From the Guidelines
Additional workup is indicated for this 49-year-old patient with persistent epigastric pain, gastritis, multiple ulcers, and mild anemia despite H2 blocker therapy and negative H. pylori testing. I recommend endoscopic evaluation for Zollinger-Ellison syndrome (gastrinoma) with serum gastrin level measurement while the patient is off acid-suppressing medications for at least 1 week, as suggested by the most recent guidelines 1. If gastrin levels are elevated (>1000 pg/mL), secretin stimulation testing should follow. Imaging studies including abdominal CT or MRI with contrast should be performed to locate potential gastrinomas, as CT examinations can identify findings suggestive of gastritis or peptic ulcer disease, such as gastric or duodenal wall thickening due to submucosal edema, mucosal hyperenhancement, or fat stranding due to inflammation 1. Additionally, testing for other causes of non-H. pylori ulcers is warranted, including NSAID use assessment, screening for other infections like CMV or HSV (particularly if immunocompromised), and evaluation for Crohn's disease. The patient's anemia requires investigation with complete blood count, iron studies, and stool occult blood testing. Consider switching from H2 blockers to a proton pump inhibitor (such as omeprazole 40mg daily) for better acid suppression while completing the workup, as full dose PPI therapy has been shown to be effective in relieving symptoms in patients with ulcer-like dyspepsia 1. This comprehensive approach is necessary because multiple refractory ulcers with negative H. pylori testing suggests an underlying condition beyond common peptic ulcer disease, with gastrinoma being a significant concern that requires specific diagnostic steps and targeted treatment. It is also important to consider the patient's quality of life and potential complications, such as gastric cancer, and to follow the recommended workup and treatment guidelines for gastric cancer 1 and gastric marginal zone lymphoma of MALT type 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Additional Workup Indicated
The patient has gastritis and several ulcers, and the biopsy for H pylori is negative. Despite being on an H2 blocking agent, the patient still experiences epigastric pain, which is worse two or three hours after meals. Considering the patient's symptoms and negative H pylori biopsy, additional workup may be indicated to rule out other possible causes of gastritis and ulcers.
- The patient's mild anemia and persistent symptoms despite H2 blocker treatment suggest that further evaluation is needed to determine the underlying cause of the gastritis and ulcers.
- According to 2, even with recommended treatment regimens, approximately 20% of patients will fail to obtain H. pylori eradication, and in cases of treatment failure, a case-by-case approach is recommended.
- The use of proton pump inhibitors (PPIs) may be considered, as they have been shown to have antibacterial effects against H. pylori 3, and may also be beneficial in treating gastritis and ulcers.
- However, as noted in 4, profound acid suppressive therapy with PPIs can induce a corpus-predominant pangastritis, which is associated with accelerated corpus gland loss and development of atrophic gastritis.
- The patient's response to H2 blockers is limited, and as discussed in 5 and 6, H2 blockers have a relatively short duration of action and may not be effective in achieving optimum conditions for healing more severe forms of oesophagitis or gastritis.
Possible Next Steps
- Consider switching to a proton pump predictor (PPI) to see if it provides better symptom relief and healing of the ulcers.
- Further diagnostic testing, such as upper endoscopy or imaging studies, may be necessary to rule out other possible causes of the patient's symptoms and to assess the extent of the gastritis and ulcers.
- As mentioned in 2, a susceptibility-guided strategy, if available, is recommended to choose the best third-line treatment, and culture can reveal the presence of H. pylori-sensitive strains to clarithromycin or other antimicrobials.