What are the guidelines for managing peptic ulcers?

Guidelines for Management of Peptic Ulcers

The management of peptic ulcers requires a comprehensive approach focused on eradication of H. pylori infection, acid suppression therapy, and prevention of complications to reduce morbidity and mortality.

Diagnosis

• Test for H. pylori infection using:

  • Urea breath test (sensitivity 88-95%, specificity 95-100%)
  • Stool antigen test (sensitivity 94%, specificity 92%)
  • Endoscopic tissue biopsy (if endoscopy is performed) 1

• Endoscopy is indicated for:

  • Patients ≥55 years with weight loss
  • Patients >40 years with family history of gastroesophageal cancer
  • Patients with signs of bleeding or complications
  • Patients ≥55 years with treatment-resistant symptoms 1

First-Line Treatment

H. pylori Eradication Therapy

For H. pylori-positive peptic ulcers in areas with low clarithromycin resistance:

Standard Triple Therapy (14 days) 2, 1:

• PPI standard dose twice daily
• Clarithromycin 500 mg twice daily
• Amoxicillin 1000 mg twice daily

For areas with high clarithromycin resistance:

Sequential Therapy (10 days) 2:

• Days 1-5: PPI standard dose twice daily + Amoxicillin 1000 mg twice daily
• Days 6-10: PPI standard dose twice daily + Clarithromycin 500 mg twice daily + Metronidazole 500 mg twice daily

Acid Suppression Therapy

• For duodenal ulcers: PPI (e.g., omeprazole 20 mg once daily) for 4 weeks 1, 3
• For gastric ulcers: PPI (e.g., omeprazole 40 mg once daily) for 4-8 weeks 1, 3

Second-Line Treatment

If first-line therapy fails:

Levofloxacin-based Triple Therapy (10 days) 2:

• PPI standard dose twice daily
• Levofloxacin 500 mg once daily or 250 mg twice daily
• Amoxicillin 1000 mg twice daily

Bismuth Quadruple Therapy (10-14 days) 1:

• PPI standard dose twice daily
• Bismuth subcitrate
• Metronidazole 500 mg twice daily
• Tetracycline

Management of Bleeding Peptic Ulcers

1. Rapid resuscitation to stabilize hemodynamic parameters 2
2. Pre-endoscopy management:
   • Start PPI therapy immediately 2, 1
   • Consider erythromycin administration before endoscopy to improve visualization 2
3. Endoscopic intervention as first-line treatment 2, 1
4. Post-endoscopic management:
   • High-dose PPI as continuous infusion for first 72 hours 2, 1
   • Continue PPI for 6-8 weeks to allow mucosal healing 2
   • Eradicate H. pylori if positive 2, 1

Prevention of Recurrence and Complications

• H. pylori eradication reduces ulcer recurrence from 50-60% to 0-2% 1, 4
• NSAID-associated ulcers:
  • Discontinue NSAIDs if possible (heals 95% of ulcers) 4
  • If continued NSAID use is necessary:
    • For moderate risk: NSAID + PPI or selective COX-2 inhibitor alone
    • For high bleeding risk: Selective COX-2 inhibitor + PPI 1
• Follow-up testing to confirm H. pylori eradication 1

Special Considerations

1. Refractory ulcers (resistant to standard therapy):

   • Consider higher PPI doses (omeprazole 40 mg daily) 5
   • Rule out gastric malignancy, especially in older patients 6, 7
   • Evaluate compliance with therapy

2. Long-term management:

   • Long-term PPI therapy is not recommended unless ongoing NSAID use is necessary 2, 1
   • Monitor for potential PPI adverse effects including:
     • Clostridium difficile-associated diarrhea 6, 7
     • Bone fracture risk with long-term use 6, 7
     • Vitamin B12 deficiency 7
     • Hypomagnesemia 7

3. Recurrent bleeding risk:

   • 33% risk of rebleeding in 1-2 years
   • 40-50% rebleeding risk over subsequent 10 years without H. pylori eradication 2

The management of peptic ulcers has significantly improved outcomes, but prompt recognition and appropriate treatment remain essential to reduce morbidity and mortality, especially in elderly and high-risk patients 2.