What is the initial treatment for a patient with a stomach ulcer?

Initial Treatment for Stomach Ulcer

The initial treatment for a patient with a stomach ulcer is a proton pump inhibitor (PPI) at standard dose once daily for 4-8 weeks, along with testing for H. pylori infection and appropriate eradication therapy if positive. 1

Diagnostic Approach

• Initial evaluation should include:
  • Endoscopy to confirm the presence of ulcer
  • Testing for H. pylori infection
  • Laboratory studies (complete blood count, liver and renal function tests)
  • Assessment for NSAID use as a potential cause 1, 2

Treatment Algorithm

Step 1: Start PPI Therapy

• Begin with standard dose PPI once daily for 4-8 weeks 1
  • Options include:
    • Omeprazole 20 mg daily
    • Lansoprazole 30 mg daily
    • Pantoprazole 40 mg daily
    • Rabeprazole 20 mg daily
    • Esomeprazole 20 mg daily
• Larger gastric ulcers (>2 cm) may require 8 weeks of treatment 2
• PPI therapy achieves healing rates of 80-100% within 4 weeks 1, 2

Step 2: Test for H. pylori and Treat if Positive

• If H. pylori positive, provide eradication therapy:

  • Standard triple therapy (preferred in areas with low clarithromycin resistance):

    • PPI standard dose twice daily
    • Clarithromycin 500 mg twice daily
    • Amoxicillin 1000 mg twice daily
    • Duration: 14 days 1, 3

  • Sequential therapy (for areas with high clarithromycin resistance):

    • Days 1-5: PPI + amoxicillin
    • Days 6-10: PPI + clarithromycin + metronidazole 1

• H. pylori eradication reduces ulcer recurrence from 50-60% to 0-2% 1, 2

Step 3: Address NSAID Use

• If the patient is taking NSAIDs:
  • Discontinue NSAID use if possible (95% healing rate) 2
  • If NSAID continuation is necessary:
    • Consider switching to a less ulcerogenic NSAID
    • Continue PPI therapy during NSAID use 1, 2

Special Considerations

For Bleeding Ulcers

• Higher dose PPI therapy is required:
  • Initial IV therapy: 80 mg bolus followed by 8 mg/h continuous infusion for 72 hours
  • Followed by oral therapy: 40 mg twice daily for 6-8 weeks 1
• Endoscopic therapy may be required for active bleeding 1

Follow-up Care

• Outpatient follow-up within 1-2 weeks
• Confirmatory testing for H. pylori eradication 4 weeks after completing therapy
• Consider endoscopic follow-up in 8-12 weeks to confirm healing and rule out malignancy for gastric ulcers 1

Treatment Duration

• Uncomplicated peptic ulcers: 4-8 weeks of PPI therapy
• H. pylori eradication: 14 days of PPI with appropriate antibiotics
• Post-bleeding: 6-8 weeks of PPI therapy 1

Common Pitfalls to Avoid

• Failure to test for H. pylori infection
• Inadequate duration of PPI therapy (especially for larger ulcers)
• Not confirming H. pylori eradication after treatment
• Continuing NSAIDs without gastroprotection
• Not following up gastric ulcers to rule out malignancy 1, 2

Long-term PPI maintenance therapy is generally not recommended unless ongoing NSAID use is necessary 1.