When should I consider referring a patient with peptic ulcer disease for specialist evaluation?

Consider referring a patient with peptic ulcer disease for specialist evaluation if:

• They have refractory or recurrent symptoms despite optimal management in primary care.
• Treatment with a second-line Helicobacter pylori eradication regimen has been unsuccessful.
• There are limited antibiotic options for H. pylori eradication therapy due to hypersensitivity, known local high antibiotic resistance rates, or previous use of clarithromycin, metronidazole, and a quinolone.
• A proven gastric ulcer has not healed on repeat endoscopy following treatment.
• There are alarm features suggestive of complications or serious underlying pathology, such as significant acute gastrointestinal bleeding, which require immediate referral.

Referral may also be considered if there is doubt about the diagnosis or if symptoms do not adequately respond to treatment in primary care.

These recommendations align with NICE and PHE guidance emphasizing that specialist referral is appropriate when management in primary care is insufficient or complicated by treatment failure or diagnostic uncertainty.

References: NICE CKS, NICE CKS, NICE CG184