What is the management approach for marginal ulcers?

Management of Marginal Ulcers

Initiate high-dose proton pump inhibitor (PPI) therapy for 3-6 months minimum combined with immediate elimination of all modifiable risk factors (smoking, NSAIDs, steroids), and perform mandatory endoscopic surveillance every 3 months until complete healing is documented. 1

Initial Medical Management

The cornerstone of treatment for uncomplicated marginal ulcers requires a three-pronged approach:

• Start high-dose PPI therapy immediately for a minimum of 3-6 months as the primary pharmacologic intervention 1
• Mandate complete smoking cessation - smoking is a significant modifiable risk factor with an odds ratio of 2.5 for marginal ulcer formation 1, 2
• Discontinue all NSAIDs and steroids immediately to reduce ongoing ulcer risk 1
• Address diabetes aggressively if present, as it carries an odds ratio of 5.6 for marginal ulcer development on multivariate analysis 2

Mandatory Endoscopic Surveillance

Obtain biopsy of all ulcers at initial endoscopy to exclude malignancy - this is a strong recommendation that cannot be skipped 1, 3

• Perform endoscopic surveillance every 3 months until complete ulcer healing is documented 1
• Monitor specifically for stenosis development during follow-up endoscopy 1
• At first endoscopic follow-up, approximately 67% of ulcers will have healed with appropriate medical therapy 2

Critical Intraoperative Assessment for Perforated Ulcers

When surgical intervention is required for perforation:

• Always assess for gastro-gastric fistula in the presence of a perforated marginal ulcer, as 75% of patients requiring surgical intervention have associated fistulae 1, 3
• Exploration of the gastric remnant to rule out fistula decreases recurrent marginal ulcers 1

Management of Bleeding Marginal Ulcers

The approach depends on hemodynamic stability:

• Hemodynamically unstable patients should proceed directly to surgical exploration without delay 1
• For hemodynamically stable patients with bleeding, perform endoscopy first as it can achieve hemostasis and reduce rebleeding, need for surgery, and mortality 1
• Use standard endoscopic techniques such as injection and mechanical methods rather than thermal techniques to minimize ischemia risk 1
• Consider angiography with transcatheter angioembolization if endoscopic hemostasis fails or is unavailable 1

Management of Perforated Marginal Ulcers

For stable patients with small perforations:

• Laparoscopic primary suture repair with omental patch reinforcement is safe and effective for stable patients with perforation <1cm 1
• Omental patch repair or primary closure is sufficient - revision of anastomosis is not mandatory for perforation 4
• Damage control surgery and open abdomen approach should be considered for unstable patients 1

Antibiotic Management for Perforated Ulcers

• Initiate early empiric broad-spectrum antimicrobial therapy targeting Gram-negative bacilli and anaerobes 1
• Use short-course therapy (3-4 days IV antibiotics) after adequate source control 1
• Do not use empiric antifungal therapy for perforated marginal ulcers in community-acquired intra-abdominal infections 1

Management of Refractory Ulcers

If marginal ulcers persist despite 3-6 months of optimal medical therapy:

• Rule out Zollinger-Ellison syndrome 1
• Evaluate for structural problems including gastro-gastric fistula 1
• Consider endoscopic management by covering the ulcer bed using oversewing and/or deploying a fully covered self-expandable metallic stent before proceeding to surgery - this achieves 90% complete ulcer healing at 8 weeks 5
• Proceed to revisional surgery only after exhausting medical and endoscopic options, as only 36% of patients achieve symptom resolution and 57% develop recurrent ulcers after surgical intervention 1

Critical Pitfalls to Avoid

• Do not delay endoscopic surveillance - regular monitoring every 3 months is essential to confirm healing and detect complications like stenosis 1
• Do not proceed to surgery prematurely - given the high recurrence rate (57%) and poor symptom resolution (only 36%), exhaust medical and endoscopic options first 1
• Do not forget to obtain biopsies at initial endoscopy - malignancy must be excluded in all cases 1, 3
• Do not assume all marginal ulcers are related to NSAID use - the association with NSAIDs was not significant in multivariate analysis, while diabetes and smoking were the primary risk factors 2