What is the treatment for peptic ulcer disease?

Treatment of Peptic Ulcer Disease

The first-line treatment for peptic ulcer disease includes proton pump inhibitor (PPI) therapy for 4-8 weeks combined with H. pylori eradication therapy when indicated, which reduces ulcer recurrence from 50-60% to 0-2%. 1, 2

Diagnosis and Assessment

• Endoscopy is the definitive diagnostic method for peptic ulcer disease
• Risk factors to assess:
  • H. pylori infection (present in ~42% of peptic ulcer cases)
  • NSAID/aspirin use (present in ~36% of cases)
  • Ulcer size (>2cm requires longer treatment)
  • Location (posterior duodenal ulcers involving gastroduodenal artery have higher risk)
  • Presence of complications (bleeding, perforation, obstruction)

Treatment Algorithm

Step 1: PPI Therapy

• Standard dose PPI once daily for 4-8 weeks for uncomplicated peptic ulcers 1
  • Omeprazole 20 mg daily
  • Lansoprazole 30 mg daily
  • Pantoprazole 40 mg daily
  • Rabeprazole 20 mg daily
  • Esomeprazole 20 mg daily
• Gastric ulcers typically require 8 weeks of treatment, especially if larger than 2 cm 1, 2
• Duodenal ulcers typically heal within 4 weeks 3

Step 2: H. pylori Eradication (if positive)

• Standard triple therapy (14-day course): 1

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

• Alternative regimens for areas with high clarithromycin resistance: 1

  • Sequential therapy:
    • Days 1-5: PPI + amoxicillin
    • Days 6-10: PPI + clarithromycin + metronidazole
  • Levofloxacin-amoxicillin triple therapy (10-day course):
    • PPI standard dose twice daily
    • Levofloxacin 500 mg once daily or 250 mg twice daily
    • Amoxicillin 1000 mg twice daily

Step 3: Management of Bleeding Ulcers

• Endoscopic therapy indicated for high-risk lesions (Forrest 1a, 1b, and 2a) 1
• High-dose PPI therapy: 1
  • Initial IV: 80 mg bolus followed by 8 mg/h continuous infusion for 72 hours
  • Followed by oral: 40 mg twice daily for 6-8 weeks
• Mechanical therapy with epinephrine injection for active bleeding

Step 4: NSAID-Associated Ulcers

• Discontinue NSAIDs if possible (heals 95% of ulcers and reduces recurrence from 40% to 9%) 2
• If NSAIDs must be continued:
  • Switch to lower-risk NSAID (e.g., from ketorolac to ibuprofen)
  • Add PPI therapy
  • Eradicate H. pylori if present

Follow-up and Maintenance

• Outpatient follow-up within 1-2 weeks 1
• Confirmatory testing for H. pylori eradication 4 weeks after completing therapy
• Consider endoscopic follow-up in 8-12 weeks for gastric ulcers to confirm healing and rule out malignancy
• Long-term PPI therapy not recommended unless ongoing NSAID use is necessary 1

Special Considerations

• For patients with cardiovascular disease on aspirin: continue aspirin therapy even after endoscopic hemostasis 1
• Patients taking aspirin with history of upper GI bleeding should remain on PPI therapy 1
• H. pylori-negative ulcers (39% of non-NSAID users) are more aggressive with higher recurrence rates and increased risk of bleeding/perforation 4

Common Pitfalls to Avoid

1. Inadequate treatment duration: Gastric ulcers require longer treatment (8 weeks) than duodenal ulcers (4 weeks)
2. Failure to test for H. pylori: Testing and treating H. pylori is essential to prevent recurrence
3. Premature discontinuation of PPI: Complete the full course of therapy
4. Overlooking NSAID use: Always assess and address NSAID/aspirin use
5. Missing follow-up endoscopy: Particularly important for gastric ulcers to rule out malignancy

PPIs have revolutionized peptic ulcer treatment with healing rates of 80-100% within 4 weeks 1, 2, significantly outperforming older treatments like H2-receptor antagonists 3.