What is the recommended treatment for stomach ulcers?

Treatment of Stomach Ulcers

The recommended first-line treatment for stomach ulcers is a combination of proton pump inhibitor (PPI) therapy and Helicobacter pylori eradication therapy (if H. pylori positive), with standard triple therapy consisting of a PPI, clarithromycin, and amoxicillin for 14 days, followed by continued PPI therapy for a total of 4-8 weeks to ensure complete healing. 1

Diagnostic Approach

1. Test all patients with suspected stomach ulcers for H. pylori infection using:
   • Urea breath test (sensitivity 88-95%, specificity 95-100%)
   • Stool antigen testing (sensitivity 94%, specificity 92%)
   • Endoscopic tissue biopsy (if endoscopy is performed) 1, 2

Treatment Algorithm

Step 1: H. pylori Testing and Eradication

• All patients with stomach ulcers should be tested for H. pylori infection 2, 1

• If H. pylori positive, initiate eradication therapy:

  For areas with low clarithromycin resistance:

  • Standard triple therapy for 14 days:
    • PPI standard dose twice daily
    • Clarithromycin 500 mg twice daily
    • Amoxicillin 1000 mg twice daily 2, 1

  For areas with high clarithromycin resistance:

  • Sequential therapy (10 days):
    • PPI standard dose twice daily + amoxicillin 1000 mg twice daily for first 5 days
    • PPI standard dose twice daily + clarithromycin 500 mg twice daily + metronidazole 500 mg twice daily for next 5 days 2, 1

  If first-line therapy fails:

  • Levofloxacin-based triple therapy (10 days):
    • PPI standard dose twice daily
    • Levofloxacin 500 mg once daily or 250 mg twice daily
    • Amoxicillin 1000 mg twice daily 2

Step 2: PPI Therapy

• For active gastric ulcers, continue PPI therapy for 4-8 weeks total 1, 3
• Omeprazole 20-40 mg daily is FDA-approved for short-term treatment (4-8 weeks) of active benign gastric ulcer 3
• Studies show healing rates of 74.8% at 8 weeks with omeprazole 20 mg daily and 82.7% with omeprazole 40 mg daily 3

Step 3: NSAID Management

• If patient is taking NSAIDs:
  • Discontinue NSAID use if possible 1
  • 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

Special Considerations

Bleeding Ulcers

• For bleeding ulcers:
  • Start PPI therapy immediately 2
  • Consider pre-endoscopy erythromycin to improve visualization 2
  • After successful endoscopic hemostasis, administer high-dose PPI as continuous infusion (80 mg bolus followed by 8 mg/h) for the first 72 hours 2, 1
  • Continue PPI for 6-8 weeks following endoscopic treatment 2

Monitoring and Follow-up

• Confirm H. pylori eradication after treatment 1
• H. pylori eradication reduces ulcer recurrence from 50-60% to 0-2% 1
• Long-term PPI therapy is not recommended unless ongoing NSAID use is necessary 2, 1

Efficacy of Treatment

• Omeprazole is superior to H2-receptor antagonists in healing gastric ulcers, with healing rates of up to 100% after 4-8 weeks 4
• For NSAID-associated ulcers, omeprazole 20 mg daily has shown higher healing rates (83% for gastric ulcers) compared to ranitidine (64%) and misoprostol (74%) 5
• For refractory ulcers that failed H2-receptor antagonist therapy, omeprazole 40 mg daily has demonstrated a 97% healing rate 6

By following this evidence-based approach to stomach ulcer treatment, focusing on H. pylori eradication when present and appropriate PPI therapy, most patients will achieve complete ulcer healing and significant reduction in recurrence risk.