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Gastric ulcer — Clinical Guidelines

Overview

Gastric ulcers are sores that develop on the lining of the stomach, often associated with Helicobacter pylori infection, nonsteroidal anti-inflammatory drug (NSAID) use, or other factors leading to mucosal damage and inflammation. 5 22

Diagnosis

Clinical Presentation: Epigastric pain, often relieved by food or antacids.

Endoscopy: Gold standard for visualizing ulcers and assessing severity.

Biopsy: Histopathologic evaluation for H. pylori presence and ulcer characteristics. 4 5

Serology/Urease Tests: Detect H. pylori infection (e.g., urea breath test, serology).

Gastric Content Analysis: Ultrasound assessment for solid contents to prevent aspiration risks. 3 11

Imaging: CT or upper GI series for complications like perforation or bleeding. 8 33

Management

First-Line Treatment:

- Antibiotics: Triple therapy (proton pump inhibitor + two antibiotics) for H. pylori eradication. 5 - Proton Pump Inhibitors (PPIs): Reduce gastric acid secretion to promote healing (e.g., omeprazole).

Adjunctive Treatments:

- H2 Receptor Antagonists: For additional acid suppression if needed. - NSAID Cessation/Alternative Therapy: Discontinue NSAIDs or use gastroprotective agents like misoprostol cautiously due to adverse events. 2

Monitoring: Regular endoscopic follow-up to ensure healing and rule out recurrence. 17

Special Populations

Pregnancy: Use of NSAIDs should be minimized; PPIs are generally considered safe but monitor closely. 2

Elderly: Increased risk of complications; careful monitoring and management of comorbidities like bleeding disorders. 10

Comorbidities: Consider interactions with concurrent medications, especially anticoagulants, and adjust treatment accordingly. 10

Key Recommendations

Endoscopic Surveillance: Regular endoscopic follow-up for all gastric ulcers until healing is confirmed (Evidence: Moderate) 17

H. pylori Eradication Therapy: Implement triple therapy for confirmed H. pylori infection to prevent recurrence (Evidence: Strong) 5

Sedation and Monitoring During Procedures: Ensure adequate sedation and intraprocedural monitoring during endoscopic procedures to prevent complications like aspiration pneumonia (Evidence: Moderate) 12 10

References

1 Gong EJ, Woo J, Lee JJ, Bang CS. Role of artificial intelligence in gastric diseases. World journal of gastroenterology 2025. link 2 Yang L, Xu W. A disproportionality analysis of FDA adverse event reporting system events for misoprostol. Scientific reports 2025. link 3 Wang J, Yu X, Wang Y, Xu J, Wang Z, Zhang Y. Ultrasonic assessment of gastric solid contents in patients undergoing upper endoscope with sedation. BMC anesthesiology 2024. link 4 Laohawetwanit T, Wanpiyarat N, Lerttanatum N, Apornvirat S, Kantasiripitak C, Atiroj N et al.. Histopathologic evaluation of gastric intestinal metaplasia in non-neoplastic biopsy specimens: Accuracy and interobserver reliability among general pathologists and pathology residents. Annals of diagnostic pathology 2024. link 5 Fazio A, Bitrán-Ambler M, Ramírez-Rivera S, Zaffiri V, Bernal G. Genotyping of Helicobacter pylori CagA/CagE strains in gastric mucosa and its association with gastric illness. Diagnostic microbiology and infectious disease 2023. link 6 Kato H, Kobayashi M, Yano M. Examination of a large electrode tip system device in gastric endoscopic submucosal dissection. Digestive endoscopy : official journal of the Japan Gastroenterological Endoscopy Society 2023. link 7 Schizas D, Tomara N, Katsaros I, Sakellariou S, Machairas N, Paspala A et al.. Primary gastric melanoma in adult population: a systematic review of the literature. ANZ journal of surgery 2021. link 8 Jetty S, Fultz PJ, Patel A, Chaturvedi A. Imaging of acute gastric emergencies: a case-based review. Clinical imaging 2021. link 9 Elfadadny A, Mandour AS, Ragab RF, Alsharif KF, Batiha GE, Samir H et al.. A comparative time-dependent study of hematology, serum gastrin concentrations, and gastroscopic assessment of meloxicam-induced gastric ulceration in dogs. Journal of veterinary internal medicine 2021. link 10 Togo M, Akazawa Y, Akashi T, Yamashita R, Yoshitomi I, Ohba K et al.. Comprehensive Prospective Analysis of the Factors Contributing to Aspiration Pneumonia Following Endoscopic Submucosal Dissection in Patients with Early Gastric Neoplasms. Acta medica Okayama 2020. link 11 Arzola C, Carvalho JC, Cubillos J, Ye XY, Perlas A. Anesthesiologists' learning curves for bedside qualitative ultrasound assessment of gastric content: a cohort study. Canadian journal of anaesthesia = Journal canadien d'anesthesie 2013. link 12 Sasaki T, Tanabe S, Ishido K, Azuma M, Katada C, Higuchi K et al.. Recommended sedation and intraprocedural monitoring for gastric endoscopic submucosal dissection. Digestive endoscopy : official journal of the Japan Gastroenterological Endoscopy Society 2013. link 13 Ribeiro-Mourão F, Pimentel-Nunes P, Dinis-Ribeiro M. Endoscopic submucosal dissection for gastric lesions: results of an European inquiry. Endoscopy 2010. link 14 Corrigan MA, Shields CJ, Keohane C, Kirwan WO. The immunohistochemical demonstration of Helicobacter pylori in rectal ectopia. Surgical laparoscopy, endoscopy & percutaneous techniques 2009. link 15 van der Steen WJ, Ho VK. Drugs versus diets: disillusions with Dutch health care. Acta biotheoretica 2001. link 16 Rao GM, Satyanarayana Y, Janaki M, Hayath MS. Primary melanocarcinoma of stomach. Indian journal of gastroenterology : official journal of the Indian Society of Gastroenterology 1999. link 17 Breslin NP, Sutherland LR. Survey of current practices among members of CAG in the follow-up of patients diagnosed with gastric ulcer. Canadian journal of gastroenterology = Journal canadien de gastroenterologie 1999. link 18 Misra V, Misra SP, Dwivedi M, Gupta SC. Helicobacter pylori in areas of intestinal metaplasia in gastric antral mucosa. Pathology 1997. link 19 Cave DR. Helicobacter pylori and its interaction with chief and parietal cells. The Yale journal of biology and medicine 1996. link 20 Krakowka S, Eaton KA, Rings DM. Occurrence of gastric ulcers in gnotobiotic piglets colonized by Helicobacter pylori. Infection and immunity 1995. link 21 Meyer JH. Nutritional outcomes of gastric operations. Gastroenterology clinics of North America 1994. link 22 De Boni M, De Bona M, Cielo R. Helicobacter pylori and pre-neoplastic and neoplastic gastric lesions. The Italian journal of gastroenterology 1994. link 23 Klomp LW, van Rens L, Strous GJ. Identification of a human gastric mucin precursor: N-linked glycosylation and oligomerization. The Biochemical journal 1994. link 24 Muto N, Yamamoto M, Tani S, Yonezawa S. Characteristic distribution of cathepsin E which immunologically cross-reacts with the 86-kDa acid proteinase from rat gastric mucosa. Journal of biochemistry 1988. link 25 Asano S, Iino T, Tabuchi Y, Takeguchi N. Properties of light and heavy vesicles simultaneously prepared from hog gastric mucosae. Journal of biochemistry 1988. link 26 Vuylsteke P, De Coster M, Noyez D. Gastric pseudolymphoma. Acta chirurgica Belgica 1987. link 27 Shireman PK. Intramural cyst of the stomach. Human pathology 1987. link80061-8) 28 O'Doherty DP, Baker AR, Barrie WW. Rupture of the stomach after hemorrhage from a gastric ulcer. Gastroenterology 1986. link90460-9) 29 Gjørup T, Nielsen H, Jensen LB, Jensen AM. Interobserver variation in the radiographic diagnosis of gastric ulcer. Gastroenterologists' guesses as to level of interobserver variation. Acta radiologica: diagnosis 1985. link 30 Pieterse AS, Rowland R, Labrooy JT. Gastric xanthomas. Pathology 1985. link 31 Tsutsumi Y. Immunohistochemical studies on glucagon, glicentin and pancreatic polypeptide in human stomach: normal and pathological conditions. The Histochemical journal 1984. link 32 Campbell R, Kennedy T, Johnston GW. Gastric ulceration after Nissen fundoplication. The British journal of surgery 1983. link 33 Falke TH, Ziedses des Plantes BG, Liem BT. CT of the stomach and duodenum. Part II: Pathology. European journal of radiology 1983. link 34 Duffy BL. Regurgitation during pelvic laparoscopy. British journal of anaesthesia 1979. link 35 Hardin WJ. Evaluation of autosutures in gastrointestinal surgery. Southern medical journal 1977. link 36 Flint FJ, Grech P. Pyloric regurgitation and gastric ulcer. Gut 1970. link

Gastric ulcer