Is an immediate EGD (esophagogastroduodenoscopy) needed for a patient with a gastric ulcer, Mallory-Weiss tear, and visible vessel treated with epinephrine (epi) and clipping, who is also positive for H. pylori and awaiting eradication therapy?

Repeat EGD After Successful Endoscopic Treatment of Gastric Ulcer with Mallory-Weiss Tear

Yes, a repeat EGD is mandatory at approximately 6 weeks after discharge to confirm ulcer healing and exclude malignancy, regardless of the successful initial hemostasis. 1

Why Repeat Endoscopy is Required

Gastric ulcers require follow-up endoscopy to exclude underlying malignancy, unlike duodenal ulcers or Mallory-Weiss tears alone. 1 This is a critical distinction because:

• Some gastric malignancies can only be detected during or following the healing process 2
• The follow-up endoscopy is mandatory for gastric ulcers due to the risk of underlying malignancy 1
• This requirement applies even when initial endoscopic hemostasis was successful with epinephrine and clipping 2

Management Between Initial and Follow-up EGD

PPI Therapy

• Continue oral PPI therapy for 6-8 weeks after endoscopic treatment to allow complete mucosal healing 1, 3
• The standard regimen after the acute phase is PPI 40mg once daily 1
• PPI therapy should continue until complete healing is confirmed on follow-up endoscopy 1

H. pylori Management

• Tests for H. pylori have increased false-negative rates during acute bleeding episodes 2, 1
• A confirmatory test should be performed outside the acute bleeding context if the initial test was negative 1
• If H. pylori is confirmed positive, initiate eradication therapy (standard triple therapy for 14 days) and document cure 1, 3
• Post-treatment H. pylori infection status is an independent predictor of rebleeding 2

NSAID/Aspirin Management

• All NSAIDs and aspirin should be immediately suspended 1
• If NSAIDs must be continued for valid medical reasons, use the least harmful agent (ibuprofen) combined with PPI therapy 1

The Follow-up EGD Protocol

The repeat endoscopy at 6 weeks should include:

• Multiple targeted biopsy specimens from the antrum and body (at least 2 from each location) 2
• Additional biopsies from the ulcer site to exclude malignancy 2, 1
• Histological assessment of any mucosal abnormalities 2
• Confirmation of complete ulcer healing 1

Special Consideration for the Mallory-Weiss Component

The Mallory-Weiss tear component does not require follow-up endoscopy if successfully treated, as these lesions have a low risk of rebleeding once hemostasis is achieved 2, 4. However, the presence of the gastric ulcer mandates the follow-up EGD regardless 1.

Common Pitfalls to Avoid

• Do not assume healing based on symptom resolution alone - gastric ulcers require endoscopic confirmation 1
• Do not rely on a single negative H. pylori test during acute bleeding - repeat testing outside the acute context is essential 2, 1
• Do not discontinue PPI therapy prematurely - maintain for the full 6-8 weeks until healing is confirmed 1, 3
• Failure to perform follow-up endoscopy may miss underlying gastric malignancy 2, 1