What is the appropriate workup and treatment for a patient with a gastric ulcer and anemia?

Management of Gastric Ulcer with Anemia

For a patient with gastric ulcer and anemia, immediately initiate high-dose PPI therapy (omeprazole 40 mg daily or equivalent), perform urgent upper endoscopy within 12-24 hours to assess bleeding risk and obtain biopsies to exclude malignancy, test for H. pylori and eradicate if positive, and begin oral iron supplementation (ferrous sulfate 200 mg once daily) after endoscopic hemostasis is achieved.

Immediate Resuscitation and Stabilization

• Assess hemodynamic stability first: Place two large-bore IV catheters and initiate volume resuscitation with crystalloids to restore tissue perfusion 1
• Transfuse red blood cells using a restrictive strategy: Maintain hemoglobin threshold of 7 g/dL with target range of 7-9 g/dL after transfusion, unless the patient has massive hemorrhage or cardiovascular comorbidity requiring higher thresholds 1
• Start high-dose PPI immediately: Begin omeprazole 80 mg IV bolus followed by 8 mg/hour continuous infusion, or equivalent dosing with other PPIs, as soon as gastric ulcer bleeding is suspected—do not wait for endoscopic confirmation 1

The 2020 WSES guidelines emphasize starting PPI therapy as early as possible, even before endoscopy, as this significantly reduces rebleeding rates (5.9% vs 10.3%, p=0.03) 1. The restrictive transfusion strategy from the 2018 EASL guidelines is critical, as overtransfusion increases mortality without improving outcomes 1.

Urgent Endoscopic Evaluation

• Perform upper endoscopy within 12-24 hours to identify the ulcer, assess bleeding risk using Forrest classification, and provide endoscopic hemostasis if high-risk stigmata are present 1
• Obtain multiple biopsies from the ulcer edges and base to exclude gastric malignancy, as this is mandatory for all gastric ulcers 1
• Apply dual-modality endoscopic hemostasis (injection plus thermal or mechanical therapy) for Forrest Ia (spurting), Ib (oozing), IIa (visible vessel), or IIb (adherent clot) lesions 1

The 2002 BSG guidelines stress that gastric ulcers require biopsy to exclude malignancy, unlike duodenal ulcers 1. If expertise is available, adherent clots should be dislodged with vigorous irrigation for at least 5 minutes before applying hemostasis 1.

H. pylori Testing and Eradication

• Test for H. pylori using biopsy-based methods (rapid urease test, histology, or culture) during the initial endoscopy 1
• Eradicate H. pylori with triple therapy if positive: Omeprazole 20 mg twice daily plus clarithromycin 500 mg twice daily plus amoxicillin 1000 mg twice daily for 14 days 2
• Continue PPI monotherapy for 6-8 weeks total after completing H. pylori eradication to ensure complete ulcer healing 1

H. pylori eradication reduces duodenal ulcer recurrence from 60% to 3-6% at 6-12 months 1, 2. The FDA-approved triple therapy achieves eradication rates of 74-83% 2. Patients who fail therapy should undergo susceptibility testing, as clarithromycin resistance develops more commonly with dual therapy 2.

Anemia Workup and Treatment

Initial Laboratory Assessment

• Obtain complete iron studies: Serum iron, total iron-binding capacity (TIBC), transferrin saturation, and ferritin to confirm iron deficiency as the cause of anemia 3
• Check MCV and RDW: Microcytic anemia (MCV <80 fL) with elevated RDW suggests iron deficiency 3
• Interpret ferritin in context: Ferritin up to 100 ng/mL can still indicate iron deficiency in the presence of inflammation; values 30-100 ng/mL suggest combined iron deficiency and anemia of chronic disease 3

Oral Iron Supplementation

• Start ferrous sulfate 200 mg (65 mg elemental iron) once daily after endoscopic hemostasis is achieved and active bleeding has stopped 3, 4
• Add vitamin C 500 mg with each iron dose to enhance absorption, particularly critical when transferrin saturation is severely low 3
• Take iron on an empty stomach for optimal absorption, though taking with food is acceptable if gastrointestinal side effects occur 3
• Continue oral iron for 3 months after hemoglobin normalizes to fully replenish iron stores 3

The 2025 Praxis guidelines emphasize once-daily dosing over multiple daily doses, as hepcidin elevation after oral iron blocks further absorption for 48 hours, increasing side effects without benefit 3. Alternative formulations (ferrous fumarate or ferrous gluconate) are equally effective if ferrous sulfate is not tolerated 3.

When to Switch to Intravenous Iron

• Use IV iron if the patient cannot tolerate at least two different oral iron preparations despite optimization strategies 3, 5
• Switch to IV iron if hemoglobin fails to rise by 2 g/dL after 4 weeks of compliant oral therapy, indicating continued blood loss, malabsorption, or non-adherence 3, 4
• Consider IV iron for ongoing gastrointestinal bleeding that exceeds oral replacement capacity 3, 5

Preferred IV iron formulations include ferric carboxymaltose (500-1000 mg single doses) or iron sucrose, which can replace iron deficits in 1-2 infusions 3, 5. Avoid iron dextran due to higher anaphylaxis risk requiring test doses 3.

Follow-Up Endoscopy and Monitoring

• Repeat endoscopy at 6-8 weeks to confirm gastric ulcer healing and repeat biopsies to definitively exclude malignancy 1
• Continue PPI therapy until healing is endoscopically confirmed 1
• Check hemoglobin at 4 weeks after starting iron therapy, expecting a rise of approximately 2 g/dL 3
• Monitor hemoglobin and red cell indices every 3 months for the first year, then again after another year 3

The 2002 BSG guidelines mandate repeat endoscopy for gastric ulcers (unlike duodenal ulcers) because 3-5% harbor malignancy that may be missed on initial biopsy 1.

Management of NSAID-Associated Ulcers

• Discontinue NSAIDs and aspirin if possible during the acute healing phase 1
• If NSAIDs must be continued, use the least damaging agent (ibuprofen) with a PPI 1
• Consider COX-2 selective anti-inflammatory drugs as an alternative 1
• Test and eradicate H. pylori even in NSAID users, though data are conflicting on whether eradication alone prevents recurrence in patients continuing NSAIDs 1

Surgical Intervention Criteria

• Consult surgery if rebleeding occurs twice despite optimal endoscopic therapy, particularly in elderly patients with comorbidities or giant posterior gastric ulcers with multiple bleeding points 1
• Perform partial gastrectomy or local excision depending on ulcer size, location, and suspicion for malignancy 1
• Avoid midnight-to-7am operations when possible, as mortality correlates with preoperative APACHE II scores and timing 1

Critical Pitfalls to Avoid

• Do not delay PPI therapy waiting for endoscopy—start high-dose IV PPI immediately when gastric ulcer bleeding is suspected 1
• Do not skip gastric ulcer biopsies—malignancy must be excluded in all cases 1
• Do not prescribe multiple daily doses of oral iron—once-daily dosing improves tolerance with equal or better efficacy 3
• Do not stop iron therapy when hemoglobin normalizes—continue for 3 months to replenish stores 3
• Do not fail to repeat endoscopy at 6-8 weeks—gastric ulcers require confirmation of healing and repeat biopsies 1
• Do not continue oral iron if hemoglobin fails to rise by 2 g/dL at 4 weeks—switch to IV iron 3, 4
• Do not overlook vitamin C supplementation—it significantly enhances iron absorption when transferrin saturation is low 3