What is the treatment for ulcers?

Treatment of Peptic Ulcers

The first-line treatment for peptic ulcers is proton pump inhibitor (PPI) therapy for 6-8 weeks, with H. pylori eradication therapy if infection is present, and discontinuation of NSAIDs if applicable. 1, 2

Pharmacological Management

First-Line Treatment

• Start PPI therapy (such as omeprazole 20-40mg once daily) as soon as possible after diagnosis for 6-8 weeks to allow complete mucosal healing 1
• For active duodenal ulcers, omeprazole 20mg daily heals 75% of ulcers within 4 weeks, compared to only 27% with placebo 3
• For active gastric ulcers, short-term treatment (4-8 weeks) with PPIs is indicated 3

H. pylori Eradication

• Test all patients with peptic ulcers for H. pylori infection 1
• For H. pylori-positive ulcers, eradication therapy is strongly recommended to prevent recurrent bleeding and promote healing 4
• Standard triple therapy for 14 days is recommended if low clarithromycin resistance is present:
  • PPI + clarithromycin + amoxicillin or metronidazole 4
  • Omeprazole 20mg twice daily + clarithromycin 500mg twice daily + amoxicillin 1g twice daily for 10 days shows 77-90% H. pylori eradication rates 3
• Sequential therapy for 10 days is recommended if high clarithromycin resistance is detected 4
• H. pylori eradication decreases peptic ulcer recurrence rates from approximately 50-60% to 0-2% 2

NSAID-Associated Ulcers

• Discontinue NSAID therapy when possible, as this heals 95% of ulcers and reduces recurrence from 40% to 9% 2
• Maintain PPI therapy long-term if NSAID therapy must continue 1
• Omeprazole 20mg daily is more effective than ranitidine or misoprostol for healing NSAID-associated ulcers, with 83% healing rates for gastric ulcers and 93% for duodenal ulcers at 8 weeks 5

Management of Bleeding Ulcers

Resuscitation

• Maintain hemoglobin levels >7 g/dl during resuscitation 6
• Follow resuscitation targets similar to those used in bleeding trauma patients 6

Endoscopic Management

• Endoscopy is recommended as first-line treatment for diagnosis and management of bleeding ulcers 1
• Pre-endoscopy erythromycin improves visualization and reduces the need for repeat endoscopy 1, 6
• For bleeding ulcers, high-dose PPI therapy is recommended: 80mg bolus followed by 8mg/hour continuous infusion for 72 hours 1, 6
• Dual modality endoscopic hemostasis is suggested for actively bleeding ulcers 6
• Doppler probe-guided endoscopic hemostasis can reduce 30-day rebleeding rates 6

Risk Stratification

• Stratify patients based on the Blatchford score 6:
  • Very low-risk: outpatient endoscopy 6
  • Low-risk: early inpatient endoscopy (≤24h of admission) 6
  • High-risk: urgent inpatient endoscopy (≤12h of admission) 6

Duration of Treatment

• PPIs are recommended for 6-8 weeks following endoscopic treatment of bleeding ulcers 6, 1
• Long-term PPI is not recommended unless the patient has ongoing NSAID use 6
• For H. pylori-positive ulcers, standard triple therapy should be started after 72-96 hours of intravenous PPI administration 4

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 an acidic environment 1
• Proton pump inhibitors should not replace urgent endoscopy in patients with active bleeding 1, 6
• H. pylori-negative ulcers are more aggressive, with higher recurrence rates and increased risk of bleeding and perforation, and may require long-term PPI therapy 7

Special Considerations

• For patients with refractory bleeding despite combined pharmacological and endoscopic therapy, surgical intervention may be necessary 8
• Angioembolization may be considered in hemodynamically stable patients where endoscopic hemostasis fails twice or is not possible 8