Gastric Ulcer

A mucosal defect of the stomach that extends through the muscularis mucosae into the submucosa or deeper, usually on the lesser curve near the incisura angularis.

• Causes: H. pylori infection (60 to 70%), NSAIDs and aspirin (up to 25 to 40%), smoking, alcohol, critical illness, malignancy (gastric adenocarcinoma presenting as an ulcer, in about 2 to 5% of ulcers that look benign), and less commonly Crohn disease, cytomegalovirus, ischaemia, radiation, Zollinger-Ellison syndrome, and drugs such as bisphosphonates, potassium chloride and corticosteroids with NSAIDs.
• Incidence is about 0.1 to 0.2% per year; peak age 50 to 70 years; annual rebleeding and recurrence is high without H. pylori eradication (more than 50% at 1 year) and falls to about 5% after eradication.
• Mechanism: imbalance between acid and pepsin aggression and mucosal defence (mucus, bicarbonate, blood flow, prostaglandins); H. pylori causes corpus or pangastritis with impaired defences, and NSAIDs inhibit prostaglandins.

Epigastric pain (burning or gnawing), often worse after eating, early satiety, nausea, vomiting, loss of appetite and weight; pain may be unrelated to meals.

• Complications at presentation: haematemesis (fresh blood or coffee grounds), melaena, anaemia, and sudden severe abdominal pain with a rigid abdomen (perforation).
• Examination: epigastric tenderness, pallor, a succussion splash with outlet obstruction.
• Differential diagnosis: duodenal ulcer, gastric cancer, gastric lymphoma, gastritis, functional dyspepsia, pancreatitis, biliary disease, reflux, Crohn disease, cytomegalovirus.
• Complications: bleeding (the commonest, about 15 to 20% in the lifetime of untreated patients), perforation (about 2 to 5%), gastric outlet obstruction from pyloric scarring (about 2%), penetration into the pancreas, malignancy missed, and recurrence.

Upper endoscopy for all patients with a gastric ulcer: describe size, site and appearance (clean base, flat spot, adherent clot, visible vessel, active oozing or spurting); take 4 to 6 biopsies from the ulcer edge and base, plus gastric biopsies for H. pylori.

• Repeat endoscopy with biopsies after 6 to 8 weeks of treatment to confirm healing and exclude malignancy (especially for ulcers more than 2 cm, with irregular or rolled edges, or when healing is incomplete); an unhealed ulcer at 12 weeks needs expert review.
• Helicobacter pylori testing by histology and rapid urease test at endoscopy (false negatives occur in bleeding or on proton pump inhibitors), or urea breath test or stool antigen after stopping proton pump inhibitors for 2 weeks.
• Blood tests: full blood count, ferritin, urea, creatinine, liver tests, group and crossmatch in bleeding; fasting gastrin for refractory or multiple ulcers; CT for perforation, penetration or suspected tumour; chest X-ray (free air under the diaphragm).
• NSAID and aspirin history; assess for alarm features.

Acid suppression: omeprazole 40 mg daily (or esomeprazole 40 mg, lansoprazole 30 mg, pantoprazole 40 mg daily) for 8 weeks, taken 30 minutes before breakfast; healing in about 90% at 8 weeks; extend or double the dose for large ulcers.

• Helicobacter pylori eradication for 14 days (most important to prevent recurrence):
  • Omeprazole 20 mg twice daily, amoxicillin 1 g twice daily and clarithromycin 500 mg twice daily (where clarithromycin resistance is less than 15%).
  • Omeprazole 20 mg twice daily, bismuth subsalicylate 524 mg four times daily, tetracycline 500 mg four times daily and metronidazole 500 mg three to four times daily (first choice in high resistance areas, penicillin allergy and after treatment failure).
  • Rescue therapy after failure: omeprazole 20 mg twice daily, amoxicillin 1 g twice daily and levofloxacin 500 mg daily for 14 days, or rifabutin 150 mg twice daily instead of levofloxacin.
  • Test of cure at least 4 weeks after antibiotics and 2 weeks off the proton pump inhibitor.
• Stop NSAIDs where possible; if they must continue, use celecoxib 100 to 200 mg twice daily plus omeprazole 20 to 40 mg daily; aspirin 75 mg daily for secondary prevention continues with omeprazole 20 mg daily; stop smoking and alcohol.
• Bleeding ulcer:
  • Resuscitation: two large-bore cannulae, crystalloid, transfuse at 70 g/L (80 g/L in cardiovascular disease), correct coagulopathy (vitamin K 10 mg IV, prothrombin complex concentrate 25 to 50 units/kg for warfarin, platelets to 50 x 10^9/L or more), hold anticoagulants.
  • Endoscopy within 24 hours: for active spurting or oozing and visible vessels, give adrenaline 1 in 10,000 (up to 10 mL) with a thermal probe, haemoclip or haemostatic powder; ulcers with a clean base or flat spot need no endoscopic therapy.
  • After endoscopic therapy: omeprazole 80 mg IV bolus then 8 mg/hour for 72 hours (or 40 mg IV twice daily), then omeprazole 40 mg orally twice daily for 2 weeks, then 40 mg daily for the remaining 6 weeks; keep inpatients for 72 hours after high-risk stigmata.
  • Rebleeding (about 10 to 15%): repeat endoscopic therapy, then angiographic embolisation (left gastric or gastroduodenal artery), or surgery (oversewing or partial gastrectomy) if bleeding persists.
  • Tranexamic acid is not helpful.
• Perforation: nil by mouth, fluid resuscitation, nasogastric drainage, omeprazole 40 mg IV, antibiotics (piperacillin-tazobactam 4.5 g IV every 6 hours, or ceftriaxone 2 g IV daily with metronidazole 500 mg IV every 8 hours), and urgent laparoscopic or open omental patch repair with biopsy (resection for large or suspicious ulcers).
• Outlet obstruction: nasogastric decompression, IV fluids with potassium, omeprazole 40 mg IV daily, correction of alkalosis, then endoscopic balloon dilatation (up to 15 to 18 mm), with surgery (gastrojejunostomy or resection) for failure.
• Refractory ulcer (no healing at 12 weeks): check adherence, H. pylori status, covert NSAID or aspirin use, smoking, malignancy (repeat biopsies), Zollinger-Ellison syndrome (gastrin), cytomegalovirus, Crohn disease, and consider surgery.
• Special groups: children (rare, secondary to NSAIDs, stress or H. pylori; omeprazole 1 mg/kg daily, maximum 40 mg, with weight-based eradication using amoxicillin 25 mg/kg twice daily and clarithromycin 7.5 mg/kg twice daily); pregnancy (alginates, famotidine 20 mg twice daily, omeprazole 20 to 40 mg daily; defer eradication; endoscopy if bleeding); elderly (higher mortality, stop NSAIDs, endoscopy and biopsy at lower threshold); renal impairment (famotidine 10 to 20 mg daily; avoid aluminium antacids and sucralfate); anticoagulated patients (review need, restart when haemostasis is secure).
• Red flags: haematemesis, melaena, collapse, rigid abdomen, persistent vomiting, weight loss, dysphagia, anaemia, an ulcer not healed at 8 to 12 weeks.
• Follow-up: clinical review at 4 to 8 weeks; repeat endoscopy at 6 to 8 weeks (and biopsy) to confirm healing; test of cure for H. pylori at 4 to 8 weeks; haemoglobin and ferritin at 3 months; long-term proton pump inhibitor for continuing NSAID or aspirin use.