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Peptic ulcer disease

Key sources
The following summarized guidelines for the evaluation and management of peptic ulcer disease are prepared by our editorial team based on guidelines from the Korean College of Helicobacter and Upper Gastrointestinal Research (KCHUGR 2023), the American Academy of Family Physicians (AAFP 2023), the American College of Gastroenterology (ACG 2021; 2017; 2012), the American Society for Gastrointestinal Endoscopy (ASGE 2021; 2010), and the World Society of Emergency Surgery (WSES 2020).
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Guidelines

1.Classification and risk stratification

Risk and severity assessment, bleeding ulcer, WSES: obtain prompt surgical and medical evaluation in patients with bleeding peptic ulcer to prevent further bleeding and to reduce mortality.
B
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  • Risk and severity assessment (perforated ulcer)

2.Diagnostic investigations

Laboratory testing, bleeding ulcer: obtain blood-typing, hemoglobin, hematocrit and electrolytes, and coagulation assessment in patients with suspected bleeding peptic ulcer.
B

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  • Laboratory testing (perforated ulcer)

  • Diagnostic imaging (bleeding ulcer)

  • Diagnostic imaging (perforated ulcer)

  • Testing for H. pylori infection

3.Diagnostic procedures

Upper gastrointestinal endoscopy
As per WSES 2020 guidelines:
Perform endoscopy in patients with suspected bleeding peptic ulcer as soon as possible, especially in the high-risk group.
B
Consider guiding management decisions according to stigmata of recent hemorrhage during endoscopy because they can predict the risk of further bleeding.
B

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  • Biopsy

4.Medical management

Initial resuscitation, bleeding ulcer
Use several resuscitation targets, similar to those of damage control resuscitation in patients with bleeding trauma.
B
Maintain an hemoglobin level of at least > 7 g/dL during the resuscitation phase in patients with bleeding peptic ulcer.
B

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  • Initial resuscitation (perforated ulcer)

  • Indications for nonoperative management (bleeding ulcer)

  • Indications for nonoperative management (perforated ulcer)

  • Antimicrobial therapy (bleeding ulcer)

  • Antimicrobial therapy (perforated ulcer)

  • Eradication therapy

  • PPIs

5.Therapeutic procedures

Endoscopic interventions, bleeding ulcer, ACG: perform endoscopic therapy in patients with upper gastrointestinal bleeding due to ulcers with active spurting, active oozing, and nonbleeding visible vessels.
B
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  • Endoscopic interventions (perforated ulcer)

  • Angioembolization (bleeding ulcer)

6.Surgical interventions

Indications for surgery, perforated ulcer
Perform operative treatment in patients with perforated peptic ulcer with significant pneumoperitoneum or extraluminal contrast extravasation or signs of peritonitis.
B
Perform surgery as soon as possible, especially in patients with delayed presentation and patients > 70 years old.
B

More topics in this section

  • Indications for surgery (bleeding ulcer)

  • Choice of surgical approach (bleeding ulcer)

  • Choice of surgical approach (perforated ulcer)

  • Choice of surgical intervention (bleeding ulcer)

  • Choice of surgical intervention (perforated ulcer)

7.Specific circumstances

Patients with erosive gastritis
Consider initiating PPIs to improve endoscopic findings in patients with NSAID-related erosive gastritis.
C
Do not use mucoprotective agents to improve the erosions in patients with erosive gastritis.
D

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  • Patients with NSAID-associated ulcer (prevention)

  • Patients with NSAID-associated ulcer (management)

  • Patients with gastric outlet obstruction

8.Follow-up and surveillance

Surveillance endoscopy: consider performing surveillance endoscopy in patients with duodenal ulcers experiencing persistent symptoms despite an appropriate course of therapy, specifically to rule out refractory peptic ulcers and ulcers with nonpeptic etiologies.
C
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