eMedicine Specialties > Gastroenterology > Stomach

Gastric Ulcers: Follow-up

Author: Sanjeeb Shrestha, MD, Consulting Staff, Division of Gastroenterology, North West Arkansas Gastroenterology Clinic
Coauthor(s): Daryl Lau, MD, MPH, FRCP(C), Director of Translational Liver Research, Beth Israel Deaconess Medical Center; Associate Professor of Medicine, Harvard Medical School
Contributor Information and Disclosures

Updated: Aug 24, 2009

Follow-up

Further Inpatient Care

  • Patients who have a rebleeding episode while in the hospital should have a second endoscopy prior to surgical management. Patients should continue taking PPIs for at least 8 weeks.

Further Outpatient Care

  • Patients should be reevaluated in 6-8 weeks with a repeat endoscopy to document complete healing of the gastric ulcer. If the ulcer is not healed, multiple biopsies of the ulcer are indicated to conclusively rule out gastric malignancy.

Inpatient & Outpatient Medications

  • Maintenance therapy with antisecretory medications (eg, H2 blockers, PPIs) for 1 year is indicated in high-risk patients. High-risk patients include those with recurrent ulcers and those with complicated or giant ulcers. If H pylori eradication is not achieved despite repeat treatment, maintenance antisecretory therapy should be recommended.
  • Some preliminary evidence suggests that PPIs impair the absorption of calcium in the gut and also independently may inhibit osteoclastic activity. Gastric acid increases insoluble calcium absorption and medicines that decrease gastric acid may thereby decrease calcium absorption. A 2006 study demonstrated that high-dose PPIs when taken over several years may independently increase the risk for hip fracture. Patients on long-term or high-dose PPIs should take calcium supplements.

Deterrence/Prevention

  • In patients with gastric ulcers, documenting the eradication of H pylori with UBT, rapid urease test, or histology studies on a biopsy sample is imperative. If H pylori is not eradicated, treatment should be repeated with another regimen.

Complications

  • Complications of gastric ulcers include hemorrhage, perforation, and gastric outlet obstruction.
  • Patients with gastric ulcers are also at risk of developing gastric malignancy.
    • The risk is approximately 2% in the initial 3 years.
    • One of the important risk factors is related to H pylori infection. H pylori is associated with atrophic gastritis, which, in turn, predisposes to gastric cancer.
    • H pylori infection is associated with gastric lymphoma or mucosa-associated lymphoid tissue (MALT) lymphoma. The normal gastric mucosa is devoid of organized lymphoid tissue. H pylori infection promotes acquisition of lymphocytic infiltration and often forms lymphocytic aggregates and follicles from which MALT lymphoma develops. Eradication of H pylori is very important in this group of patients because eradication of H pylori has been shown to cause a remission of MALT lymphoma.

Prognosis

  • The prognosis of patients with benign gastric ulcers is excellent, especially if H pylori is completely eradicated and NSAIDs are avoided.
    • Patients with recurrent gastric ulcers should be questioned in detail about NSAID use (particularly over-the-counter varieties), and endoscopy with biopsies should be repeated to help rule out malignancy and to check for the persistence of H pylori.
    • Malignancy should be strongly considered in the case of a persistent nonhealing gastric ulcer. Endoscopic ultrasound examination may be helpful for assessing mucosal invasion or detecting associated adenopathy in such patients. Surgical resection should be considered if evidence of cancerous transformation is present.

Patient Education

  • Instruct patients to avoid NSAIDs.
  • Discourage alcohol consumption and cigarette smoking because these activities impair gastric mucosal protection.
  • For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education article Peptic Ulcers.

Miscellaneous

Medicolegal Pitfalls

  • Failure to be vigilant about gastric cancer in patients with nonhealing ulcers or any alarm signs, such as anemia or weight loss
  • Failure to document the eradication of H pylori with UBT, fecal stool antigen, or repeat upper endoscopy with biopsy in a patient with bleeding PUD.
 


More on Gastric Ulcers

Overview: Gastric Ulcers
Differential Diagnoses & Workup: Gastric Ulcers
Treatment & Medication: Gastric Ulcers
Follow-up: Gastric Ulcers
Multimedia: Gastric Ulcers
References
Further Reading
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References

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  2. Sadic J, Borgström A, Manjer J, Toth E, Lindell G. Bleeding peptic ulcer - time trends in incidence, treatment and mortality in Sweden. Aliment Pharmacol Ther. Aug 15 2009;30(4):392-8. [Medline].

  3. Taha AS, McCloskey C, Prasad R, Bezlyak V. Famotidine for the prevention of peptic ulcers and oesophagitis in patients taking low-dose aspirin (FAMOUS): a phase III, randomised, double-blind, placebo-controlled trial. Lancet. Jul 11 2009;374(9684):119-25. [Medline].

  4. Baldwin CM, Keam SJ. Rabeprazole: a review of its use in the management of gastric acid-related diseases in adults. Drugs. 2009;69(10):1373-401. [Medline].

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  6. Lai KC, Chu KM, Hui WM, et al. Esomeprazole with aspirin versus clopidogrel for prevention of recurrent gastrointestinal ulcer complications. Clin Gastroenterol Hepatol. Jul 2006;4(7):860-5. [Medline].

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Further Reading

Related eMedicine Topics

Clinical trials

National Guideline Clearinghouse

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Keywords

gastric ulcers, ulcers, peptic ulcer disease, PUD, peptic ulcer, Helicobacter pylori infection, H pylori infection, NSAID toxicity, nonsteroidal anti-inflammatory drug toxicity, Zollinger-Ellison syndrome, ZES, gastrinoma, gastric cancer, stomach ulcer, GI ulcer, gastrointestinal ulcer, gastric ulcer, duodenal ulcer, cigarette smoking, gastroduodenal ulcer, hypersecretion of gastric acid, chronic renal insufficiency, diabetes, ulcer pain, epigastric pain, hematemesis, melena, presyncope, peritonitis, gastric perforation

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Contributor Information and Disclosures

Author

Sanjeeb Shrestha, MD, Consulting Staff, Division of Gastroenterology, North West Arkansas Gastroenterology Clinic
Sanjeeb Shrestha, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, and American Society of Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Coauthor(s)

Daryl Lau, MD, MPH, FRCP(C), Director of Translational Liver Research, Beth Israel Deaconess Medical Center; Associate Professor of Medicine, Harvard Medical School
Daryl Lau, MD, MPH, FRCP(C) is a member of the following medical societies: American Association for the Study of Liver Diseases and American Gastroenterological Association
Disclosure: Nothing to disclose.

Medical Editor

David Greenwald, MD, Fellowship Program Director, Associate Professor, Department of Medicine, Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine
David Greenwald, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Simmy Bank, MD, Chair, Professor, Department of Internal Medicine, Division of Gastroenterology, Long Island Jewish Hospital, Albert Einstein College of Medicine
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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