Peptic ulcers

Diagnosis made on OGD after management through the dyspepsia pathway

Gastric Ulceration

H. pylori negative:

• Full dose PPI (omeprazole 20mg daily) for 4 or 8 weeks then repeat endoscopy to confirm healing
  • If healed then low dose maintenance or as required PPI, step down to antacid/ alginate if possible. Annual review
  • If not healed - Refer
• See 1.3 Antisecretory drugs and mucosal protectants
• See 1.1 Dyspepsia and gastro-oesophageal reflux disease

H. pylori positive:

• Repeat endoscopy with H. pylori testing 6-8 weeks after starting eradication therapy
  • If still H. pylori positive, give 2nd line eradication therapy and repeat the endoscopy as above
  • Ulcer healed and H. pylori negative, continue low dose PPI (omperazole 10mg daily) as maintenance or as required, step down to antacid/ alginate if possible. Annual review
  • Ulcer not healed and H. pylori negative - Refer
• See 1.3 Antisecretory drugs and mucosal protectants
• See 1.1 Dyspepsia and gastro-oesophageal reflux disease

Duodenal Ulceration

H. pylori negative:

• Full dose PPI (omeprazole 20mg daily) for 4 or 8 weeks
  • If symptoms resolve then follow with low dose maintenance or as required PPI, step down to antacid/ alginate if possible. Annual review.
  • If no response to PPI, exclude other causes:
    • Non-compliance/malignancy
    • Failure to detect H. pylori
    • Aspirin or other NSAID use
    • Ulceration due to other drugs (SSRI, bisphosphonates, Sando-K, immunosuppressant)
    • Crohn's disease (Zollinger-Ellison-Syndrome)
• See 1.3 Antisecretory drugs and mucosal protectants
• See 1.1 Dyspepsia and gastro-oesophageal reflux disease

H. pylori positive:

• If ulcer associated with NSAID use then full dose PPI (omeprazole 20mg) for 8 weeks then H. pylori eradication
• If no NSAID then try H. pylori eradication
• If no response to eradication therapy or symptom relapse then retest and if negative, for low dose PPI (omeprazole 10mg daily) or as required maintenance, but if non response consider other causes as above. If positive – 2nd line eradication
• See 1.3 Antisecretory drugs and mucosal protectants
• See 1.1 Dyspepsia and gastro-oesophageal reflux disease

Joint formulary – Chapter 5 – Eradication therapy

Joint formulary – Chapter 1 - Gastrointestinal

Referral Criteria

• Refer to specialist if ulcer does not heal
• Refer to specialist if H. pylori positive and inadequate symptom responses or relapse
• Consider referral to specialist if patient remains H. pylori positive.

Referral Instructions

Refer using e-Referral Service:

• Specialty: GI and Liver (Medicine and Surgery)
• Clinic Type: Upper GI inc Dyspepsia
• Service: DRSS-Western-GI and Liver (Medicine and Surgery)-Devon CCG-15N

Referral Forms

DRSS Referral Proforma

Patient Information

Dyspepsia (indigestion) – patient.co.uk

Non-ulcer (Functional) Dyspepsia – patient.co.uk

Evidence

NICE guidance

Pathway Group

This pathway was signed off by the NEW Devon CCG Western Locality Clinical Pathway Group.

Publication date: August 2015