Peptic ulceration - NSAIDs

Question 1

What is the management of proven peptic ulcer in a patient who has tested H. pylori negative?

Answer 1

full-dose PPI therapy for 4-8 weeks, depending on clinical judgement

Question 2

What are 4 alternative causes of peptic ulceration to H. pylori colonisation?

Answer 2

1. Malignancy
2. NSAIDs/ aspirin/bisphosphonates/ SSRIs
3. Zollinger-Ellison syndrome
4. Crohn’s disease

Question 3

For patients with proven peptic ulcer with ongoing symptoms despite 4-8 weeks of full dose PPI, what are 3 options for ongoing management?

Answer 3

1. Switch to alternative acid suppression therapy e.g. H₂RA
2. Consider need for long-term acid suppression therapy
3. Annual review of symptoms and treatment

Question 4

What are 5 situations when you should arrange a referral to gastroenterologist for peptic ulcer disease?

Answer 4

1. Refractory or recurrent symptoms despite optimal management in primary care
2. Treatment with second-line H. pylori eradicatin regimen has been unsuccessful
3. There are limited antibiotics options for H. pylori eradication therapy due to hypersensitivity, local high antibiotic resistance rates, previous use of clarithromycin/metronidazole/quinolone
4. Proven gastric ulcer hasn’t healed on repeat endoscopy following H. pylori eradication and/or PPI therapy
5. Zollinger-Ellison syndrome or another non-peptic cause of ulcer disease suspected

Question 5

What is the acute management of an NSAID-induced peptic ulcer?

Answer 5

same A-E management as other cause - fluid resuscitation/give blood

nil by mouth, urgent endoscopy (24h), stop the NSAIDs

endoscopic interventions: adrenaline injection + heat probe/ulcer clipping

followed by IV PPI, long term PPI 4-8 weeks