What is the recommended treatment for stomach ulcers?

Treatment of Stomach Ulcers

The recommended treatment for stomach ulcers includes proton pump inhibitors (PPIs) for 6-8 weeks along with Helicobacter pylori eradication therapy if the infection is present. 1

Diagnostic Approach

Before initiating treatment, proper diagnosis is essential:

• CT scan is recommended for suspected perforated ulcers (if available)
• Chest/abdominal X-ray if CT is not promptly available
• Endoscopy to confirm diagnosis and assess for bleeding
• H. pylori testing for all patients with stomach ulcers

Treatment Algorithm

Step 1: Initial Management

For Bleeding Ulcers:

• Start PPI therapy as soon as possible 1
• Administer pre-endoscopy erythromycin to improve visualization
• After successful endoscopic hemostasis, administer high-dose PPI as continuous infusion for first 72 hours (80 mg bolus followed by 8 mg/hour) 1

For Non-Bleeding Ulcers:

• Start standard dose PPI therapy (omeprazole 20 mg, lansoprazole 30 mg, pantoprazole 40 mg, or rabeprazole 20 mg daily) 2
• For severe ulcers, consider higher dose regimen (omeprazole 40 mg, lansoprazole 60 mg, pantoprazole 80 mg or rabeprazole 40 mg daily) 2

Step 2: H. pylori Testing and Eradication

• Test all patients with stomach ulcers for H. pylori infection 1
• For H. pylori-positive patients, initiate eradication therapy:

First-line therapy (if low clarithromycin resistance):

• Standard triple therapy: PPI + amoxicillin + clarithromycin for 14 days 1
  • Clarithromycin 500 mg twice daily
  • Amoxicillin 1 gram twice daily
  • PPI (omeprazole 20 mg or lansoprazole 30 mg) twice daily 3

Alternative (if high clarithromycin resistance):

• Sequential therapy with four drugs (PPI + amoxicillin + clarithromycin + metronidazole) for 10 days 1

Second-line therapy (if first-line fails):

• 10-day levofloxacin-amoxicillin triple therapy with PPI 1

Step 3: Continued PPI Therapy

• Continue PPI therapy for 6-8 weeks to allow complete mucosal healing 1
• For gastric ulcers, treatment duration is typically 4-8 weeks 2
• For duodenal ulcers, treatment duration is typically 2-4 weeks 2

Step 4: Long-term Management

• After mucosal healing, discontinue PPI therapy unless:
  • Patient requires ongoing NSAID use
  • Patient has recurrent symptoms
• For NSAID-induced ulcers, consider continued PPI therapy if NSAIDs cannot be discontinued 1, 2

Special Considerations

NSAID-Related Ulcers:

• Discontinue NSAIDs if possible
• If NSAIDs must be continued, maintain PPI therapy for protection 1, 4

Refractory Ulcers:

• Higher-dose PPI therapy (40 mg omeprazole daily) has shown 97% healing rates in ulcers resistant to H2-receptor antagonists 5
• Consider newer PPIs (rabeprazole, pantoprazole, lansoprazole) which may provide greater symptom relief than omeprazole 6

Recurrent Bleeding:

• Endoscopy is recommended as first-line treatment 1
• Consider transcatheter angioembolization as an alternative where available 1

Pitfalls and Caveats

1. Don't miss H. pylori testing: Failure to test and treat H. pylori leads to high recurrence rates (33% risk of rebleeding in 1-2 years and 40-50% over 10 years) 1

2. Don't stop PPI therapy too early: Complete the full 6-8 week course to ensure mucosal healing 1

3. Don't forget to confirm H. pylori eradication: Test to confirm successful eradication and retreat if necessary 1

4. Don't rely solely on PPI therapy: While PPIs heal ulcers, they don't address the underlying cause (H. pylori or NSAIDs) 4

5. Don't miss gastric cancer: All gastric ulcers require biopsy and histological examination to rule out malignancy 4