Overview
Chronic gastric ulcers are persistent sores in the stomach lining that fail to heal within several weeks, often associated with significant morbidity and mortality 3. These ulcers can result from various etiologies including but not limited to Helicobacter pylori infection, NSAID use, and less commonly, atypical causes such as autoimmune conditions or malignancies 2.Diagnosis
Clinical Presentation: Persistent abdominal pain, especially between meals or at night, nausea, vomiting, weight loss 12.
Diagnostic Tests: Upper endoscopy with biopsy for histopathological examination, urea breath test or stool antigen test for H. pylori 2.
Evaluation for Atypical Causes: Consider autoimmune panel, hypercoagulable panel, infectious disease panel, and ulcer biopsy for microbiologic, DIF, and histopathologic evaluation if standard therapies fail 2.Management
First-Line Treatments:
- Antibiotics for H. pylori: Triple therapy (proton pump inhibitor + two antibiotics) 2.
- Proton Pump Inhibitors (PPIs): For acid suppression 2.
Adjunctive Treatments:
- Novel Acidoxidising Solutions: For wound cleansing in recalcitrant cases (e.g., Nexodyn) 4.
- Extracorporeal Shock Wave Therapy (ESWT): For stimulating healing in chronic ulcers unresponsive to conventional treatments 5.
Lifestyle Modifications: Particularly important for males with comorbidities like diabetes, hypercholesterolemia, and obesity 1.Special Populations
Comorbidities:
- Diabetes: Associated with higher multimorbidity and mortality risk 13.
- Arterial Ulcers: Higher mortality risk compared to other etiologies 3.
Gender Differences: Males more likely to have diabetes, hypercholesterolemia, and obesity; females more likely to have autoimmune diseases 1.Key Recommendations
Evaluate for H. pylori Infection: Initiate appropriate antibiotic therapy if H. pylori is identified (Evidence: Strong 2).
Consider Atypical Causes in Treatment-Resistant Cases: Obtain comprehensive testing including autoimmune, infectious disease, and histopathologic evaluations (Evidence: Moderate 2).
Utilize Novel Therapies for Refractory Ulcers: Consider adjunctive treatments like acidoxidising solutions or ESWT for chronic ulcers unresponsive to standard care (Evidence: Weak 45).
Tailored Management Based on Comorbidities: Focus on lifestyle modifications and specific disease management in patients with diabetes and obesity (Evidence: Expert opinion 1).References
1 Kuikko K, Salmi T, Huhtala H, Kimpimäki T. Characteristics of chronic ulcer patients by gender and ulcer aetiology from a multidisciplinary wound centre. International wound journal 2024. link
2 Nickles MA, Tsoukas MM, Sweiss N, Ennis W, Altman IA. Atypical ulcers: a stepwise approach for clinicians. Wounds : a compendium of clinical research and practice 2022. link
3 Salenius JE, Suntila M, Ahti T, Huhtala H, Vaalasti A, Salmi TT et al.. Long-term Mortality among Patients with Chronic Ulcers. Acta dermato-venereologica 2021. link
4 Ricci E. The management of chronic ulcers with an acidoxidising solution. Journal of wound care 2016. link
5 Saggini R, Figus A, Troccola A, Cocco V, Saggini A, Scuderi N. Extracorporeal shock wave therapy for management of chronic ulcers in the lower extremities. Ultrasound in medicine & biology 2008. link