Ulcers – Upper GI
Diagnosis/Definition
Any gastric or duodenal ulcer found by Upper GI.
Initial Diagnosis and Management
- Attempt to stop NSAIDs in all cases (consider Tylenol +/- codeine for analgesia; Cox-2 NSAID).
- DUODENAL ULCER NOT RELATED TO NSAIDs: Give treatment to eradicate H. pylori (can assume patient has H. pylori) followed by four weeks of bid H2-blockers.
- BENIGN APEARING GASTRIC ULCER: Whether or not related to NSAIDs, initiate treatment with bid H2-blockers, then refer for endoscopy to document healing (endoscopy will typically be done at the end of an eight week course of therapy).
Ongoing Management and Objectives
- In patients that cannot stop NSAIDs that have a DU that is believed related to these (H pylori titer is negative), an H2-blocker in full dosage (bid) can be continued to prevent NSAID related DUs.
- If it is a GU, misoprostol 200 mcg tid can be given as prophylaxis.
- Proton pump inhibitors (PPIs) will provide prophylaxis for both NSAID-related DU and GU but may not prevent the NSAID-related dyspepsia.
- Cox-2 NSAIDs cause less ulceration compared to regular NSAIDS
- At present, most patients treated for H. pylori do not need to have repeat testing done in an attempt to document eradication unless there are complications (bleeding, perforation, obstruction).
Indications for Specialty Care Referral
Gastric ulcer (GU) following 8 weeks of therapy.
Iron deficiency anemia.
Upper GI suggestive of malignancy by radiology report.
Significant weight loss.
Gastric ulcer > 2.5 cm.
Ongoing acid peptic pain after completion of treatment course.
Duodenal ulcers DO NOT need to be followed to healing.
Criteria for Return to Primary Care
Completed GI evaluation that outlines further care.
