What is the recommended acute management for a patient presenting with a severe gastric ulcer?

Acute Management of Severe Gastric Ulcer

For a patient presenting with a severe gastric ulcer, immediate resuscitation with hemodynamic stabilization is the priority, followed by urgent upper endoscopy within 12-24 hours for both diagnosis and therapeutic hemostasis in stable patients, while hemodynamically unstable patients require immediate surgical exploration without delay. 1, 2

Immediate Resuscitation and Stabilization

Hemodynamic Assessment and Resuscitation:

• Establish two large-bore intravenous lines (≥18 gauge) and initiate crystalloid infusion immediately 1
• Maintain hemoglobin >7 g/dL with packed red blood cell transfusion; type and cross-match 2-4 units 1, 3
• Target systolic blood pressure 90-100 mmHg during initial resuscitation 3
• Normalize lactate and base deficit, and correct or prevent coagulopathy 3
• Keep the patient nil per os (NPO) immediately 1
• Obtain routine laboratory studies and arterial blood gas analysis 4

Risk Stratification:

• Use the Blatchford score to determine timing of endoscopy: very low-risk patients undergo outpatient endoscopy, low-risk patients undergo early inpatient endoscopy, and high-risk patients require urgent inpatient endoscopy 3
• Even a hemoglobin drop of ~2 g/dL with melena and orthostatic symptoms indicates significant bleeding requiring urgent intervention 1

Diagnostic Approach

Imaging for Suspected Perforation:

• CT scan is the strongly recommended first-line imaging modality for suspected perforated peptic ulcer 4, 3
• If CT is not promptly available, perform chest/abdominal X-ray as initial diagnostic assessment 4
• When free air is not seen on imaging but suspicion remains high, perform imaging with water-soluble contrast (oral or via nasogastric tube) 4

Endoscopic Evaluation:

• Upper endoscopy within 12-24 hours is first-line for hemodynamically stable patients; it reduces rebleeding, need for surgery, and mortality 1, 3, 2, 5
• Mandatory biopsy of all gastric ulcers must be obtained to exclude malignancy, as gastric ulcers cannot be reliably distinguished as benign by appearance alone 1, 3, 2
• Multiple biopsies should be obtained from the ulcer margin and base 3
• During endoscopy, assess for gastro-gastric fistula (present in ~75% of patients requiring surgical intervention) 1

Therapeutic Interventions

Medical Management:

• Initiate high-dose proton pump inhibitor (PPI) therapy immediately: intravenous bolus followed by continuous infusion for active bleeding, then oral therapy (e.g., pantoprazole 40 mg twice daily) for minimum 3-6 months 1, 3, 5
• Administer pre-endoscopic erythromycin to increase diagnostic yield at first endoscopy 5
• Pre-endoscopic PPI may decrease need for endoscopic therapy but does not improve clinical outcomes 5

Endoscopic Hemostasis:

• Perform dual modality endoscopic therapy for spurting ulcers, oozing ulcers, and ulcers with non-bleeding visible vessels (e.g., bipolar electrocoagulation, heater probe, sclerosant, clips) 3, 5
• Standard endoscopic techniques such as injection and mechanical methods are preferred over thermal techniques to minimize ischemia risk 1
• Ulcers with adherent clots may receive endoscopic therapy 5
• Flat spots or clean-based ulcers do not require endoscopic therapy or intensive PPI 5

Interventional Radiology:

• If endoscopic hemostasis fails or is unavailable, angiography with transcatheter angioembolization is recommended when technical skills and equipment are available 1, 3, 2

Surgical Management:

• Hemodynamically unstable patients should proceed directly to surgical exploration without delay 1, 2
• For recurrent bleeding after endoscopic therapy, perform second endoscopic treatment; if bleeding persists or recurs, proceed to surgery or interventional radiology 5
• For perforated ulcers in stable patients with perforation <1-2 cm, laparoscopic primary suture repair with omental patch reinforcement is safe and effective 1, 6
• For large perforations (≥2 cm) or bleeding gastric ulcers, resection should be performed if possible 7
• Damage control surgery and open abdomen approach should be considered for unstable patients 1

Antimicrobial and Eradication Therapy

Antibiotic Management for Perforation:

• Initiate early empiric broad-spectrum antimicrobial therapy targeting Gram-negative bacilli and anaerobes 1
• Short-course therapy (3-4 days IV antibiotics) is effective after adequate source control 1
• Empiric antifungal therapy is not supported for perforated ulcers in community-acquired intra-abdominal infections 1

H. pylori Testing and Eradication:

• All patients with gastric ulcers must be tested for H. pylori infection using urea breath test or stool antigen test 3, 5, 8
• Negative H. pylori tests obtained during acute bleeding should be repeated, as acute bleeding causes false-negative results 3
• Eradicate H. pylori with combination therapy (antibiotics, ranitidine bismuth citrate, bismuth, and proton pump inhibitors), which reduces ulcer recurrence from 50-60% to 0-2% 3, 8
• Confirm eradication after treatment 3

Risk Factor Modification

Immediate Interventions:

• Enforce complete smoking cessation 1, 3
• Discontinue all NSAIDs and steroids immediately 1, 3
• Address any ongoing immunosuppression 1
• For patients requiring continued NSAID therapy after healing, use low-dose COX-2-selective NSAID plus PPI 5
• Patients with established cardiovascular disease requiring aspirin should start PPI and generally re-institute aspirin soon after bleeding ceases (within 7 days, ideally 1-3 days) 5

Follow-Up and Monitoring

Short-Term Monitoring:

• Monitor for signs of rebleeding (hematemesis, worsening melena, hemodynamic changes, falling hemoglobin) with serial hemoglobin checks every 4-6 hours until stability is confirmed for 24 hours 1
• Continue high-dose PPI for at least 3-6 months 1, 3

Mandatory Endoscopic Surveillance:

• All gastric ulcers require repeat endoscopy at approximately 6 weeks to confirm healing and exclude malignancy 3
• Perform endoscopic surveillance every 3 months until complete ulcer healing is documented and to rule out stenosis development 1
• Continue PPI therapy until repeat endoscopy confirms healing 3

Refractory Ulcers:

• If ulcers persist despite 3-6 months of optimal medical therapy, evaluate for Zollinger-Ellison syndrome, structural problems (gastro-gastric fistula, pouch enlargement), and consider revisional surgery 1
• Only 36% of patients achieve symptom resolution after surgical intervention, and 57% develop recurrent ulcers, underscoring the need to exhaust medical options first 1

Critical Pitfalls to Avoid

• Do not delay endoscopy in hemodynamically stable patients; early endoscopy reduces mortality and need for surgery 1, 2
• Never omit ulcer biopsy—malignancy must be excluded in every case 1, 3, 2
• Always assess for gastro-gastric fistula, given its presence in 75% of cases that progress to surgery 1
• Do not perform angiography before endoscopy, as this results in unacceptable rates of negative investigations 3
• Do not use H2-receptor antagonists instead of PPIs, as they result in inferior healing rates 3
• Do not proceed directly to surgery in stable patients; endoscopic management succeeds in the majority of cases 1, 2
• Do not delay endoscopic surveillance—regular monitoring is essential to confirm healing and detect complications like stenosis or malignancy 1, 3