Management of Nonbleeding Superficial Gastric Ulcers
Nonbleeding superficial gastric ulcers with clean bases or flat pigmented spots do not require endoscopic hemostatic therapy and should be managed conservatively with medical therapy alone. 1
Risk Stratification and Endoscopic Management
Patients with low-risk endoscopic stigmata have excellent prognosis with conservative treatment and should NOT receive endoscopic intervention. 1
Low-Risk Stigmata (No Endoscopic Therapy Indicated):
- Clean ulcer base - rebleeding risk <5%, managed medically only 1
- Flat black or red spots (nonprotuberant pigmented dots) - low rebleeding risk, no intervention needed 1
High-Risk Stigmata (Endoscopic Therapy Required):
- Active spurting or oozing hemorrhage (Forrest 1a/1b) 1
- Non-bleeding visible vessel (Forrest 2a) 1
- Adherent clot - controversial; attempt targeted irrigation to dislodge, then treat underlying lesion if high-risk stigmata revealed 1
Pharmacologic Management
All patients with gastric ulcers should receive proton pump inhibitor (PPI) therapy regardless of bleeding risk. 1
PPI Regimen:
- Single daily-dose oral PPI for patients with low-risk endoscopic findings 1
- Duration dictated by underlying cause (typically until ulcer healing confirmed) 1
- For ulcers requiring endoscopic therapy: IV loading dose followed by continuous infusion for 72 hours, then transition to oral twice-daily dosing for 14 days, followed by once-daily 1
H2-receptor antagonists are NOT recommended for acute ulcer management 1
Essential Diagnostic Workup
All gastric ulcers require biopsy and histological examination to exclude malignancy, unlike duodenal ulcers. 2, 3
Mandatory Testing:
- Multiple biopsies from ulcer margins - gastric ulcers can harbor malignancy 2, 3
- H. pylori testing - all patients must be tested and receive eradication therapy if positive 1
- Confirmation of H. pylori eradication after treatment 1
Critical Caveat:
- Negative H. pylori tests obtained during acute bleeding should be repeated after resolution, as acute bleeding can cause false-negative results 1
Follow-Up Requirements
Gastric ulcers require surveillance endoscopy approximately 6 weeks after initial diagnosis to confirm healing and exclude malignancy. 2
This is a critical distinction from duodenal ulcers, which do not require routine surveillance endoscopy 2. The follow-up endoscopy should include repeat biopsies if the ulcer has not completely healed 2.
Hospital Management
Patients with low-risk endoscopic findings can be fed within 24 hours and do not require prolonged hospitalization. 1
- Early feeding is safe after endoscopy confirms low-risk stigmata 1
- Discharge with oral PPI prescription 1
- Outpatient follow-up endoscopy at 6 weeks 2
Risk Factor Modification
Identify and address underlying causes:
- NSAID use - discontinue if possible; if NSAIDs required, use COX-2 inhibitor plus PPI 1
- Smoking cessation - significantly reduces ulcer recurrence 1
- Avoid aspirin/anticoagulants unless cardiovascular risk outweighs bleeding risk; if required, continue PPI prophylaxis 1
When to Escalate Care
Surgical consultation is NOT indicated for nonbleeding superficial ulcers with low-risk stigmata. 1
Surgery is reserved for: