Perforated and Bleeding Peptic Ulcer Clinical Practice Guidelines (2020)
Perforated and bleeding peptic ulcer clinical practice guidelines were released in January 2020 by the World Society of Emergency Surgery. [68]
Perforated Peptic Ulcer
The recommended biochemical and imaging investigations in the diagnosis of perforated peptic ulcer are as follows:
-
Suspected gastroduodenal perforation: Routine laboratory studies and arterial blood gas analysis
-
Acute abdomen from suspected perforated peptic ulcer: CT scanning
-
Acute abdomen from suspected perforated peptic ulcer: Chest and abdominal radiography as initial diagnostic assessment in the event CT scanning is not immediately available
-
Acute abdomen from suspected perforated peptic ulcer if free air is not seen on imaging and perforation remains a concern: Imaging with water-soluble contrast (oral or via nasogastric tube)
The recommended targets for resuscitation in unstable patients with a perforated peptic ulcer are as follows:
-
Rapid resuscitation to reduce mortality
-
Restoration of physiological parameters with a mean arterial pressure 65 mm Hg or higher, urine output of 0.5 mL/kg/h or greater, and lactate normalization
-
Use of hemodynamic monitoring (invasive or noninvasive) to optimize fluid/vasopressor therapy, with an individualized resuscitation strategy
Surgical indications and appropriate timing of surgery in patients with perforated peptic ulcer are as follows:
-
In association with significant pneumoperitoneum, extraluminal contrast extravasation, or signs of peritonitis: Operative treatment strongly recommended
-
Performing surgery as soon as possible, particularly in patients with delayed presentation or those older than 70 years
The recommended surgical approach (laparoscopic vs open) for perforated peptic ulcer is as follows:
-
Stable patients: Laparoscopic approach, unless equipment and skilled personnel are not available, in which case an open approach is recommended
-
Unstable patients: Open surgery
The recommended antimicrobial and antifungal therapy strategies in perforated peptic ulcer are as follows:
-
Administration of broad-spectrum antibiotics
-
Microbiological sample collection for analysis for bacterial and fungal pathogens in all patients undergoing surgery, with postanalysis antibiotic therapy adjustment as needed
-
Antifungal agents not suggested as standard empiric therapy; may be appropriate in high-risk patients, such as those who are immunocompromised, have comorbidities, or are of advanced age
The recommended antimicrobial regimen and duration of therapy in perforated peptic ulcer are as follows:
-
Initiation of empiric broad-spectrum antibiotics as soon as possible, targeting gram-negative, gram-positive, and anaerobic bacteria
-
Short course of 3-5 days or until inflammatory markers normalize
Bleeding Peptic Ulcer
The recommended biochemical and imaging/procedural investigations in the diagnosis of suspected bleeding peptic ulcer are as follows:
-
Blood-typing; hemoglobin, hematocrit, and electrolyte values; and coagulation assessment
-
Performing endoscopy as soon as possible, particularly in high-risk patients (Management decisions can be guided based on the damage noted from recent hemorrhage during endoscopy, as this can help predict further bleeding risk.)
The recommended parameters for evaluation at emergency department referral and the criteria for defining an unstable patient are as follows:
-
Rapid, careful medical/surgical evaluation to prevent further bleeding and reduce mortality
-
Upon emergency department referral, evaluation of signs, symptoms, and laboratory findings to assess stability versus instability
-
Evaluation according to Rockall and Glasgow-Blatchford scoring systems to assess disease severity and guide therapy
The recommended nonoperative and endoscopic strategies in patients with bleeding peptic ulcer are as follows:
-
Nonoperative management as first-line management after endoscopy
-
Endoscopic treatment to achieve hemostasis and to help prevent rebleeding, the need for surgery, and mortality
-
Administration of pre-endoscopy erythromycin
-
Initiation of proton-pump inhibitor therapy as soon as possible
-
Post successful endoscopic hemostasis, high-dose proton-pump inhibitor therapy as a continuous infusion for the first 72 hours
-
Proton-pump inhibitor therapy for 6-8 weeks following endoscopic treatment (Long-term proton-pump inhibitor therapy is not recommended except in patients with ongoing NSAID use.)
Indications for surgical treatment and the appropriate approach for surgery in patients with bleeding peptic ulcer are as follows:
-
Surgical hemostasis, or, if equipment and qualified personnel are available, angiographic embolization, after failure of repeated endoscopy
-
Refractory bleeding peptic ulcer: Surgical intervention with open surgery
-
Intraoperative endoscopy to facilitate localization of the bleeding site
Indications for antimicrobial therapy and for Helicobacter pylori testing in patients with bleeding peptic ulcer are as follows:
-
Empirical antimicrobial therapy not recommended
-
H pylori testing in all patients
-
If positive for H pylori, eradication therapy recommended
-
First-line eradication therapy: Standard triple therapy (ie, amoxicillin, clarithromycin, proton-pump inhibitor)
-
First-line therapy if high clarithromycin resistance detected: Ten-day sequential therapy with four drugs (ie, amoxicillin, clarithromycin, metronidazole, proton-pump inhibitor)
-
Second-line therapy if first-line failed: Ten-day levofloxacin-amoxicillin triple therapy
-
Start standard triple therapy after 72-96 hours of intravenous proton-pump inhibitor, for 14-day duration
ASGE Guidelines for Sedation and Anesthesia in Gastrointestinal Endoscopy (2018)
Guidelines for sedation and anesthesia in gastrointestinal endoscopy were released in January 2018 by the American Society for Gastrointestinal Endoscopy (ASGE). [34]
It is recommended that all patients undergoing endoscopic procedures be evaluated to assess their risk of sedation related to preexisting medical conditions.
The combination of an opioid and benzodiazepine is recommended to be a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events.
It is suggested to use an appropriate adjunctive agent (eg, diphenhydramine, promethazine, or droperidol) in combination with conventional sedative drugs in select clinical circumstances.
Providers should undergo specific training in the administration of endoscopic sedation and possess the skills necessary for the diagnosis and management of sedation-related adverse events, including rescue from a level of sedation deeper than that intended.
Recommend the routine monitoring of blood pressure, oxygen saturation, and heart rate in addition to clinical observation for changes in cardiopulmonary status during all endoscopic procedures using sedation. Supplemental oxygen administration should be considered for moderate sedation and should be administered during deep sedation. Supplemental oxygen should be administered if hypoxemia is anticipated or develops.
Suggest that capnography monitoring be considered for patients undergoing endoscopy targeting deep sedation. Anesthesia provider–administered sedation should be considered for complex endoscopic procedures or patients with multiple medical comorbidities or at risk for airway compromise.
It is suggested that endoscopists use propofol-based sedation (endoscopist-directed or anesthesia-provider administered) when it is expected to improve patient safety, comfort, procedural efficiency, and/or successful procedure completion.
ACG H Pylori Infection Guidelines (2017)
The 2017 American College of Gastroenterology (ACG) guidelines for the treatment of H pylori infection (HPI) include the following recommendations for testing for H pylori [33] :
-
All patients with active or past history of peptic ulcer disease (unless previous cure of HPI has been documented), low-grade gastric mucosa-associated lymphoid tissue (MALT) lymphoma, or a history of endoscopic resection of early gastric cancer
-
Patients with dyspepsia who are undergoing upper endoscopy (gastric biopsy specimens)
-
Patients on long-term, low-dose aspirin
-
Patients initiating long-term therapy with nonsteroidal anti-inflammatory agents (NSAIDs)
-
Patients with unexplained iron deficiency anemia following standard workup
-
Adults with idiopathic thrombocytopenic purpura
The 2017 ACG guidelines also recommend posttreatment testing to prove eradication of HPI with the use of a urea breath test, fecal antigen test, or biopsy-based testing at least 4 weeks following completion of antimicrobial therapy and after proton pump inhibitors have been withheld for 1-2 weeks. [33]
The guidelines indicate that selection of an HPI management regimen should take into account any previous antibiotic exposure(s). The ACG also includes the following therapeutic strategies for first-line treatment [33] :
-
10-14 days of bismuth quadruple therapy (bismuth, proton pump inhibitor [PPI], tetracycline, and a nitroimidazole) (strong recommendation), particularly in those with previous macrolide exposure or are penicillin allergic
-
(Recommended option) 10-14 days of concomitant PPI, clarithromycin, amoxicillin, and a nitroimidazole (strong recommendation)
-
14 days of clarithromycin triple therapy (clarithromycin, a PPI, and amoxicillin or metronidazole) should be reserved for patients with no previous history of macrolide exposure who live in regions where clarithromycin resistance among H pylori isolates is known to be low (< 15%) (conditional recommendation)
-
(Suggested option) 5-7 days of sequential therapy with a PPI and amoxicillin, followed by 5-7 days with clarithromycin, a PPI, and a nitroimidazole (conditional recommendation)
-
(Suggested option) 7 days of a hybrid therapy with a PPI and amoxicillin, followed by 7 days with a PPI, amoxicillin, clarithromycin, and a nitroimidazole (conditional recommendation)
-
(Suggested option) 10-14 days of levofloxacin triple therapy (levofloxacin, a PPI, and amoxicillin) (conditional recommendation)
-
(Suggested option) 5-7 days of fluoroquinolone sequential therapy (a PPI and amoxicillin), followed by 5-7 days of a PPI, fluoroquinolone, and nitroimidazole (conditional recommendation)
Salvage treatment if first-line therapy fails and HPI persists include the following options [33] :
-
Avoid previously used antibiotics, if feasible (strong recommendation)
-
Preferred for patients who previously received first-line clarithromycin regimens: Bismuth quadruple therapy or levofloxacin salvage regimens (conditional recommendation)
-
Preferred for patients who previously received first-line bismuth quadruple therapy: Clarithromycin or levofloxacin-containing salvage regimens (conditional recommendation)
Salvage treatment regimens include the following [33] :
-
(Recommended) Bismuth quadruple therapy or levofloxacin triple therapy for 14 days (strong recommendation)
-
Avoid clarithromycin triple therapy (conditional recommendation)
-
(Suggested) Concomitant therapy for 10-14 days (conditional recommendation
-
(Suggested) Rifabutin triple regimen (rifabutin, a PPI, and amoxicillin) for 10 days (conditional recommendation)
-
(Suggested) High-dose dual therapy (a PPI and amoxicillin) for 14 days (conditional recommendation)
Resources
For more information go to Surgical Treatment of Perforated Peptic Ulcer.
For more Clinical Practice Guidelines, go to Guidelines.
-
Peptic ulcer disease. Vagal innervation of the stomach.
-
Peptic ulcer disease. Gastric ulcer with a punched-out ulcer base and whitish fibrinoid exudates.
-
Peptic ulcer disease. Gastric ulcer (lesser curvature) with a punched-out ulcer base with a whitish exudate.
-
Peptic ulcer disease. Gastric cancer. Note the irregular heaped-up overhanging margins.
-
Peptic ulcer disease. Gastric cancer with an ulcerated mass.
-
Peptic ulcer disease. Gross pathology specimen of a gastric ulcer.
-
Peptic ulcer disease. Gastric cancer with an ulcerated mass.
-
Peptic ulcer disease. Endoscopic view of an ulcer (at the upper center) in the wall of the duodenum, the first part of the small intestine. This ulcer is an open sore. Image courtesy of Science Source | Gastrolab.
-
Peptic ulcer disease. Duodenal ulcer in a 65-year-old man with osteoarthritis who presented with hematemesis and melena. The patient took naproxen on a daily basis.
