruple therapy, sequential therapy, or levofloxacin-based therapy may be considered based on resistance patterns 2
     • Eradication significantly reduces ulcer recurrence (6-8% vs 43-68% when not eradicated) 7

3. Endoscopic Treatment (for bleeding ulcers) 1:

   • Recommended for spurting ulcers (Forrest 1a), oozing ulcers (Forrest 1b), and ulcers with non-bleeding visible vessels (Forrest 2a) 1
   • Dual modality endoscopic hemostasis is suggested 1
   • Consider prokinetic drugs (erythromycin) before endoscopy to improve visualization 1

Management of Complications

1. Bleeding Ulcers:

   • Non-operative management as first line after endoscopy 1
   • For recurrent bleeding, emergency endoscopy is first-line management 1
   • Transcatheter angioembolization suggested as alternative when endoscopy fails or isn't feasible 1
   • Angiography for diagnostic purposes should be considered as second-line investigation after negative endoscopy 1

2. Perforated Ulcers:

   • CT scan is strongly recommended as first radiological examination 4
   • Surgical intervention is typically required 4

Follow-up and Prevention

• Test for H. pylori eradication at least 4 weeks after treatment completion 5
• Long-term acid suppression therapy beneficial for chronic NSAID users and H. pylori-infected patients 1
• For NSAID users with H. pylori infection (increased PUD risk), consider misoprostol or PPIs for prevention 2
• Patients with history of ulcer disease should be monitored for complications including bleeding, perforation, gastric outlet obstruction, and gastric cancer 2

Common Pitfalls and Caveats

• Failure to test for H. pylori in all patients with gastric ulcers 1
• Inadequate follow-up of gastric ulcers that fail to heal within 12-15 weeks (need to exclude malignancy) 8
• Not considering medication-induced ulcers (NSAIDs, antiplatelet drugs, warfarin, SSRIs, bisphosphonates) 2
• Performing angiography before endoscopy, which results in unacceptable rates of negative investigations 1
• Inadequate biopsy sampling during endoscopy (at least three biopsies from non-adjacent sites recommended) 6