Guideline sources The following summarized guidelines for the evaluation and management of peptic ulcer disease are prepared by our editorial team based on guidelines from the Korean College of Helicobacter and Upper Gastrointestinal Research (KCHUGR 2023), the American College of Gastroenterology (ACG 2021; 2017; 2012), the American Society for Gastrointestinal Endoscopy (ASGE 2021; 2010), and the World Society of Emergency Surgery (WSES 2020). 1 2 3 4 5 6 7 Calculator AIMS65 score for upper GI bleed Guidelines 1. Classification and risk stratification Risk and severity assessment bleeding ulcer: https://web.pathway.md/diseases/recjjHxTkIW5BsTNh 1/7 6/29/23, 11:03 PM Peptic ulcer disease Pathway Risk and severity assessment, bleeding ulcer: As per WSES 2020 guidelines, obtain prompt surgical and medical evaluation in patients with bleeding peptic ulcer to prevent further bleeding and to reduce mortality. B Show 3 more As per ACG 2012 guidelines, consider discharging patients from the emergency department without inpatient endoscopy if the urea nitrogen < 18.2 mg/dL, Hgb 13.0 g/dL for males (12.0 g/dL for females), systolic BP 110 mmHg, pulse < 100 bpm, and absence of melena, syncope, cardiac failure, and liver disease, as they have < 1% chance of requiring intervention. C Risk and severity assessment (perforated ulcer): Obtain a prompt evaluation to recognize sepsis associated with a perforated peptic ulcer, in order to prevent further organ failure and to reduce mortality. B Consider using the following scoring systems in patients with perforated peptic ulcer: the Boey, PULP and ASA score for risk stratification and prediction of outcomes the Sequential Organ Failure Assessment and qSOFA scores for the evaluation and assessment of the severity of the disease. C 2. Diagnostic investigations Laboratory testing (bleeding ulcer): obtain blood-typing, Hgb, hematocrit and electrolytes, and coagulation assessment in patients with suspected bleeding peptic ulcer. B Laboratory testing (perforated ulcer): obtain routine laboratory studies and arterial blood gas analysis in patients with suspected gastroduodenal perforation. B Diagnostic imaging (bleeding ulcer): Consider obtaining contrast-enhanced CT in patients with suspected bleeding peptic ulcer, if endoscopy is not available. C Consider obtaining angiography for diagnostic purposes as second-line investigation after a negative endoscopy in patients with bleeding peptic ulcer. C Diagnostic imaging (perforated ulcer): obtain CT in patients with acute abdomen from suspected perforated peptic ulcer. B Show 2 more Testing for Helicobacter pylori infection: As per WSES 2020 guidelines, obtain H. pylori testing in all patients with bleeding peptic ulcer. B As per ACG 2017 guidelines, obtain testing for H. pylori infection in all patients with active peptic ulcer disease, a past history of peptic ulcer disease (unless previous cure of H. pylori infection has been documented). A As per ASGE 2010 guidelines, obtain testing for H. pylori infection in all patients with peptic ulcer disease because it is a common etiology. B 3. Diagnostic procedures https://web.pathway.md/diseases/recjjHxTkIW5BsTNh 2/7 6/29/23, 11:03 PM Peptic ulcer disease Pathway Upper gastrointestinal endoscopy: As per WSES 2020 guidelines: Perform endoscopy in patients with suspected bleeding peptic ulcer as soon as possible, especially in the high-risk group. B Consider guiding management decisions according to stigmata of recent hemorrhage during endoscopy because they can predict the risk of further bleeding. B As per ASGE 2010 guidelines: Do not perform endoscopy for the evaluation of benign-appearing, uncomplicated duodenal ulcers identified on radiologic imaging. D Perform endoscopy early in the course of hospitalization of patients with bleeding peptic ulcer, given its effectiveness in the diagnosis, prognostication, and therapy. A Biopsy: As per WSES 2020 guidelines, perform either an immediate or delayed endoluminal biopsy in patients with bleeding peptic ulcer. B As per ASGE 2010 guidelines: Do not perform routine biopsy of duodenal ulcers because these ulcers are extremely unlikely to be malignant. D Consider performing biopsy of most gastric ulcers because malignant gastric ulcers may appear endoscopically benign. However, recognize that in some clinical situations, such as young patients taking NSAIDs with multiple benign-appearing ulcers, the risk of malignancy is very low. Therefore, individualize the decision of performing biopsy and/or surveillance endoscopy. C 4. Medical management Initial resuscitation (bleeding ulcer): Use several resuscitation targets, similar to those of damage control resuscitation in patients with bleeding trauma. B Maintain an Hgb level of at least > 7 g/dL during the resuscitation phase in patients with bleeding peptic ulcer. B Initial resuscitation (perforated ulcer): initiate rapid resuscitation to reduce mortality in unstable patients with perforated peptic ulcer. B Show 2 more Indications for non-operative management (bleeding ulcer): use nonoperative management as the first-line care pathway after endoscopy in patients with bleeding peptic ulcer. B Indications for non-operative management (perforated ulcer): consider avoiding the routine use of nonoperative management in patients with perforated peptic ulcer. Consider offering nonoperative management in extremely selected cases where perforation has sealed as confirmed on water-soluble contrast study. D Antimicrobial therapy (bleeding ulcer): do not administer empirical antimicrobial therapy in patients with bleeding peptic ulcer. D https://web.pathway.md/diseases/recjjHxTkIW5BsTNh 3/7 6/29/23, 11:03 PM Peptic ulcer disease Pathway Antimicrobial therapy (perforated ulcer): administer broad-spectrum antibiotics in patients with perforated peptic ulcer. B Show 4 more Eradication therapy: offer eradication therapy in patients with H. pylori-positive bleeding peptic ulcer to avoid recurrent bleeding. B Show 4 more Proton pump inhibitors: As per ACG 2021 guidelines: Initiate high-dose PPI therapy continuously or intermittently for 3 days after successful endoscopic hemostatic therapy of a bleeding ulcer. B Consider continuing PPI therapy BID until 2 weeks after index endoscopy in high-risk patients with upper gastrointestinal bleeding due to ulcers received endoscopic hemostatic therapy followed by short-term high-dose PPI therapy in hospital. C As per WSES 2020 guidelines, initiate PPI therapy as soon as possible in patients with bleeding peptic ulcer. B Show 2 more 5. Therapeutic procedures Endoscopic interventions, bleeding ulcer: As per ACG 2021 guidelines, perform endoscopic therapy in patients with upper gastrointestinal bleeding due to ulcers with active spurting, active oozing, and nonbleeding visible vessels. B Show 7 more As per WSES 2020 guidelines, perform endoscopic treatment in patients with bleeding peptic ulcer to achieve hemostasis and reduce re-bleeding, the need for surgery, and mortality. B Show 6 more As per ASGE 2010 guidelines, perform repeated endoscopic intervention in patients rebleeding after initial endoscopic hemostasis, before proceeding with surgical or radiologic intervention. B Endoscopic interventions, perforated ulcer: As per WSES 2020 guidelines, consider avoiding endoscopic treatment (such as clipping, fibrin glue sealing, stenting) in patients with perforated peptic ulcer. D As per ASGE 2010 guidelines, do not perform endoscopic intervention in patients with clinical evidence of acute perforation. D Angioembolization, bleeding ulcer: As per ACG 2021 guidelines, consider performing transcatheter arterial embolization in patients with bleeding ulcers failed endoscopic therapy. C As per WSES 2020 guidelines, consider performing transcatheter angioembolization as an alternative to endoscopic therapy in patients with recurrent bleeding where resources are available. C Show 3 more https://web.pathway.md/diseases/recjjHxTkIW5BsTNh 4/7 6/29/23, 11:03 PM Peptic ulcer disease Pathway 6. Surgical interventions Indications for surgery (perforated ulcer): Perform operative treatment in patients with perforated peptic ulcer with significant pneumoperitoneum or extraluminal contrast extravasation or signs of peritonitis. B Perform surgery as soon as possible, especially in patients with delayed presentation and patients > 70 years old. B Indications for surgery (bleeding ulcer): consider performing surgical hemostasis after failure of repeated endoscopy in patients with bleeding peptic ulcer. Consider performing surgical intervention without repeated endoscopy in patients with hypotension and/or hemodynamic instability and/or ulcer > 2 cm at first endoscopy. B Choice of surgical approach (bleeding ulcer): consider using an open approach in patients with refractory bleeding peptic ulcer. C Choice of surgical approach (perforated ulcer): Consider using a laparoscopic approach in stable patients with perforated peptic ulcer. Use an open approach in the absence of appropriate laparoscopic skills and equipment. C Use an open approach in unstable patients with perforated peptic ulcer. B Choice of surgical intervention (bleeding ulcer): consider choosing the surgical procedure according to the location and extension of the ulcer and the characteristics of the bleeding vessel. C Show 2 more Choice of surgical intervention (perforated ulcer): consider performing primary repair in patients with perforated peptic ulcer < 2 cm. Insufficient evidence to support whether the use of an omental patch can provide further protection of the repair. C Show 2 more 7. Specific circumstances Patients with erosive gastritis: Consider initiating PPIs to improve endoscopic findings in patients with NSAID-related erosive gastritis. C Do not use mucoprotective agents to improve the erosions in patients with erosive gastritis. D Patients with NSAID-associated ulcer: reevaluate the need for NSAIDs carefully in patients with NSAIDs-associated bleeding ulcers, and avoid resuming NSAIDs if possible. In patients who must resume NSAIDs, use a COX-2 selective NSAID at the lowest effective dose plus daily PPI. A Show 3 more Patients with gastric outlet obstruction: Insufficient evidence to uniformly support either endoscopic or surgical management in patients with mixed varieties of benign gastric outlet obstruction. Take into account the etiology of benign gastric outlet obstruction, length of stricture, and response to initial endoscopic balloon dilation in determining appropriate management. I https://web.pathway.md/diseases/recjjHxTkIW5BsTNh 5/7 6/29/23, 11:03 PM Peptic ulcer disease Pathway Perform endoscopy for the evaluation of gastric outlet obstruction in patients with peptic ulcer disease. A Consider performing endoscopic balloon dilation for gastric outlet obstruction in patients with peptic ulcer disease. C 8. Follow-up and surveillance Surveillance endoscopy: consider performing surveillance endoscopy in patients with duodenal ulcers experiencing persistent symptoms despite an appropriate course of therapy, specifically to rule out refractory peptic ulcers and ulcers with nonpeptic etiologies. C Show 2 more Studies 2020 PEPTIC In patients requiring invasive mechanical ventilation within 24 hours of ICU admission, proton pump inhibitors were inferior to histamine-2 receptor blockers with respect to the rate of death in the hospital by day 90. PEPTIC Investigators for the Australian and New Zealand Intensive Care Society Clinical Trials Group et al. JAMA. 2020 Feb 18. 2002 Celecoxib vs. diclofenac in arthritis with recent ulcer bleeding In patients with arthritis and a recent history of ulcer bleeding, celecoxib was noninferior to diclofenac plus omeprazole with respect to the rate of probability of recurrent bleeding during the 6-month period. Chan FK et al. N Engl J Med. 2002 Dec 26. References 1. Antonio Tarasconi, Federico Coccolini, Walter L Biffl et al. Perforated and bleeding peptic ulcer: WSES guidelines. World J Emerg Surg. 2020 Jan 7;15 3. Open 2. ASGE Standards of Practice Committee, Subhas Banerjee, Brooks D Cash et al. The role of endoscopy in the management of patients with peptic ulcer disease. Gastrointest Endosc. 2010 Apr;71 4 663 8. Open 3. Loren Laine, Alan N Barkun, John R Saltzman et al. ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding. Am J Gastroenterol. 2021 May 1;116 5 899 917. Open 4. Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol. 2012 Mar;107 3 345 60. Open 5. Seung Joo Kang, Jae Gyu Kim, Hee Seok Moon et al. Clinical Practice Guideline for Gastritis in Korea. J Korean Med Sci. 2023 Apr 3;38 13):e115. Open 6. Chey WD, Leontiadis GI, Howden CW et al. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol. 2017 Feb;112 2 212 239. Open https://web.pathway.md/diseases/recjjHxTkIW5BsTNh 6/7 6/29/23, 11:03 PM Peptic ulcer disease Pathway 7. ASGE Standards of Practice Committee, Terry L Jue, Andrew C Storm et al. ASGE guideline on the role of endoscopy in the management of benign and malignant gastroduodenal obstruction. Gastrointest Endosc. 2021 Feb;93 2 309 322.e4. Open 8. Satoh K, Yoshino J, Akamatsu T et al. Evidence-based clinical practice guidelines for peptic ulcer disease 2015. J Gastroenterol. 2016 Mar;51 3 177 94. Open 9. Laura E Targownik, Deborah A Fisher, Sameer D Saini. AGA Clinical Practice Update on De- Prescribing of Proton Pump Inhibitors: Expert Review. Gastroenterology. 2022 Feb 16;S0016 5085 21 04083 X. Open 10. Barbara Farrell, Kevin Pottie, Wade Thompson et al. Deprescribing proton pump inhibitors: Evidence-based clinical practice guideline. Can Fam Physician. 2017 May;63 5 354 364. Open https://web.pathway.md/diseases/recjjHxTkIW5BsTNh 7/7