Interpretation of JSGE peptic ulcer clinical practice guidelines, the most comprehensive in the whole network (part 2)

This guide is only for medical professionals to read and reference.
This guide is the third edition of the Japanese Society of Gastroenterology (JSGE) Peptic Ulcer Clinical Practice Guide.
It focuses on the prevention and treatment of peptic ulcer bleeding (PUB), covering drug-induced ulcers and non-pyloric ulcers.
Helicobacter (Hp) non-steroidal anti-inflammatory drugs (NSAID) ulcers, gastric ulcers and other aspects
.

This guide uses the GRADE classification to classify the quality of evidence into A (high), B (medium), C (low) and D (very low); the strength of recommendation is divided into "strong recommendation" or "weak recommendation"
.

5.
Low-dose aspirin-induced ulcers ▌ Treatment 1.
How should low-dose aspirin (LDA) related peptic ulcers be treated? (1) For LDA-related peptic ulcers, it is recommended to use proton pump inhibitor (PPI) combined with continuous LDA therapy
.

(Strength of recommendation: strong; 100% agree; level of evidence: A) Analysis: For patients with a history of LDA-related PUB, the combined use of PPI and continuous LDA after endoscopic hemostasis is compared with the simultaneous use of placebo and PPI, PUB The recurrence rate is comparable
.

In addition, continuous LDA treatment can reduce the overall mortality associated with cardiovascular (CV) events [20]
.

The rate of ulcer healing in the PPI alone group is similar to that in the PPI and LDA combined treatment group [21]
.

2.
How to combine drugs to effectively reduce the incidence and prevalence of LDA-related peptic ulcers? (1) It is recommended to use PPI or H2RA to reduce the incidence and prevalence of LDA-related peptic ulcers
.

(Strength of recommendation: strong; 100% agree; level of evidence: A) 3.
How to combine drugs to effectively reduce the incidence and prevalence of LDA-related PUB? (1) It is recommended to use PPI or Vonolasan to reduce the incidence and prevalence of LDA-related PUB
.

(Strength of recommendation: strong; 100% agree; level of evidence: A) Analysis: Among LDA users with a history of ulcers, compared with 15 mg of lansoprazole, 10 mg and 20 mg of voronoxane can significantly reduce stomach or twelve months The incidence of digital bleeding [22]
.

4.
How to combine medication to effectively reduce the incidence and prevalence of LDA-related PUB recurrence? (1) Eradication of Hp infection and use of PPI can reduce the incidence and prevalence of LDA-related PUB recurrence
.

(Strength of recommendation: strong; 100% agree; level of evidence: B) (2) Eradicating Hp infection and using H2RA can reduce the incidence and prevalence of LDA-related PUB recurrence
.

(Strength of recommendation: weak; 100% agree; level of evidence: C) 5.
How should patients with a history of peptic ulcer prevent the recurrence of LDA-related peptic ulcer? (1) It is recommended to use PPI or Vonolasan to reduce the recurrence rate of LDA-related peptic ulcers
.

(Strength of recommendation: strong; 100% agree; level of evidence: A) (2) H2RA is recommended to reduce the recurrence rate of LDA-related peptic ulcers
.

(Strength of recommendation: weak; 100% agree; level of evidence: C) 6.
For patients without a history of peptic ulcer, is it necessary to prevent LDA-related peptic ulcer? (1) It is recommended to use PPI for the primary prevention of LDA-related peptic ulcer in patients without a history of ulcers
.

(Strength of recommendation: strong; 82% agree; level of evidence: A) Analysis: Scheiman et al.
[23] pointed out that in 73% of patients without a history of peptic ulcer, esomeprazole reduced the digestibility of patients taking LDA The incidence of ulcers
.

Ng et al.
[24] found that in 95% of patients without peptic ulcer, esomeprazole is superior to famotidine in preventing upper gastrointestinal complications related to LDA, clopidogrel and antithrombotic drugs
.

7.
When combined with LDA, can COX-2 selective inhibitors reduce the risk of peptic ulcer compared with non-selective NSAIDs? (1) Compared with non-selective NSAIDs, COX-2 selective inhibitors can reduce the risk of peptic ulcer and bleeding in patients taking LDA
.

(Strength of recommendation: strong; 100% agree; level of evidence: A) (2) For low- and medium-risk peptic ulcer patients who require LDA and NSAID treatment, it is recommended to use celecoxib and PPI in combination to prevent gastric injury
.

(Strength of recommendation: strong; 100% agree; level of evidence: A) Analysis: For patients at high risk of cardiovascular and gastrointestinal events who require combined use of LDA and NSAID, compared with naproxen and esomeprazole, Celecoxib and PPI are the first choice treatments to reduce the risk of recurrent UGIB [25]
.

A study found that in 45% of arthritis patients taking LDA, the risk of gastrointestinal events for celecoxib was lower than naproxen or ibuprofen [26]
.

COX-2 selective inhibitors and non-selective non-steroidal anti-inflammatory drugs increase the risk and incidence of cardiovascular events [27], and celecoxib is not inferior to naproxen or naproxen in terms of cardiovascular safety.
Profen[25,26]
.

In addition, the American College of Gastroenterology (ACG) guidelines recommend that for patients at high risk of peptic ulcer, LDA should not be combined with COX-2 selective inhibitors or non-selective NSAID drugs [28]
.

8.
Among patients taking LDA, is it recommended to use PPI to prevent the recurrence of peptic ulcer in patients receiving NSAID treatment? (1) After receiving NSAID treatment for patients taking LDA, it is recommended to use celecoxib combined with PPI to prevent the recurrence of peptic ulcer
.

(Strength of recommendation: strong; 100% agree; level of evidence: A) 6.
Other ▌ Non-Hp non-NSAID ulcers 1.
How to treat non-Hp non-NSAID ulcers? (1) It is recommended to use PPI as the initial treatment for non-Hp non-NSAID idiopathic ulcers, and use PPI or H2RA to prevent recurrence
.

(Strength of recommendation: weak; 100% agree; level of evidence: C) Analysis: Due to hyperacidity and hypergastrinemia in patients with idiopathic ulcers, PPI is recommended as the initial treatment
.

However, Kanno et al.
[30] reported that after 12 weeks of PPI treatment, the cure rate of idiopathic ulcers was 77.
4%, while the cure rate of Hp ulcers could reach 95.
0%
.

Therefore, PPI may not be sufficient to treat idiopathic ulcers
.

Wong et al.
[31] reported that without preventive treatment, the 7-year cumulative recurrence rate of the idiopathic ulcer group was 42.
3%, which was higher than that of the Hp ulcer group (11.
2%)
.

Subsequently, their RCT showed that PPI (lansoprazole: 30 mg/day) and H2RA (famotidine: 40 mg/day) showed no significant difference in the efficacy of preventing recurrence of idiopathic ulcers (at 24 months, The cumulative incidence of UGIB was 0.
88% and 2.
63%, respectively, P=0.
336)[32]
.

Therefore, both PPI and H2RA can effectively prevent recurrence
.

▌ Remnant gastric ulcer 1.
What is the treatment method for remnant gastric ulcer? (1) It is recommended to use PPI to treat residual gastric ulcer
.

(Strength of recommendation: strong; 100% agree; level of evidence: C) Analysis: The first choice for the treatment of gastric ulcer is drug therapy
.

In an open-label trial comparing omeprazole, cimetidine, sucralfate, colloidal bismuth, and misoprostol in the treatment of residual gastric ulcers, omeprazole was the best in terms of cure rate and speed of cure [ 33], using the above-mentioned drugs for 2 weeks, the ulcer cure rates were 66.
7%, 43.
3%, 22.
2%, 22.
2%, and 16.
7%, respectively
.

So far, there is no RCT on the eradication effect of Hp for the treatment of residual gastric ulcer
.

However, some cross-sectional studies have shown that there is no difference in the positive rate of Hp in the remnant stomach with and without ulcers [34-37]
.

From these results, the Hp eradication effect of gastric ulcer remains unclear
.

The effect of eradicating the remnant stomach on the prevention of cancer is also unclear
.

However, from the perspective of histological improvement after Hp eradication, it is speculated that eradication can effectively prevent gastric cancer
.

▌ Surgical treatment 1.
Is it recommended to eradicate Hp after peptic ulcer surgery? (1) If Hp is positive, it is recommended to eradicate Hp after peptic ulcer omentum patch or omentum filling
.

(Strength of recommendation: strong; 100% agree; level of evidence: A) Analysis: For the treatment of ischemic duodenal ulcer, it is recommended to use PPI or misoprostol as a conservative treatment
.

At the same time, check for underlying diseases, such as thrombosis and arterial stenosis
.

If the patient's condition worsens after conservative treatment, IVR or surgery may be considered
.

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