What is the treatment for Hunter's ulcer?

Treatment for Hunter's Ulcer

The treatment for Hunter's ulcer requires a combination of antibiotic therapy, proton pump inhibitors, and H. pylori eradication therapy if infection is present. 1

Initial Management

• Start empiric broad-spectrum antibiotic therapy as soon as possible, ideally after collecting peritoneal fluid samples 1
• Initiate high-dose proton pump inhibitor therapy immediately (omeprazole 80 mg bolus followed by 8 mg/hour infusion for 72 hours) 2
• Perform diagnostic testing for H. pylori infection using either urea breath test (sensitivity 88-95%) or stool antigen testing (sensitivity 94%) 1

Antibiotic Regimen

For non-critically ill patients with normal renal function:

• Piperacillin/tazobactam 4.5 g every 6 hours 1

For critically ill patients with normal renal function:

• Piperacillin/tazobactam 4.5 g every 6 hours or cefepime 2 g every 8 hours plus metronidazole 500 mg every 6 hours 1
• For patients at risk of ESBL-producing Enterobacteriaceae: meropenem 1 g every 8 hours or doripenem 500 mg every 8 hours or imipenem/cilastatin 1 g every 8 hours 1

Duration of Antibiotic Therapy

• Short-course antibiotic therapy (3-5 days or until inflammatory markers normalize) is recommended 1
• Longer courses may be necessary for complicated infections or immunocompromised patients 1

H. pylori Eradication Therapy

If H. pylori testing is positive:

• Start standard triple therapy after 72-96 hours of intravenous PPI administration 1

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

  • PPI standard dose twice daily
  • Clarithromycin 500 mg twice daily
  • Amoxicillin 1000 mg twice daily (or metronidazole 500 mg twice daily)
  • Continue for 14 days 1, 3

• For areas with high clarithromycin resistance, use sequential therapy:

  • PPI plus amoxicillin for 5 days, followed by
  • PPI plus clarithromycin plus metronidazole for 5 days 1, 2

• Second-line therapy if first-line fails:

  • 10-day levofloxacin-amoxicillin triple therapy 1

Antifungal Considerations

• Antifungal therapy is generally not recommended for community-acquired fungal infections unless the patient is critically ill or severely immunocompromised 1
• If antifungal therapy is indicated in critically ill patients:
  • Fluconazole (loading dose 12 mg/kg up to 800 mg; maintenance dose 6 mg/kg/day) 1
  • Echinocandins are recommended as first-line therapy for invasive infections and candidemia in non-neutropenic critically ill patients 1

Surgical Management

• Surgical intervention is indicated for patients with significant pneumoperitoneum, extraluminal contrast extravasation, or signs of peritonitis 1
• Surgery should be performed as soon as possible, especially in patients with delayed presentation and those older than 70 years 1
• Each hour of surgical delay beyond hospital admission is associated with a 2.4% decreased probability of survival 1

Post-Treatment Monitoring

• Allow patients to drink and start a light diet 4-6 hours after endoscopy if hemodynamically stable 2
• Confirm H. pylori eradication with follow-up testing at least 4 weeks after completion of therapy and at least 2 weeks after PPI discontinuation 2
• Follow-up endoscopy at 4-6 weeks is recommended 1

Common Pitfalls to Avoid

• Delaying antibiotic administration while waiting for culture results 2
• Failure to test for H. pylori in all patients with peptic ulcer disease 2
• Inadequate acid suppression during the acute phase of treatment 2
• Prolonged antibiotic therapy beyond what is necessary (3-5 days is typically sufficient) 1