eMedicine Specialties > Gastroenterology > Stomach
Gastric Ulcers: Treatment & Medication
Updated: Aug 24, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
The medical treatment of gastric ulcers is aimed at restoring the balance between aggressive factors (acid secretion) and mucosal protective factors. In patients infected with H pylori, the most effective treatment is therapy to eradicate the organism and to suppress acid secretion.
In patients with bleeding PUD, volume resuscitation with IV fluid and blood products is the most important initial therapy. An intravenous proton pump inhibitor (PPI) is started. This is followed by checking for acute anemia, thrombocytopenia, or coagulopathy, which needs correction with vitamin K or fresh frozen plasma.
- Histamine 2 blockers (H2 blockers)
- Therapy can be directed toward histamine release, that is, H2 blockers, such as cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid),3 and nizatidine (Axid). These agents selectively block the H2 receptors in the parietal cells.
- All H2 blockers are comparable in efficacy and, when used in twice-daily doses for a period of 8 weeks, have a healing rate of higher than 70%.
- Hydrogen pump antagonists or PPIs
- PPIs are drugs that covalently bind and irreversibly inhibit the H+/K+ adenosine triphosphatase (ATPase) pump, effectively inhibiting acid release. Omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex),4 pantoprazole (Protonix), and esomeprazole (Nexium) given in daily or twice-daily doses for 4 weeks heal 80-100% of gastric ulcers if H pylori infection is not present or has been eradicated.
- All PPIs are comparable in efficacy. The PPI should preferentially be taken on an empty stomach to allow maximum inhibition of H+/K+ pumps. Prilosec binds irreversibly with the H+/K+ pumps and suppresses acid secretion. This inhibition is at its maximum in 24-48 hours, and when Prilosec is stopped, the secretory activity gradually returns to normal in the next 2-3 days.
- Newer forms of the PPI delivery system include Prevacid SoluTab, which is a chewable version of Prevacid with more rapid action. Zegrid is an oral suspension of esomeprazole, which appears to be rapid acting with prolonged efficacy.
- Studies have shown that continuous intravenous infusion of omeprazole in patients with active bleeding from gastric ulcer decreases the following: need for transfusion, mortality, and hospital stay. Although widely available in Europe and Asia, IV omeprazole is currently not available in the United States. Available IV PPIs in the United States are Prevacid and Protonix. Prevacid is given as a bolus of 60 mg IV with infusion at the rate of 6 mg/h, while Protonix is given as a bolus of 60-80 mg IV with a continuous infusion at the rate of 6-8 mg/h.
- van Rensburg et al compared IV pantoprazole with IV ranitidine for bleeding ulcers in 1256 patients.23 After endoscopic hemostasis, patients were randomized to pantoprazole 80 mg plus 8 mg/h or ranitidine 50 mg plus 13 mg/h, both for 72 hours. A second-look endoscopy was performed on day 3 or sooner, if clinically indicated. The investigators found similar outcomes between the 2 groups, including 72-hour clinically detected rebleeding, surgery, or day-3 mortality.23 However, patients in the pantoprazole group had significantly decreased cumulative frequencies of spurting lesions and gastric ulcers.
- Mucosal protectants
- Mucosal protectants, such as bismuth and sucralfate, can also be effective in healing gastric ulcers; however, they are not as effective as H2 blockers.
- Patients taking NSAIDs should discontinue them if possible. If discontinuing NSAIDs is not possible, omeprazole at 40 mg/d (or another PPI) should be given concurrently. However, only misoprostol (Cytotec) has been shown to be cytoprotective when taken with NSAIDs. However, the use of misoprostol is limited because of its adverse effects, including diarrhea and abdominal pain observed in 14-40% of patients, and because it needs to be taken 4 times a day.
- A 2005 study showed that in patients with aspirin-induced ulcer, contrary to popular belief, aspirin plus esomeprazole (Nexium) was superior to clopidogrel (Plavix) in preventing recurrent gastric ulcer bleeding.5 This was further confirmed in a double-blind randomized study in 2006 by Lai and colleagues.6
- H pylori eradication
- Multiple regimens have been evaluated for the eradication of H pylori infection; however, triple therapy has consistently been shown to eradicate the organism more than 90% of the time.
- The 5 different regimens approved by AmericanCollege of Gastroenterology are as follows (all 5 regimens are given for a total of 2 wk):
- Bismuth, metronidazole, and tetracycline qid with H2 blockers bid
- Bismuth, metronidazole, and tetracycline bid with a PPI (Helidac)
- Prevacid, amoxicillin, and clarithromycin bid (PrevPac)
- Prilosec, metronidazole, and clarithromycin bid
- Ranitidine, bismuth, and clarithromycin with amoxicillin, metronidazole, or tetracycline bid
- Endoscopic therapy
- Upper GI bleeding secondary to a bleeding peptic ulcer is a common medical condition. Endoscopic evaluation of the bleeding ulcer can decrease the duration of the hospital stay by identifying patients at low risk for rebleeding. Moreover, endoscopic therapy reduces the likelihood of recurrent bleeding and decreases the need for surgery.
- Patients can be stratified as high or low risk for rebleeding depending on the presence or absence of stigmata during their initial endoscopic examination. High-risk stigmata are active hemorrhage (90% risk of rebleeding), a visible vessel (50% risk of rebleeding), or a fresh overlying clot (30% risk of rebleeding). In the absence of these stigmata, patients can be discharged home on medical therapy within 48 hours.
- Ulcers with stigmata (ie, visible vessel, oozing, overlying blood clot) require endotherapy, while ulcers with a clean base crater need not be treated endoscopically.
- Several modalities of endotherapy are available, such as injection therapy, coagulation therapy, hemostatic clips, argon plasma coagulator, and combination therapy.7 Injection therapy is performed with epinephrine in a 1:10,000 dilution or with absolute alcohol. Thermal endotherapy is performed with a heater probe, bipolar circumactive probe, or gold probe. Pressure is applied to cause coagulation of the underlying artery (coaptive coagulation). Combination therapy with epinephrine injection followed by thermal coagulation appears to be more effective than monotherapy for ulcers with a visible vessel, active hemorrhage, or adherent clot.
- Different hemoclips have been used successfully to treat an acutely bleeding ulcer by approximating 2 folds and clipping them together. Several clips may need to be deployed to approximate the gastric ulcer folds. In treating high-risk bleeding ulcers, combined therapy with epinephrine and hemoclips seems to be more efficacious than injection alone. However, it is not clear if hemoclip use or thermal coagulation is more effective in treating an acutely bleeding ulcer; both modalities are used depending on physician experience and equipment availability.
Surgical Care
- With the advent of aggressive intravenous PPI infusion, effective therapy for H pylori infection, and advanced endotherapy, most ulcers can be managed effectively with medical treatment. However, surgery still has a role in life-threatening hemorrhage that cannot be controlled with medical management alone.
- Other indications for surgical therapy are ulcer perforation, gastric outlet obstruction, giant gastric ulcer, and a transfusion requirement of more than 6 units in 24 hours.
- Distal gastrectomy with Billroth I (gastroduodenostomy) or Billroth II (gastrojejunostomy) is the preferred procedure for these complications. The surgery involves the removal of both the ulcer (mostly on the lesser curvature) and the diseased antrum.
- Medical therapy for gastric ulcer has shifted from antisecretory therapy to antimicrobial therapy; however, surgical therapy relies on acid reduction with vagotomy. Although vagotomy may be unnecessary, truncal or selective vagotomy is performed routinely.
Consultations
In all patients with acute upper GI hemorrhage, a gastroenterologist should be consulted early. Some institutions have a structured GI bleed team consisting of a gastroenterologist, a surgeon, and an interventional radiologist who are consulted simultaneously for all GI bleeds.
Diet
Insufficient data exist to support any special diet for the healing of gastric ulcers. In the event of acute upper GI bleeding, patients should be kept without food for the initial 24 hours so that endoscopic evaluation can be expedited without fear of aspiration.
Activity
Normal activity is encouraged.
Medication
PPIs given daily or twice daily have an ulcer-healing rate of 80-100% and are the most effective drugs used to treat gastric ulcers. H2 blockers and mucosal protectants (ie, sucralfate, bismuth) are also effective.
Proton pump inhibitors
These agents act by irreversibly binding the H+/K+ -ATPase pump and effectively suppressing acid secretion.
Omeprazole (Prilosec)
Decreases gastric acid secretion by inhibiting the parietal cell H+/K+ -ATPase pump. Indicated for gastric ulcers, duodenal ulcers, GERD, erosive esophagitis, and for eradication of H pylori when combined with other medications.
Adult
40 mg PO qd for 4-8 wk
Pediatric
Not established
May decrease effects of itraconazole and ketoconazole; may increase toxicity of warfarin, digoxin, and phenytoin
Documented hypersensitivity
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Bioavailability may increase in elderly patients; symptomatic response does not exclude possibility of malignancy
Lansoprazole (Prevacid)
Inhibits gastric acid secretion. Indicated for gastric ulcers, duodenal ulcers, GERD, erosive esophagitis, and for eradication of H pylori when combined with other medications.
Adult
15-30 mg PO qd for 4-8 wk
Pediatric
Not established
May decrease effects of ketoconazole and itraconazole; may increase theophylline clearance
Documented hypersensitivity
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Symptomatic response does not exclude possibility of malignancy; consider adjusting dose in liver impairment
Rabeprazole (Aciphex)
For short-term (4-8 wk) treatment and relief of symptomatic erosive or ulcerative GERD. If not healed after 8 wk, consider additional 8-wk course.
Adult
20 mg DR tab PO qd for 4-8 wk
Pediatric
Not established
None reported
Documented hypersensitivity
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Symptomatic response does not exclude possibility of malignancy
Pantoprazole (Protonix)
Indicated for short-term treatment of GERD associated with erosive esophagitis. Also effective in treating gastric ulcers, including those caused by H pylori.
Adult
40 mg PO qd
Pediatric
Not established
May decrease bioavailability of ketoconazole and itraconazole
Documented hypersensitivity
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Symptomatic response does not exclude possibility of malignancy
Esomeprazole magnesium (Nexium)
S-isomer of omeprazole. Inhibits gastric acid secretion by inhibiting H+/K+ -ATPase pump at secretory surface of gastric parietal cells.
Adult
40 mg PO qd for 10 d
Pediatric
Not established
Amoxicillin or clarithromycin may increase plasma levels when used concurrently; may reduce absorption of dapsone; may increase levels of diazepam and GI absorption of digoxin; may decrease absorption of iron, ketoconazole, and itraconazole
Documented hypersensitivity
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Symptomatic relief may mask symptoms of gastric malignancy
Histamine H2 antagonists
These drugs inhibit histamine stimulation of H2 receptor in gastric parietal cells.
Nizatidine (Axid)
Effectively reduces gastric acid secretion, gastric volume, and hydrogen concentrations.
Adult
75 mg PO bid 30-60 min ac or with beverages
Pediatric
Not established
None reported
Documented hypersensitivity
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Caution in renal or liver impairment; if changes in renal function occur during therapy, consider adjusting dose or discontinuing treatment
Ranitidine hydrochloride (Zantac)
Effectively reduces gastric acid secretion, gastric volume, and hydrogen concentrations.
Adult
150 mg PO bid; not to exceed 600 mg/d
Alternatively, 50 mg/dose IV/IM q6-8h
Pediatric
<12 years: Not established
>12 years
PO: 1.25-2.5 mg/kg/dose q12h; not to exceed 300 mg/d
IV/IM: 0.75-1.5 mg/kg/dose q6-8h; not to exceed 400 mg/d
May decrease effects of ketoconazole and itraconazole; may alter serum levels of ferrous sulfate, diazepam, nondepolarizing muscle relaxants, and oxaprozin
Documented hypersensitivity
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Caution in renal or liver impairment; if changes in renal function occur during therapy, consider adjusting dose or discontinuing treatment
Helicobacter pylori eradication agents
Antibiotics and other agents are used as adjuvants to treat duodenal ulcer disease associated with H pylori.
Clarithromycin (Biaxin)
Component of drug combination therapy that effectively treats duodenal ulcer or gastric ulcer associated with H pylori infection. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Adult
250-500 mg PO q12h for 7-14 d
Pediatric
15 mg/kg PO divided bid
Toxicity increases with coadministration of fluconazole and pimozide; effects decrease and adverse GI effects may increase with coadministration of rifabutin or rifampin; may increase toxicity of anticoagulants, cyclosporine, tacrolimus, digoxin, omeprazole, carbamazepine, ergot alkaloids, triazolam, and HMG CoA-reductase inhibitors
Plasma levels of certain benzodiazepines may increase, prolonging CNS depression; arrhythmias and increase in QTc intervals occur with disopyramide; coadministration with omeprazole may increase plasma levels of both agents
Documented hypersensitivity; coadministration of pimozide
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Coadministration with ranitidine or bismuth citrate not recommended with CrCl <25 mL/min; give half dose or increase dosing interval if CrCl <30 mL/min; diarrhea may be sign of pseudomembranous colitis; superinfections may occur with prolonged or repeated antibiotic therapy
Metronidazole (Flagyl)
Component of drug combination therapy that effectively treats duodenal ulcer or gastric ulcer associated with H pylori infection. Active against various anaerobic bacteria and protozoa. Appears to be absorbed into cells. Intermediate-metabolized compounds formed bind DNA and inhibit protein synthesis, causing cell death.
Adult
250 mg PO qid
Pediatric
Not established
May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity; disulfiramlike reaction may occur with orally ingested ethanol
Documented hypersensitivity
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy
Bismuth subsalicylate (Pepto-Bismol)
Component of drug combination therapy that effectively treats duodenal ulcer or gastric ulcer associated with H pylori infection. Antimicrobial and cytoprotective effects produced by bismuth and subsalicylate.
Adult
2 tab or 30 mL PO qid
Pediatric
<3 years: Not established
3-6 years: One third tab or 5 mL PO qid
6-9 years: Two thirds tab or 10 mL PO qid
9-12 years: 1 tab or 15 mL PO qid
>12 years: Administer as in adults
Coadministration with anticoagulants may increase risk of bleeding; may increase toxicity of aspirin and hypoglycemics; decreases effects of tetracyclines and uricosurics
Documented hypersensitivity
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
May cause temporary and harmless darkening of tongue and/or black stool; alcohol consumption may cause abdominal cramps, nausea, and vomiting
Tetracycline (Sumycin)
Component of drug combination therapy that effectively treats duodenal ulcer or gastric ulcer associated with H pylori infection. Treats gram-positive and gram-negative organisms and mycoplasmal, chlamydial, and rickettsial infections.
Adult
250 mg PO qid for 14 d
Pediatric
<8 years: Not recommended
>8 years: 25-50 mg/kg/d (10-20 mg/lb) PO qid
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy; tetracyclines can increase hypoprothrombinemic effects of anticoagulants
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Unsafe in pregnancy
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Amoxicillin (Trimox)
Component of drug combination therapy that effectively treats duodenal ulcer or gastric ulcer associated with H pylori infection. Interferes with synthesis of cell wall mucopeptides during active multiplication, resulting in bactericidal activity against susceptible bacteria.
Adult
500 mg PO qid for 14 d
Pediatric
20-50 mg/kg/d PO qid
Reduces efficacy of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Adjust dose in renal impairment; may increase possibility of candidiasis
Gastrointestinal agents
These agents protect GI lining. Shown to be effective in treating peptic ulcers and preventing relapse. Mechanism of action not clear. Multiple doses are required, and agents are not as effective as other options.
Sucralfate (Carafate)
Forms viscous adhesive substance that protects GI lining against pepsin, peptic acid, and bile salts. Use for short-term management of ulcers.
Adult
1 g PO qid
Pediatric
Not established; 40-80 mg/kg/d PO divided q6h suggested
May decrease effects of ketoconazole, ciprofloxacin, tetracycline, phenytoin, warfarin, quinidine, theophylline, and norfloxacin
Documented hypersensitivity
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Caution in renal failure and conditions that impair excretion of absorbed aluminum
Nonsteroidal anti-inflammatory agents
These agents are the most commonly used medications to control mild to moderate pain and to decrease inflammation.
Celecoxib (Celebrex)
Primarily inhibits COX-2. COX-2 is considered an inducible isoenzyme, induced by pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited, thus incidence of GI toxicity, such as endoscopic peptic ulcers, bleeding ulcers, perforations, and obstructions, may be decreased when compared to nonselective NSAIDs. Seek lowest dose for each patient.
Neutralizes circulating myelin antibodies through anti-idiotypic antibodies; down-regulates pro-inflammatory cytokines, including INF-gamma; blocks Fc receptors on macrophages; suppresses inducer T and B cells and augments suppressor T cells; blocks complement cascade; promotes remyelination; may increase CSF IgG (10%).
Has a sulfonamide chain and is primarily dependent upon cytochrome P450 enzymes (a hepatic enzyme) for metabolism.
Adult
200 mg/d PO qd; alternatively, 100 mg PO bid
Pediatric
Not established
Coadministration with fluconazole may cause increase in celecoxib plasma concentrations because of inhibition of celecoxib metabolism; coadministration of celecoxib with rifampin may decrease celecoxib plasma concentrations
Documented hypersensitivity
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Category D in third trimester of pregnancy;
may cause fluid retention and peripheral edema; caution in compromised cardiac function, hypertension, and conditions predisposing to fluid retention; caution in severe heart failure and hyponatremia because may deteriorate circulatory hemodynamics; NSAIDs may mask usual signs of infection; caution in the presence of existing controlled infections; evaluate therapy when symptoms or lab results suggest liver dysfunction
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 |
| « Previous Page | Next Page » |
References
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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].
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].
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].
Chan KL, Ching YL, Hung CY. Clopidogrel versus aspirin and esomeprazole to prevent ulcer bleeding. N Eng J Med. 2005;352:238-44. [Full Text].
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].
Wang HM, Hsu PI, Lo GH, Chen TA, Cheng LC, Chen WC, et al. Comparison of Hemostatic Efficacy for Argon Plasma Coagulation and Distilled Water Injection in Treating High-risk Bleeding Ulcers. J Clin Gastroenterol. May 14 2009;[Medline].
[Best Evidence] Ford AC, Delaney BC, Forman D, Moayyedi P. Eradication therapy for peptic ulcer disease in Helicobacter pylori positive patients. Cochrane Database Syst Rev. 2006;(2):CD003840. [Medline].
Graham DY, Klein PD. Accurate diagnosis of Helicobacter pylori. 13C-urea breath test. Gastroenterol Clin North Am. Dec 2000;29(4):885-93, x. [Medline].
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Lo CC, Hsu PI, Lo GH, et al. Comparison of hemostatic efficacy for epinephrine injection alone and injection combined with hemoclip therapy in treating high-risk bleeding ulcers. Gastrointest Endosc. May 2006;63(6):767-73. [Medline].
Silverstein FE, Faich G, Goldstein JL, et al. Gastrointestinal toxicity with celecoxib vs nonsteroidal anti-inflammatory drugs for osteoarthritis and rheumatoid arthritis: the CLASS study: A randomized controlled trial. Celecoxib Long-term Arthritis Safety Study. JAMA. 284(10):1247-55. [Medline].
Soll AH. Consensus conference. Medical treatment of peptic ulcer disease. Practice guidelines. Practice Parameters Committee of the American College of Gastroenterology. JAMA. Feb 28 1996;275(8):622-9. [Medline].
Sonnenberg A, Everhart JE. Health impact of peptic ulcer in the United States. Am J Gastroenterol. Apr 1997;92(4):614-20. [Medline].
Steinbach G, Ford R, Glober G, et al. Antibiotic treatment of gastric lymphoma of mucosa-associated lymphoid tissue. An uncontrolled trial. Ann Intern Med. Jul 20 1999;131(2):88-95. [Medline].
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[Best Evidence] van Rensburg C, Barkun AN, Racz I, et al. Clinical trial: intravenous pantoprazole vs. ranitidine for the prevention of peptic ulcer rebleeding: a multicentre, multinational, randomized trial. Aliment Pharmacol Ther. Mar 1 2009;29(5):497-507. [Medline].
Further Reading
Related eMedicine Topics
- Gastric Ulcer [in the Radiology section]
- Duodenum, Ulcers [in the Radiology section]
- Intestinal Perforation [in the General Surgery section]
- Perforated Peptic Ulcer [in the General Surgery section]
- Peptic Ulcer Disease [in the Gastroenterology section]
- Peptic Ulcer Disease [in the Pediatrics: General Medicine section]
Clinical trials
- Comparison of Intravenous Pantoprazole and Famotidine for Stress Ulcer Prophylaxis
- Cytokine Gene Polymorphisms in Gastric Diseases
- Effect of Selective COX-2 Inhibition on Ulcer Healing
- H. Pylori Eradication on Healing of Iatrogenic Gastric Ulcer by Endoscopic Mucosal Resection
- Study to Evaluate the Incidence of Gastric Ulcers Following Administration of Either PA32540 or Enteric Coated Aspirin 325 mg in Subjects Who Are at Risk for Developing Aspirin-Associated Ulcers
National Guideline Clearinghouse
- ACR Appropriateness Criteria® hematemesis. American College of Radiology - Medical Specialty Society. 1998 (revised 2006). 7 pages. NGC:005111
- Management of acute upper and lower gastrointestinal bleeding. A national clinical guideline. Scottish Intercollegiate Guidelines Network - National Government Agency [Non-U.S.]. 2008 Sep. 57 pages. NGC:006730
- Management of helicobacter pylori infection. Gastroenterological Society of Singapore - Medical Specialty Society; Singapore Ministry of Health - National Government Agency [Non-U.S.]. 2004 Sep. 25 pages. NGC:003916
- Nausea and vomiting. Association of Comprehensive Cancer Centres - Disease Specific Society. 2006 Jan. 28 pages. NGC:006067
- Quality indicators for esophagogastroduodenoscopy. American College of Gastroenterology - Medical Specialty Society; American Society for Gastrointestinal Endoscopy - Medical Specialty Society. 2006 Apr. 6 pages. NGC:004966
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
