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Peptic ulcer disease

Guidelines

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 American Academy of Family Physicians (AAFP 2023), the European Society of Anaesthesiology and Intensive Care (ESAIC 2023), the Korean College of Helicobacter and Upper Gastrointestinal Research (KCHUGR 2023), the American College of Gastroenterology (ACG 2021,2017,2012), the ...
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Classification and risk stratification

Risk and severity assessment, bleeding ulcer: as per WSES 2020 guidelines, 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)

Diagnostic investigations

Laboratory testing, bleeding ulcer: as per WSES 2020 guidelines, 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

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

Medical management

Initial resuscitation, bleeding ulcer
As per WSES 2020 guidelines:
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

Therapeutic procedures

Endoscopic interventions, bleeding ulcer: as per ESAIC 2023 guidelines, perform endoscopic therapy combined with high-dose PPIs in patients with upper gastrointestinal bleeding due to peptic ulcer.
B

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  • Endoscopic interventions (perforated ulcer)

  • Angioembolization (bleeding ulcer)

Surgical interventions

Indications for surgery, bleeding ulcer: as per ESAIC 2023 guidelines, consider performing angioembolization and/or surgery in patients with bleeding peptic ulcer if endoscopic therapy has failed.
C

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  • Indications for surgery (perforated 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)

Specific circumstances

Patients with erosive gastritis
As per KCHUGR 2023 guidelines:
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

Follow-up and surveillance

Surveillance endoscopy: as per ASGE 2010 guidelines, 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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