What is the initial treatment approach for a patient with suspected peptic ulcer disease (PUD) versus gastritis?

Initial Treatment Approach for Suspected Peptic Ulcer Disease versus Gastritis

The initial treatment approach for suspected peptic ulcer disease (PUD) and gastritis should begin with proton pump inhibitor (PPI) therapy combined with testing for Helicobacter pylori infection and eradication therapy if positive. 1

Distinguishing Between PUD and Gastritis

Clinical Presentation

• PUD: Typically presents with epigastric pain that may be relieved by food (duodenal ulcers) or worsened by food (gastric ulcers)
• Gastritis: Often presents with epigastric discomfort, nausea, and sometimes vomiting

Diagnostic Approach

1. Non-invasive H. pylori testing should be performed for all patients with suspected PUD or gastritis 1

   • Urea breath test (sensitivity 88-95%, specificity 95-100%)
   • Stool antigen testing (sensitivity 94%, specificity 92%)

2. Endoscopy indications 2:

   • Urgent endoscopy for patients ≥55 years with weight loss
   • Urgent endoscopy for patients >40 years with family history of gastroesophageal cancer
   • Non-urgent endoscopy for patients ≥55 years with treatment-resistant symptoms
   • Non-urgent endoscopy for patients with raised platelet count, nausea, or vomiting

Initial Treatment Algorithm

Step 1: Start Empiric Acid Suppression

• PPI therapy is the first-line treatment for both conditions 2, 1
  • Omeprazole 20 mg once daily for duodenal ulcers (4 weeks) 3
  • Omeprazole 40 mg once daily for gastric ulcers (4-8 weeks) 3

Step 2: Test for H. pylori

• All patients with suspected PUD or gastritis should be tested for H. pylori infection 1
• If H. pylori testing is positive, proceed with eradication therapy

Step 3: H. pylori Eradication (if positive)

• Standard Triple Therapy (in areas with low clarithromycin resistance) 1:

  • PPI standard dose twice daily
  • Clarithromycin 500 mg twice daily
  • Amoxicillin 1000 mg twice daily
  • Duration: 14 days

• Alternative: Bismuth-containing quadruple therapy (recommended as first-line empiric therapy due to increasing clarithromycin resistance) 4:

  • PPI standard dose twice daily
  • Bismuth subsalicylate
  • Metronidazole
  • Tetracycline
  • Duration: 10-14 days

Step 4: Continue PPI Therapy

• Continue PPI therapy for the recommended duration even after H. pylori eradication 1
  • 4 weeks for duodenal ulcers
  • 4-8 weeks for gastric ulcers

Special Considerations

NSAID-Associated PUD or Gastritis

• Discontinue NSAIDs if possible 1
• If continued NSAID use is necessary:
  • For moderate risk: Use NSAID + PPI or selective COX-2 inhibitor alone 4
  • For high bleeding risk: Use selective COX-2 inhibitor + PPI 4

Bleeding Complications

• High-dose PPI therapy should be started prior to endoscopy and continued for 72 hours 1
• Emergency endoscopy is the first-line management for bleeding ulcers 1

Treatment Failures

• Consider potassium-competitive acid blockers (P-CABs) for PPI treatment failures, though not as first-line therapy due to higher costs and limited availability 2, 1
• P-CABs have shown superior efficacy in H. pylori eradication, particularly for clarithromycin-resistant infections (66-70% vs 32% eradication rates) 2

Prevention of Recurrence

• H. pylori eradication significantly reduces ulcer recurrence from 50-60% to 0-2% 5
• Risk factors for recurrence include 6, 4:
  • Steroid use
  • NSAID use
  • Persistent H. pylori infection
  • History of complicated PUD

Common Pitfalls to Avoid

1. Failing to test for H. pylori before starting treatment
2. Inadequate duration of PPI therapy (should be 4 weeks for duodenal ulcers and 4-8 weeks for gastric ulcers)
3. Not confirming H. pylori eradication in high-risk patients
4. Continuing NSAIDs without appropriate gastroprotection
5. Missing alarm symptoms that warrant urgent endoscopy

By following this structured approach, clinicians can effectively manage both PUD and gastritis, reducing the risk of complications and recurrence.