When is a repeat Esophagogastroduodenoscopy (EGD) recommended for a patient with a history of duodenal ulcers (DU)?

Repeat EGD for Duodenal Ulcers

Routine follow-up endoscopy is not necessary for uncomplicated duodenal ulcers after appropriate treatment with H. pylori eradication and/or proton pump inhibitors, unlike gastric ulcers which require mandatory repeat endoscopy. 1

Key Distinction: Duodenal vs. Gastric Ulcers

• Duodenal ulcers are virtually never malignant and do not require routine surveillance endoscopy after healing 1
• This contrasts sharply with gastric ulcers, which carry malignancy risk and mandate repeat endoscopy at 6-8 weeks to confirm healing and exclude malignancy 1

When Repeat EGD IS Indicated for Duodenal Ulcers

1. Bleeding Duodenal Ulcers

• Repeat endoscopy approximately 6 weeks after discharge is recommended for bleeding duodenal ulcers, particularly if endoscopic hemostasis was required 1
• After initial endoscopic hemostasis failure or recurrent bleeding following successful initial EGD, repeat endoscopy is indicated for stable patients with ulcers smaller than 2 cm in diameter 2
• For patients with hypotension and/or hemodynamic instability and/or ulcer larger than 2 cm at first endoscopy, surgical intervention (or angiographic embolization if immediately available) should be considered without repeated endoscopy 2

2. Persistent or Recurrent Symptoms

• If symptoms continue or recur after appropriate treatment, repeat EGD is indicated to assess for unhealed ulcer or alternative diagnosis 1
• Symptoms that persist despite therapeutic intervention should prompt further investigations to rule out complications and reassess disease severity 2

3. Failed H. pylori Eradication

• If eradication therapy fails, repeat EGD may be considered to assess ulcer status and obtain biopsies for culture/sensitivity 1
• However, most duodenal ulcers that do not heal initially despite H. pylori eradication will ultimately heal spontaneously after several weeks without additional therapy (73% healed spontaneously within one month, 98.1% ultimately healed) 3

Appropriate Post-Treatment Management Without Repeat EGD

Confirm H. pylori Eradication

• Use urea breath test or stool antigen test at least 4 weeks after completing antibiotics (and at least 2 weeks off PPIs) 1
• This non-invasive testing is preferred over repeat endoscopy for eradication confirmation 4

Address Risk Factors

• Discontinue NSAIDs/aspirin if possible; if continuation is medically necessary, use lowest effective dose with PPI co-therapy 1
• Patients who smoke, drink alcohol, or have a history of ulcer disease are at greatest risk for recurrence 5

Clinical Pitfalls to Avoid

• Do not routinely perform surveillance endoscopy in asymptomatic patients after duodenal ulcer healing 6
• Asymptomatic ulcer recurrences rarely cause clinical problems and have a spontaneous healing rate of approximately 25% annually, even without treatment 6
• Only one patient out of 36 with asymptomatic recurrence experienced bleeding during follow-up 6
• The cure of H. pylori infection is essentially the cure of duodenal ulcer recurrence in the vast majority of cases 4