Gastric Ulcer (ICD-11: DA60) - Complete Clinical Coding Guide

1. Introduction

Gastric ulcer represents one of the most prevalent gastroenterological conditions in contemporary clinical practice, characterized by a lesion in the stomach mucosa that penetrates through the muscular layer of the mucosa. This condition affects millions of people globally and constitutes an important public health problem, generating significant costs in treatments, hospital admissions, and loss of work productivity.

Gastric ulcer occurs when there is a rupture of the delicate balance between the aggressive factors of the gastric mucosa - mainly hydrochloric acid and pepsin - and the defense mechanisms of the stomach lining, such as the production of mucus, bicarbonate, and prostaglandins. This imbalance can be triggered by various factors, with the most important being infection by the bacterium Helicobacter pylori, prolonged use of nonsteroidal anti-inflammatory drugs (NSAIDs), smoking, and physiological stress.

The importance of correct coding of gastric ulcer in the ICD-11 system transcends merely administrative aspects. Accurate coding is fundamental for public health policy planning, adequate resource allocation, reliable epidemiological studies, appropriate reimbursement by health insurance systems, and, most importantly, to ensure continuity of patient care through accurate medical records. The code DA60 specific for gastric ulcer allows differentiation of this condition from other peptic ulcers, facilitating the tracking of clinical outcomes and the implementation of specific therapeutic protocols.

2. Correct ICD-11 Code

Code: DA60

Description: Gastric ulcer

Parent category: Ulcer of stomach or duodenum

Official definition: A gastric ulcer is a lesion in the lining of the stomach. This lesion is caused by corrosion from acidic digestive juices secreted by stomach cells. The disease occurs when there is an imbalance between the acidity of digestive juice and the protective mechanism of the stomach mucosa. Helicobacter pylori infection, use of anti-inflammatory medications, and smoking are some of the related factors. The disease can cause abdominal pain or epigastric pain described as discomfort, burning, or gnawing sensation, and the disease can also represent a malignancy.

The code DA60 belongs to the chapter of diseases of the digestive system in ICD-11 and is used specifically when the ulcer is located in the stomach, regardless of its etiology. This code allows clear identification that the ulcerative lesion is situated in the gastric mucosa, differentiating it from ulcers in other locations of the gastrointestinal tract. The ICD-11 classification offers a hierarchical structure that facilitates both diagnostic specificity and epidemiological data analysis on a large scale, allowing international comparisons and multicenter studies on this prevalent clinical condition.

3. When to Use This Code

The code DA60 should be used in specific clinical situations where there is confirmation of ulcerative lesion located in the gastric mucosa. Below are detailed practical scenarios:

Scenario 1: Patient with upper digestive endoscopy confirming gastric ulcer A 55-year-old patient, chronic user of anti-inflammatory drugs for arthritis, presents with burning epigastralgia for three months. Upper digestive endoscopy is performed, revealing a 1.5 cm ulcer on the gastric lesser curvature, with regular borders and fibrinous base. Biopsies are collected and confirm benign ulcer with presence of Helicobacter pylori. In this case, code DA60 is appropriate, as there is endoscopic and histological confirmation of gastric ulcer.

Scenario 2: Acute gastric ulcer in hospitalized patient A patient hospitalized in an intensive care unit for polytrauma develops epigastric pain and hematemesis. Emergency endoscopy reveals acute ulcer in the gastric body with active bleeding. This presentation of acute stress ulcer, located in the stomach, should be coded as DA60, even though it is acute in nature and related to physiological stress.

Scenario 3: Chronic gastric ulcer under follow-up A patient with previous history of treated gastric ulcer returns for follow-up endoscopy after three months of treatment with proton pump inhibitors. The examination reveals ulcer scar in the antral region with small area of residual ulceration. Code DA60 remains appropriate for documenting the persistence of gastric ulcer, even in the healing phase.

Scenario 4: Multiple gastric ulcers A patient with Zollinger-Ellison syndrome presents with multiple ulcers in the stomach, identified endoscopically in the antrum and gastric body. Even with multiple lesions, all located in the stomach, code DA60 is appropriate, and may be complemented with additional codes to specify the underlying acid hypersecretion syndrome.

Scenario 5: Perforated gastric ulcer A patient presents with acute perforation of the abdomen, with pneumoperitoneum on radiography. During exploratory laparotomy, a perforated ulcer is identified on the anterior wall of the stomach. Code DA60 should be used to identify the gastric ulcer, and may be complemented with additional codes to specify the perforative complication.

Scenario 6: Gastric ulcer with bleeding An elderly patient on anticoagulants presents with melena and hemoglobin drop. Endoscopy reveals gastric ulcer with visible vessel and signs of recent bleeding. Code DA60 is appropriate for identifying the gastric ulcer as the source of bleeding, and may be complemented with additional codes to document the gastrointestinal hemorrhage.

4. When NOT to Use This Code

The correct use of code DA60 requires recognition of situations where other codes are more appropriate. It is essential to avoid inadequate coding that may compromise medical records and epidemiological analyses.

Malignant neoplasms of the stomach: When an ulcerated lesion in the stomach is identified endoscopically, but biopsies reveal adenocarcinoma or another type of malignant neoplasm, code DA60 should NOT be used. In these cases, specific codes for malignant neoplasms of the stomach should be used. The ulcerated appearance of gastric cancer does not classify it as benign gastric ulcer, and differentiation through histopathological analysis is essential.

Acute hemorrhagic erosive gastritis: When there are multiple superficial erosions in the gastric mucosa, without the deep penetration characteristic of true ulcer, the appropriate code is not DA60. Erosions are superficial lesions that do not penetrate beyond the muscular layer of the mucosa, while ulcers are deeper lesions. Acute hemorrhagic erosive gastritis has a specific code and should not be confused with gastric ulcer.

Duodenal ulcer: When the ulcer is located in the duodenum and not in the stomach, code DA60 is not appropriate. Code DA63 should be used for duodenal ulcers. This differentiation is crucial, as gastric and duodenal ulcers, although sharing similar pathophysiological mechanisms, present distinct clinical, epidemiological, and prognostic characteristics.

Non-erosive gastritis: Patients with dyspeptic symptoms and endoscopic or histological diagnosis of gastritis without evidence of ulceration should not be coded with DA60. The presence of gastric mucosal inflammation without ulcer formation requires specific codes for gastritis.

Nonspecific gastric lesions: When there is only endoscopic description of "hyperemic mucosa" or "mucosal edema" without clear identification of ulcer crater, code DA60 should not be applied prematurely. Confirmation of ulcer requires visualization of mucosal discontinuity with characteristic depth.

5. Step-by-Step Coding Process

Step 1: Assess diagnostic criteria

The diagnosis of gastric ulcer requires objective confirmation through appropriate methods. Upper gastrointestinal endoscopy is the gold standard for diagnosis, allowing direct visualization of the ulcerative lesion, evaluation of its morphological characteristics, precise localization, and collection of material for histopathological analysis. During endoscopy, the following should be documented: anatomical location of the ulcer (antrum, body, fundus, cardia, lesser or greater curvature), lesion size, characteristics of the edges (regular or irregular), appearance of the ulcer base (fibrinous, necrotic, clean), presence of bleeding signs (active, recent, or old), and presence of other concomitant lesions.

Biopsy collection is fundamental not only to confirm the benign nature of the ulcer, excluding malignancy, but also to investigate the presence of Helicobacter pylori through histological methods, urease test, or culture. Complementary examinations such as contrast radiography of the esophagus-stomach-duodenum may suggest ulcer, but do not replace endoscopy for definitive diagnostic confirmation.

Step 2: Verify specifiers

After confirming the diagnosis of gastric ulcer, it is important to document specific characteristics that may influence treatment and prognosis. Severity can be classified by the depth of the lesion, presence of complications such as bleeding, perforation, or stenosis. Duration (acute versus chronic) should be established through clinical history and endoscopic findings. Acute ulcers generally present with edematous edges and base with fresh fibrin, while chronic ulcers show elevated and hardened edges with cleaner base and signs of attempted healing.

The presence or absence of Helicobacter pylori should be documented, as it directly influences the therapeutic strategy. The use of ulcerogenic medications, especially nonsteroidal anti-inflammatory drugs, should be recorded. Risk factors such as smoking, alcohol consumption, and family history should also be documented in the medical record, although they do not alter the main code DA60.

Step 3: Differentiate from other codes

DA61 - Peptic ulcer, site unspecified: This code should be used when there is confirmation of peptic ulcer, but the exact location (gastric versus duodenal) has not been determined or is not clearly documented. The key difference is anatomical specificity. If endoscopy or another diagnostic method clearly identified that the ulcer is in the stomach, DA60 is used. If there is only clinical suspicion or inconclusive examinations regarding the precise location, DA61 would be more appropriate.

DA62 - Anastomotic ulcer: This code is specific for ulcers occurring at sites of surgical anastomosis, typically after gastric surgeries such as partial gastrectomy with gastrojejunostomy. The key difference is the previous surgical context. An ulcer at the suture line or near the anastomosis in a patient with a history of prior gastric surgery should be coded as DA62, not DA60. Ulcers in native stomach, without prior surgery, use DA60.

DA63 - Duodenal ulcer: The fundamental difference is anatomical location. Ulcers located in the duodenum (first, second, third, or fourth portions) should be coded as DA63. Ulcers in the stomach use DA60. This distinction is crucial as duodenal and gastric ulcers present important epidemiological, pathophysiological, and prognostic differences. In rare cases of simultaneous ulcers in the stomach and duodenum, both codes may be used.

Step 4: Required documentation

For appropriate coding with DA60, the medical record must contain:

Mandatory checklist:

Upper gastrointestinal endoscopy report with detailed description of the gastric ulcer
Precise anatomical location of the ulcer in the stomach
Morphological characteristics of the lesion (size, edges, base)
Biopsy results confirming benign nature
Helicobacter pylori investigation (positive or negative)
History of ulcerogenic medication use
Presence or absence of complications (bleeding, perforation, stenosis)
Clinical symptoms presented by the patient
Treatment instituted

Adequate documentation not only justifies the coding choice but also legally protects the professional, facilitates continuity of care, and allows appropriate audit of medical records.

6. Complete Practical Example

Clinical Case:

A 62-year-old male patient seeks outpatient care with a complaint of pain in the upper abdominal region for approximately two months. He describes the pain as a burning sensation in the epigastrium, with moderate intensity, which worsens when fasting and improves partially after eating. He also reports occasional episodes of nausea, but denies vomiting. He has not presented with gastrointestinal bleeding, weight loss, or other systemic symptoms.

In his past medical history, the patient reports knee osteoarthritis diagnosed five years ago, for which he continuously uses diclofenac 50mg three times daily. He is a smoker for 40 years, smoking approximately 20 cigarettes daily. He denies alcohol use. He has no family history of gastric cancer or other relevant digestive diseases.

On physical examination, he presents in good general condition, flushed, hydrated, without signs of malnutrition. The abdomen is flat, flaccid, with mild pain on deep palpation in the epigastrium, without palpable masses or signs of peritoneal irritation. The remaining systems show no significant alterations.

Due to the persistence of symptoms and the presence of risk factors (chronic use of nonsteroidal anti-inflammatory drug and smoking), upper gastrointestinal endoscopy was requested. The examination revealed: esophagus without alterations, preserved esophagogastric junction, stomach with normal-appearing mucosa in the fundus and body, presence of an ulcer approximately 1.2 cm in diameter on the lesser curvature of the antral region, with regular and slightly elevated borders, base covered with whitish fibrin, without signs of active or recent bleeding. The pylorus was patent and the duodenum showed no lesions. Four biopsies were collected from the ulcer borders for histopathological analysis and Helicobacter pylori testing.

The histopathological result confirmed chronic ulcerative process with acute and chronic inflammation, without signs of malignancy. The urease test was positive, confirming Helicobacter pylori infection.

Step-by-Step Coding:

Criteria Analysis:

Endoscopic confirmation of ulcerative lesion in the stomach ✓
Specific location identified (gastric antrum, lesser curvature) ✓
Documented morphological characteristics (size, borders, base) ✓
Histopathological confirmation of benign ulcer ✓
Presence of Helicobacter pylori documented ✓
Exclusion of malignancy through biopsies ✓

Code Selected: DA60 - Gastric ulcer

Complete Justification: The code DA60 is appropriate because there is endoscopic and histopathological confirmation of an ulcer located specifically in the stomach (antral region). The lesion presents typical characteristics of gastric peptic ulcer, with a well-defined ulcerative crater, penetrating beyond the muscular layer of the mucosa. The biopsies excluded malignancy, confirming it is a benign ulcer. The presence of Helicobacter pylori and chronic use of nonsteroidal anti-inflammatory drug are well-established etiological factors for gastric ulcer, reinforcing the diagnosis.

It is not a duodenal ulcer (DA63), as the lesion is in the stomach. It is not an ulcer of unspecified location (DA61), as the endoscopy clearly identified the gastric location. It is not an anastomotic ulcer (DA62), as the patient has no history of prior gastric surgery.

Applicable Complementary Codes:

Code for Helicobacter pylori infection (if the coding system allows multiple codes)
Code for smoking (relevant risk factor)
Code for use of nonsteroidal anti-inflammatory drugs (medication-related cause)

The treatment instituted included triple therapy for Helicobacter pylori eradication (proton pump inhibitor, amoxicillin, and clarithromycin for 14 days), followed by proton pump inhibitor for an additional 6-8 weeks, discontinuation of diclofenac with substitution by alternative analgesic when necessary, and counseling for smoking cessation. Follow-up endoscopy was scheduled for 8-12 weeks after completion of treatment.

7. Related Codes and Differentiation

Within the Same Category:

DA61: Peptic ulcer, site unspecified

This code should be used in situations where there is clinical, laboratory, or radiological evidence suggestive of peptic ulcer, but the precise anatomical location (gastric versus duodenal) has not been determined. For example, a patient with typical dyspeptic symptoms and iron deficiency anemia suggestive of chronic digestive bleeding, where contrast radiological studies suggest ulcer, but endoscopy was not performed or was inconclusive regarding the exact location. The main difference from DA60 is anatomical specificity: DA60 requires confirmation that the ulcer is in the stomach, while DA61 is used when this specificity is not available.

DA62: Anastomotic ulcer

This code is specific for ulcers that develop at sites of surgical anastomosis of the gastrointestinal tract, particularly after gastric surgeries such as partial gastrectomy Billroth I or II, Roux-en-Y gastrectomy, or other surgical reconstructions involving the stomach. The pathophysiology of anastomotic ulcers involves factors such as ischemia of the suture line, tension at the anastomosis, presence of foreign body (surgical sutures), Helicobacter pylori infection, and acid hypersecretion. The main difference from DA60 is the surgical context: DA62 requires a history of prior gastric surgery with anastomosis, while DA60 is used for ulcers in native stomach, without prior surgery.

DA63: Duodenal ulcer

Duodenal ulcers are lesions located in the duodenum, most commonly in the first portion (duodenal bulb), although they may occur in more distal portions. Although they share similar pathophysiological mechanisms with gastric ulcers (imbalance between aggressive and protective factors of the mucosa, Helicobacter pylori infection, NSAIDs use), they present important differences. Duodenal ulcers are generally more common than gastric ulcers, tend to occur in younger patients, present pain that typically improves with eating (unlike gastric ulcers which may worsen), and have lower risk of malignancy. The main difference from DA60 is purely anatomical: DA63 for ulcers in the duodenum, DA60 for ulcers in the stomach.

Differential Diagnoses:

Erosive gastritis: Characterized by multiple superficial erosions of the gastric mucosa, without deep penetration. Endoscopically, they appear as shallow, multiple lesions, often with a hemorrhagic appearance. It differs from gastric ulcer by its superficiality (does not penetrate the muscular layer of the mucosa) and multiplicity of lesions.

Ulcerated gastric cancer: Presents endoscopically as an ulcerated lesion, but with suspicious characteristics such as irregular, elevated, friable borders, necrotic base, and rigidity of the gastric wall. Definitive differentiation requires histopathological analysis of biopsies, and it is essential to perform multiple biopsies of the edges and base of any gastric ulcer.

Gastric Crohn's disease: Although rare, Crohn's disease can affect the stomach, causing ulcers. There is usually involvement of other segments of the gastrointestinal tract, especially terminal ileum and colon. Ulcers are typically multiple, linear or aphthoid, and histology shows transmural inflammation with non-caseating granulomas.

8. Differences with ICD-10

In the ICD-10 classification, gastric ulcer was coded primarily with code K25, which included subdivisions based on characteristics such as acute versus chronic, with or without hemorrhage, with or without perforation. For example: K25.0 (acute gastric ulcer with hemorrhage), K25.1 (acute gastric ulcer with perforation), K25.2 (acute gastric ulcer with hemorrhage and perforation), K25.3 (acute gastric ulcer without hemorrhage or perforation), and similar codes for chronic ulcers (K25.4 to K25.7) and unspecified (K25.9).

The main change in ICD-11 with code DA60 is the simplification of the coding structure and greater flexibility in the use of extensions to specify additional characteristics. While ICD-10 required a mandatory additional digit to specify the presence of hemorrhage or perforation, ICD-11 allows the use of optional extension codes as needed, making coding more intuitive and adaptable to different clinical contexts.

The practical impact of these changes includes greater ease of coding in situations where all characteristics of the ulcer are not completely documented, better compatibility with electronic medical record systems, and greater uniformity in coding between different institutions and countries. Professionals accustomed to the ICD-10 system should be aware of these structural differences to ensure adequate transition and accurate coding in the new ICD-11 system.

9. Frequently Asked Questions

How is gastric ulcer diagnosed?

The diagnosis of gastric ulcer is established primarily through upper gastrointestinal endoscopy, considered the gold standard method. This procedure allows direct visualization of the ulcerative lesion, evaluation of its morphological characteristics, and collection of biopsies for histopathological analysis and Helicobacter pylori investigation. During endoscopy, the physician can identify the precise location of the ulcer, measure its size, evaluate characteristics of the edges and base, and detect signs of complications such as bleeding. Contrast radiological methods may suggest ulcer, but do not replace endoscopy for diagnostic confirmation. Non-invasive tests for Helicobacter pylori, such as urea breath test or fecal antigen detection, can be used for initial investigation or eradication control, but do not confirm the diagnosis of ulcer.

Is treatment available in public health systems?

Yes, treatment for gastric ulcer is generally available in public health systems in most countries. The medications used in treatment, especially proton pump inhibitors and antibiotics for Helicobacter pylori eradication, are part of essential medication lists from international health organizations and are usually available in public pharmacies. Upper gastrointestinal endoscopy, although it may have waiting lists in some public systems, is considered an essential procedure and is generally available. Access and waiting times may vary significantly between different regions and health systems, but the recognition of gastric ulcer as a prevalent and potentially serious condition ensures its inclusion in digestive health care programs.

How long does treatment last?

The duration of gastric ulcer treatment varies according to etiology and presence of complications. For ulcers associated with Helicobacter pylori, treatment includes bacterial eradication therapy (usually 10-14 days with a combination of proton pump inhibitor and two antibiotics), followed by acid-suppressive therapy with proton pump inhibitor for an additional 4-8 weeks. For ulcers related to nonsteroidal anti-inflammatory drug use, treatment involves discontinuation of the causative medication (when possible) and use of proton pump inhibitor for 8-12 weeks. Ulcers complicated by bleeding or perforation may require more prolonged treatment. Follow-up endoscopy is generally recommended 8-12 weeks after treatment initiation to confirm healing, especially in larger ulcers or those with suspicious characteristics.

Can this code be used in medical certificates?

Yes, the code DA60 can and should be used in medical certificates when appropriate. ICD-11 coding in medical certificates serves to document in a standardized manner the clinical condition that justifies work leave or other medical needs. Gastric ulcer, especially when symptomatic or complicated, may justify temporary leave from work activities, mainly in occupations involving intense physical effort, exposure to gastric irritant substances, or situations of significant stress. The period of leave should be individualized according to symptom severity, presence of complications, patient's type of occupation, and treatment response. It is important that the certificate contains not only the code, but also relevant clinical information that justifies the need for leave.

Can gastric ulcer transform into cancer?

Although most gastric ulcers are benign, there is a small possibility that ulcerated lesions actually represent malignant neoplasms (ulcerated gastric cancer) from the beginning, or that chronic ulcers may be associated with premalignant alterations of the gastric mucosa. For this reason, it is essential to perform biopsies of all endoscopically identified gastric ulcers, collecting multiple samples from the edges and base of the lesion. Additionally, follow-up endoscopy after appropriate treatment is recommended to confirm complete healing. Ulcers that do not heal after appropriate treatment, or that present suspicious endoscopic characteristics (irregular, friable, hardened edges), should be biopsied repeatedly and followed rigorously until definitive exclusion of malignancy.

Can I have gastric and duodenal ulcers simultaneously?

Yes, although less common, it is possible to have gastric and duodenal ulcers simultaneously. This condition is known as "kissing" ulcers when located on opposite walls, or simply as multiple peptic ulcers. When both locations are present, both codes (DA60 for gastric ulcer and DA63 for duodenal ulcer) should be used in coding. The presence of multiple ulcers may suggest underlying conditions such as Zollinger-Ellison syndrome (gastrin-secreting tumor causing acid hypersecretion), intensive use of ulcerogenic medications, or severe Helicobacter pylori infection. Treatment follows the same principles, but may require more prolonged therapy and investigation of secondary causes of acid hypersecretion.

What are the alarm signs that indicate complications?

Alarm signs suggesting complications of gastric ulcer include: vomiting with blood (hematemesis) or with coffee-ground appearance, indicating upper gastrointestinal bleeding; dark, pasty stools with foul odor (melena), also indicating bleeding; sudden, intense, and diffuse abdominal pain, suggesting perforation; persistent vomiting and abdominal distension, suggesting obstruction; unintentional weight loss, which may indicate malignancy; and progressive anemia with fatigue and pallor, indicating chronic bleeding. Any of these signs requires urgent medical evaluation. Significant bleeding and perforation are medical emergencies that may require immediate endoscopic or surgical intervention. Patients with diagnosed gastric ulcer should be informed about these alarm signs and instructed to seek immediate care if they occur.

Is it necessary to repeat endoscopy after treatment?

The need for follow-up endoscopy after gastric ulcer treatment depends on several factors. Follow-up endoscopy is generally recommended 8-12 weeks after treatment initiation for: gastric ulcers larger than 1 cm, ulcers with atypical or suspicious endoscopic characteristics, ulcers in patients with risk factors for gastric cancer (advanced age, family history, atrophic gastritis), and ulcers that did not respond adequately to initial treatment. Follow-up endoscopy allows confirmation of complete healing, performance of additional biopsies if there are residual suspicious areas, and evaluation of Helicobacter pylori eradication. For small, typical ulcers in young patients without risk factors, with complete symptom resolution, follow-up endoscopy may be omitted, opting for non-invasive tests to confirm bacterial eradication when applicable.

Final note: This article provides general guidance on coding gastric ulcer in the ICD-11 system. Coding should always be based on adequate clinical documentation and individualized assessment of each case. Health professionals should consult local guidelines and stay updated on modifications in coding systems.

External References

This article was prepared based on reliable scientific sources:

References verified on 2026-02-03

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