RMA instruments

Changes from previous instruments

SOP Bulletin 183

ICD coding

• Gastric ulcer ICD-9 531; ICD-10 K25
• Duodenal ulcer ICD-9 532; ICD-10 K26
• Gastrojejunal ulcer ICD-10 K28

Brief description

This is an upper gastrointestinal pathology affecting the stomach or duodenum resulting in ulceration of the mucosal lining. If the size of the ‘ulceration’ is too small (less than 3 mm) or too shallow (not extending into the muscularis mucosa) it is called an erosion and is not covered by the SOP.  The SOP covers both chronic “peptic” ulcer and acute ulcer.

Confirming the diagnosis:

Confirmation of diagnosis requires upper gastrointestinal endoscopy or, historically, via imaging with radiopaque contrast medium, i.e. barium swallow or meal. Histopathology is important to consider SOP exclusions.

It does not need to be symptomatic.

The relevant medical specialist is a gastroenterologist or general surgeon.

Additional diagnoses covered by these SOPs

• Acute duodenal ulcer
• Acute gastric ulcer
• Bleeding gastric or duodenal ulcer
• Chronic duodenal ulcer
• Chronic gastric ulcer
• Gastric or duodenal peptic ulcer
• Perforated gastric or duodenal ulcer

Conditions not covered by these SOPs

• Acute duodenitis^#
• Acute gastritis^#
• Chronic gastritis*
• Gastric or duodenal erosions^#
• Gastro-oesophageal reflux disease*
• Inflammatory bowel disease* - Crohn’s disease
• Malignant neoplasm of the small intestine*
• Malignant neoplasm of the stomach*
• Sarcoidosis*                                                    
• Stomach or duodenal neoplastic ulcer*
• Uraemic gastritis^#

* another SOP applies

^# non-SOP condition

Clinical onset

Once the diagnosis has been confirmed, clinical onset may be able to be backdated based on upper GI symptoms.  However, reported symptoms may be non-specific and due to other conditions, such as gastro-oesophageal reflux disease.  Frank upper gastrointestinal bleeding with haematemesis or melaena would normally be due to a gastric or duodenal ulcer.

Clinical worsening

Treatment for ulcers has varied over time.  Ulcers due to Helicobacter pylori infection can now be cured with drugs.  Other ulcers can be effectively treated with drugs such as proton pump inhibitors (e.g. omeprazole).  The presence of a complication in a previous ulcer (haemorrhage or perforation) or the need for surgery would be indicative of a clinical worsening.

Ulcers are also subject to regular surveillance to exclude the concomitant possibility of a gastric neoplasm.

Further comments on diagnosis

Most ulcers readily resolve with treatment.  Ensure that a disease is present before applying the SOP.  Note also that the RMA has declared that the isolated presence of Helicobacter pylori infection without inflammation or ulceration is not a disease or injury.

Comments on SOP factors

Note that there are several aetiological factors in this SOP that pertain to single episode triggering of ulcers, such as the drug factors (Non steroidal anti-inflammatory drugs, aspirin), specified list 1 and 2, infection, critical illness or injury, and contact with nasogastric tube.