What is the recommended treatment for stomach ulcers?

Recommended Treatment for Stomach Ulcers

The recommended treatment for stomach ulcers includes proton pump inhibitors (PPIs) for 6-8 weeks, Helicobacter pylori eradication therapy when present, and discontinuation of NSAIDs if applicable. 1, 2

First-line Pharmacological Treatment

• Start PPI therapy as soon as possible after diagnosis (e.g., omeprazole 20-40mg once daily) 1, 3
• For bleeding ulcers, high-dose PPI therapy is recommended (80mg bolus followed by 8mg/hour continuous infusion for 72 hours) 1, 2
• Continue PPI therapy for 6-8 weeks to allow complete mucosal healing 1
• Long-term PPI therapy is not recommended unless the patient has ongoing NSAID use 1

Helicobacter pylori Eradication

• Test all patients with gastric ulcers for H. pylori infection 1
• For H. pylori positive patients, provide eradication therapy 3:
  • Triple therapy: PPI + clarithromycin + amoxicillin 3
  • Dual therapy: PPI + clarithromycin (if triple therapy contraindicated) 3
• Confirm eradication after treatment completion 1
• Retreatment with alternative antibiotics is necessary if initial eradication fails 3

NSAID-Associated Ulcers

• Discontinue NSAID therapy when possible 2
• If NSAID therapy must continue:
  • Maintain PPI therapy long-term 2, 4
  • Misoprostol (200μg four times daily) is an alternative but causes more side effects like diarrhea and abdominal pain 2, 5
• Omeprazole has been shown to be better tolerated than misoprostol for NSAID-induced ulcers 4

Management of Complications

Bleeding Ulcers

• Endoscopy is the first-line treatment for diagnosis and management 1
• Pre-endoscopy erythromycin improves visualization and reduces need for repeat endoscopy 1
• For recurrent bleeding, repeat endoscopy is recommended as first-line treatment 1
• Transcatheter angioembolization is an alternative for hemodynamically stable patients when endoscopy fails 1

Treatment Duration and Monitoring

• Standard treatment duration is 6-8 weeks for uncomplicated gastric ulcers 1
• Endoscopic follow-up is important to confirm healing and exclude malignancy 6
• Patients with ulcers >20mm may require longer treatment periods 7
• Most patients show symptom improvement within days of starting PPI therapy, but complete healing takes weeks 7, 8

Common Pitfalls and Caveats

• Failure to test for H. pylori can lead to recurrence rates of 40-50% over 10 years 1
• PPIs may reduce absorption of medications requiring acidic environment 2
• All gastric ulcers require biopsy to exclude malignancy 9
• Any ulcer failing to heal within 12-15 weeks should be carefully re-examined to exclude malignancy 6
• Proton pump inhibitors should not replace urgent endoscopy in patients with active bleeding 1