What is the best treatment approach for a patient presenting with acute gastric ulcer pain?

Acute Gastric Ulcer Pain Treatment

Initiate high-dose proton pump inhibitor (PPI) therapy immediately—either intravenous omeprazole 80 mg bolus followed by 8 mg/hour continuous infusion for 72 hours if bleeding is suspected, or oral PPI 40 mg once daily for uncomplicated cases—while arranging urgent endoscopy within 24 hours and testing for H. pylori infection. 1

Immediate Pharmacological Management

PPI Therapy (First-Line)

• For suspected bleeding ulcers: Administer IV omeprazole 80 mg bolus, then 8 mg/hour continuous infusion for 72 hours after endoscopic hemostasis 1
• For uncomplicated gastric ulcers: Start oral PPI 40 mg once daily (omeprazole, pantoprazole, or equivalent) 2, 3
• Pre-endoscopic PPI therapy may downstage the endoscopic lesion and decrease need for intervention, but should not delay endoscopy 1
• After 72-hour IV infusion (if applicable), transition to oral PPI 40 mg once daily 4

Avoid Inferior Alternatives

• Do not use H2-receptor antagonists (ranitidine, cimetidine) as they are significantly less effective than PPIs for gastric ulcer healing 1, 4
• Somatostatin and octreotide are not routinely recommended 1

Urgent Endoscopic Evaluation

Timing and Indications

• Perform early endoscopy within 24 hours of presentation for all patients with acute upper GI bleeding 1
• Do not delay endoscopy in patients receiving anticoagulants 1
• Endoscopy allows risk stratification and therapeutic intervention for high-risk stigmata 1

Endoscopic Therapy Based on Findings

• High-risk stigmata (active bleeding or visible vessel): Endoscopic hemostatic therapy is indicated using thermocoagulation or sclerosant injection (strong recommendation) 1
• Epinephrine injection alone is suboptimal—must be combined with another method 1
• Through-the-scope clips may be used as alternative therapy 1
• Low-risk stigmata (clean-based ulcer): Endoscopic therapy not indicated; PPI therapy alone is sufficient 1
• Adherent clot: Attempt targeted irrigation for dislodgement; endoscopic therapy may be considered, though intensive PPI alone may suffice 1

H. pylori Testing and Eradication

Testing Strategy

• Test all patients with gastric ulcer for H. pylori infection using urea breath test (sensitivity 88-95%) or stool antigen testing (sensitivity 94%) 1, 2
• Endoscopic tissue biopsy may be obtained during endoscopy 1
• Negative tests obtained during acute bleeding should be repeated, as false-negatives occur 2
• Confirm eradication at least 4 weeks after completing therapy and at least 2 weeks after stopping PPI 2

Eradication Therapy

• Start H. pylori eradication after 72-96 hours of IV PPI administration in bleeding ulcers 1, 2
• First-line therapy (low clarithromycin resistance <20%): Standard triple therapy for 14 days 1, 2
  • PPI standard dose twice daily
  • Clarithromycin 500 mg twice daily
  • Amoxicillin 1000 mg twice daily
• High clarithromycin resistance (>20%): Bismuth-based quadruple therapy for 14 days 2
• Second-line therapy (if first-line fails): Levofloxacin-amoxicillin triple therapy for 10 days 1, 2
  • PPI standard dose twice daily
  • Levofloxacin 500 mg once daily
  • Amoxicillin 1000 mg twice daily

Duration of PPI Therapy

Post-Eradication Management

• For uncomplicated gastric ulcers after H. pylori eradication: Continue PPI until complete healing is confirmed (typically 6-8 weeks), as gastric ulcers require longer acid inhibition than duodenal ulcers 2, 5
• Most patients heal within 6 weeks; cumulative healing rates reach up to 100% after 4-8 weeks with omeprazole 30-40 mg daily 5, 3
• After successful eradication, prolonged maintenance PPI is generally not necessary 2

NSAID-Associated Ulcers

• Discontinue NSAIDs immediately if possible 4, 6
• If NSAIDs must be continued, maintain PPI co-therapy indefinitely 4
• Consider switching to COX-2 selective inhibitor plus PPI in high-risk patients 4

Transfusion Thresholds

• In patients without cardiovascular disease, give blood transfusions for hemoglobin <80 g/L 1
• In patients with cardiovascular disease, use a higher hemoglobin threshold 1

Discharge and Follow-Up Criteria

• Selected low-risk patients may be discharged promptly after endoscopy based on clinical and endoscopic criteria 1
• Most patients who underwent endoscopic hemostasis for high-risk stigmata should be hospitalized for at least 72 hours 1
• Low-risk patients after endoscopy can be fed within 24 hours 1
• Discharge with prescription for single daily-dose oral PPI for duration dictated by underlying cause 1

Surgical Consultation

• Seek surgical consultation for patients in whom endoscopic therapy has failed 1
• Where available, percutaneous embolization can be considered as alternative to surgery 1
• A second attempt at endoscopic therapy is generally recommended in cases of rebleeding 1

Common Pitfalls to Avoid

• Do not delay H. pylori treatment until after discharge—this significantly reduces treatment compliance 2
• Do not use H2-receptor antagonists as first-line therapy—they are inadequate for gastric ulcer healing 1, 4
• Do not use epinephrine injection alone for endoscopic hemostasis—combine with thermocoagulation or another method 1
• Do not perform routine second-look endoscopy—it is not recommended 1
• Negative H. pylori tests during acute bleeding may be false-negative; repeat testing is essential 2
• Eradication confirmation is mandatory for gastric ulcers to ensure cure and rule out malignancy 2