**Question:** A 68-year-old woman has been diagnosed with a benign ulcer on the greater curvature of her stomach, 5 cm proximal to the antrum. After 3 months of standard medical therapy, she continues to have guaiac positive stool, anemia, and abdominal pain with failure of the ulcer to heal. Biopsies of the gastric ulcer have not identified a malignancy. The next step in management is which of the following?

A. Increase the dose of proton pump inhibitors (PPIs)
B. Change the type of proton pump inhibitor to a more potent one
C. Introduce steroids to the treatment regimen
D. Perform endoscopy and consider surgery

**Correct Answer:** D. Perform endoscopy and consider surgery

**Core Concept:**

Benign gastric ulcers are typically treated with medical management involving proton pump inhibitors (PPIs), which are powerful inhibitors of gastric acid secretion. In this scenario, the patient's ulcer persists despite standard medical therapy, indicating that the initial treatment approach may not be effective.

**Why the Correct Answer is Right:**

Despite the patient having a benign ulcer and not showing signs of malignancy on biopsies, the ulcer has not responded to medical treatment. In such cases, endoscopy is necessary to evaluate the ulcer's etiology and rule out complications such as perforation or bleeding. If endoscopy reveals no specific cause for the ulcer or if it fails to heal despite endoscopic intervention, surgical intervention may be considered.

**Why Each Wrong Option is Incorrect:**

A. Increasing the dose of PPIs may be counterproductive, as high doses of PPIs can cause side effects and may not necessarily improve ulcer healing.

B. Changing the proton pump inhibitor to a more potent one does not consider the underlying cause of the ulcer, which should be addressed rather than simply increasing potency.

C. Administering steroids to the treatment regimen is not recommended for treating gastric ulcers as they may exacerbate the underlying cause (e.g., H. pylori infection) and may cause additional side effects.

**Clinical Pearl:**

In cases of non-healing gastric ulcers, a step-up approach should be followed. This includes initial medical management with PPIs, followed by endoscopy if the ulcer persists or recurs after healing. If endoscopy does not identify a specific cause or if the ulcer does not heal after endoscopic intervention, surgical intervention should be considered.