Workup for Gastric Ulcer
Endoscopy is the gold standard diagnostic test for gastric ulceration and should be performed as the first-line diagnostic approach, with biopsy collection mandatory to exclude malignancy. 1
Initial Diagnostic Approach
Risk Stratification and Timing of Endoscopy
- Use the Blatchford score to determine urgency of endoscopic evaluation 1:
- Very low-risk patients: Outpatient endoscopy
- Low-risk patients: Early inpatient endoscopy
- High-risk patients: Urgent inpatient endoscopy
Endoscopic Evaluation
- Endoscopy allows direct visualization of ulcers and is essential for tissue diagnosis 1
- Biopsy of all gastric ulcers is mandatory to exclude malignancy, as gastric ulcers cannot be reliably distinguished as benign by appearance alone 2, 3
- Multiple biopsies should be obtained from the ulcer margin and base 2
Essential Testing
Helicobacter pylori Testing
- All patients with gastric ulcers must be tested for H. pylori infection 2, 1
- Testing methods include:
- Biopsy-based testing during endoscopy (histology, rapid urease test, culture)
- Non-invasive testing (urea breath test, stool antigen test) 2
- Negative H. pylori tests obtained during acute bleeding should be repeated, as acute bleeding can cause false-negative results 2
Medication History
- Document all NSAID and aspirin use, as these account for approximately 36% of peptic ulcer disease cases 4
- Review other ulcerogenic medications including corticosteroids and anticoagulants 5
Initial Management Based on Presentation
For Uncomplicated Gastric Ulcers
- Initiate proton pump inhibitor therapy immediately: omeprazole 40 mg once daily for 4-8 weeks 6, 7
- PPIs heal 80-100% of peptic ulcers within 4 weeks for duodenal ulcers; gastric ulcers larger than 2 cm may require 8 weeks 4
- Discontinue NSAIDs if possible, which heals 95% of NSAID-related ulcers 4
For H. pylori-Positive Ulcers
- Eradicate H. pylori with combination therapy 2, 1:
- Eradication reduces ulcer recurrence from 50-60% to 0-2% 4
- Confirm eradication of H. pylori after treatment 2
For Bleeding Gastric Ulcers
- Perform early endoscopy in hemodynamically stable patients for both diagnosis and therapeutic intervention 2, 1
- Initial resuscitation targets 1:
- Maintain hemoglobin >7 g/dL
- Target systolic blood pressure 90-100 mmHg
- Normalize lactate and base deficit
- Correct coagulopathy
- Administer high-dose PPI therapy: IV loading dose followed by continuous infusion after successful endoscopic hemostasis 2
- Following initial treatment, use twice-daily oral PPIs for 14 days, then once daily 2
For Suspected Perforated Ulcers
- CT scan is the first-line radiological examination 1
- Surgical consultation and intervention typically required 1
Follow-Up Requirements
Repeat Endoscopy
- All gastric ulcers require repeat endoscopy at approximately 6 weeks to confirm healing and exclude malignancy 2
- Continue PPI therapy until repeat endoscopy confirms healing 2
- Duodenal ulcers do not routinely require repeat endoscopy unless NSAIDs must be continued 2
Long-Term Management
- Patients requiring continued NSAID therapy should receive ongoing PPI therapy 2
- Consider switching to less ulcerogenic NSAIDs (e.g., ibuprofen instead of ketorolac) 4
- Long-term acid suppression is beneficial for chronic NSAID users and H. pylori-infected patients 1
Common Pitfalls to Avoid
- Failing to biopsy gastric ulcers is the most critical error, as malignancy cannot be excluded without histology 2, 3
- Not testing for H. pylori in all gastric ulcer patients leads to high recurrence rates 1
- Performing angiography before endoscopy results in unacceptably high rates of negative investigations 1
- Treating empirically without endoscopy delays definitive diagnosis and risks missing gastric cancer 2
- Using H2-receptor antagonists instead of PPIs results in inferior healing rates 2, 7, 8