Peptic ulcer esophagogastroduodenoscopy

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2017 ACG Guidelines for Peptic Ulcer Disease

Guidelines for the Indications to Test for, and to Treat, H. pylori Infection

Guidelines for First line Treatment Strategies of Peptic Ulcer Disease for Providers in North America

Guidlines for factors that predict the successful eradication when treating H. pylori infection

Guidelines to document H. pylori antimicrobial resistance in the North America

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ;Associate Editor(s)-in-Chief: Manpreet Kaur, MD [2]

Overview

Peptic ulcer esophagogastroduodenoscopy

American College of Gastroenterology (ACG) guidelines 2017 for the treatment of H pylori infection (HPI) include the following recommendations for testing for H pylori:[1]

  • Active or past history of peptic ulcer disease.
  • Low-grade gastric mucosa-associated lymphoid tissue (MALT) lymphoma
  • Confirmed history of PUD (not previously treated for H. pylori)
  • Long-term therapy with nonsteroidal anti-inflammatory agents (NSAIDs) and low-dose aspirin
  • Unexplained iron deficiency anemia following standard workup
  • Idiopathic thrombocytopenic purpura

Pre-endoscopic medical therapy

  • Intravenous infusion of erythromycin 250 mg,30 min before endoscopy) can be given to improve diagnostic yield and decrease the need for repeat endoscopy
  • Intravenous PPI 80 mg bolus followed by 8 mg/h infusion can be given to decrease the number of patients who have higher risk of bleeding at endoscopy[2]

Timing of endoscopy

  • Patients with bleeding ulcer should undergo endoscopy within 24 h of admission, following resuscitative efforts to stabilize hemodynamically
  • Patients who are hemodynamically stable endoscopy should be performed early and discharged on the same day
  • Patients with unstable signs and symptoms (e.g., tachycardia, hypotension, bloody emesis or nasogastric aspirate in the hospital) endoscopy should be done within 12 hours

Algorithm for the Approach to Dyspepsia


 
 
 
 
 
Age ≥ 55 or ⊕ alarm features*?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
YES
 
 
 
 
 
 
 
NO
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Endoscopy
 
 
 
 
 
 
 
H. pylori prevalence?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
High
 
 
 
 
 
 
 
Low
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Test-and-treat strategy ± acid suppression
 
 
 
 
 
 
 
Acid suppression trial
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If eradication therapy is indicated
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Clarithromycin resistance ≥ 20%
 
 
 
 
 
 
 
Clarithromycin resistance < 20%
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Quadruple or sequential therapy
 
 
 
 
 
 
 
PCA or PCM or Bismuth quadruple therapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
PLA
 
 
 
 
 
 
 
Bismuth quadruple therapy or PLA
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Adjust Rx per susceptibility test
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider endoscopy if treatment fails
 
 
 
 
 
 
 
 
 
 
  • Alarm symptoms-unexplained weight loss, progressive dysphagia, odynophagia, recurrent vomiting, family history of gastrointestinal cancer, overt gastrointestinal bleeding, abdominal mass, iron deficiency anemia, or jaundice[3]

References

  1. "www.nature.com" (PDF).
  2. "Management of Patients with Ulcer Bleeding | American College of Gastroenterology".
  3. Bowrey DJ, Griffin SM, Wayman J, Karat D, Hayes N, Raimes SA (2006). "Use of alarm symptoms to select dyspeptics for endoscopy causes patients with curable esophagogastric cancer to be overlooked". Surg Endosc. 20 (11): 1725–8. doi:10.1007/s00464-005-0679-3. PMID 17024539.