NICE guidance - management of gastric ulcer (GU) in primary care

Management of Gastric Ulcer in Primary Care

Gastric ulcer diagnosed via endoscopy.

Step (A) Stop NSAIDs if used - note that if NSAID continuation is necessary, after ulcer healing offer long-term gastric protection or consider substitution to a newer Cox-2-selective NSAID

Step (B) Test of H.pylori (use a carbon-13 urea breath test, stool antigen test or, when performance has been validated, laboratory-based serology)

1. if H.pylori positive and ulcer associated with NSAID use then full-dose PPI for two months then (C)
2. if H.pylori positive ulcer not associated with NSAID use then (C)
3. if H.pylori negative then full-dose PPI for 1-2 months then perform endoscopy 6-8 weeks after treatment
   1. if healed then offer low-dose treatment, possibly used on an as-required basis, then (E)
   2. if not healed then refer to specialist secondary care

Step (C) Eradication Therapy

• use a H. pylori eradication therapy as linked item
• follow guidance found in the British National Formulary for selecting second-line therapies
• after two attempts at eradication manage as H. pylori negative

Perform endoscopy 6-8 weeks after treatment and re-test for H. pylori (use a carbon-13 urea breath test or stool antigen test or, when performance has been validated, laboratory-based serology)

1. if H.pylori positive then (C)
2. if ulcer not healed , H.pylori negative then refer to specialist secondary care
3. if healed ulcer, H.pylori negative then (D)

Step (D) Offer low-dose treatment, possibly used on an as-required basis, then (E)

Step (E) Review care annually, to discuss symptoms, promote stepwise withdrawal of therapy when appropriate and provide lifestyle advice. In some patients with an inadequate response to therapy it may become appropriate to refer to a specialist.

For full details then refer to the full guideline (1).

Reference:

1. NICE (September 2014).Dyspepsia and gastro-oesophageal reflux disease - Investigation and management of dyspepsia, symptoms suggestive of gastro-oesophageal reflux disease, or both