What is the first-line management for peptic ulcer?

First-Line Management of Peptic Ulcer Disease

Start proton pump inhibitor (PPI) therapy immediately at standard doses (omeprazole 20-40 mg or lansoprazole 30 mg once daily) for 4-8 weeks, test all patients for H. pylori infection, and discontinue NSAIDs/aspirin if present. 1, 2

Immediate Pharmacological Treatment

Initiate PPI therapy as soon as peptic ulcer is diagnosed:

• Standard dose: omeprazole 20-40 mg once daily or lansoprazole 30 mg once daily 1, 2
• Duration: 4 weeks for duodenal ulcers; 6-8 weeks for gastric ulcers (larger gastric ulcers >2 cm may require 8 weeks) 1, 2
• PPIs heal 80-100% of peptic ulcers within this timeframe 2

Important caveat: Potassium-competitive acid blockers (P-CABs) should NOT be used as first-line therapy due to higher costs and limited availability, though they may be useful in PPI treatment failures 3

H. pylori Testing and Eradication

Test every patient with peptic ulcer disease for H. pylori infection:

• Use noninvasive testing: urea breath test or stool antigen test (preferred methods) 4
• Can also test via biopsy during endoscopy if performed 5
• Testing is mandatory because H. pylori affects approximately 42% of peptic ulcer patients 2

If H. pylori positive, initiate eradication therapy:

• First-line: Bismuth quadruple therapy OR concomitant therapy (nonbismuth quadruple therapy) due to increasing clarithromycin resistance 4
• Alternative regimen: PPI (lansoprazole 30 mg or omeprazole 20 mg) + clarithromycin 500 mg + amoxicillin 1 g, all twice daily for 14 days 6
• Critical importance: Eradication reduces ulcer recurrence from 50-60% down to 0-2% 2
• Confirm eradication success after treatment completion 1, 5

NSAID/Aspirin Management

Immediately discontinue all NSAIDs and aspirin if present:

• Discontinuing NSAIDs heals 95% of ulcers and reduces recurrence from 40% to 9% 2
• NSAIDs affect approximately 36% of peptic ulcer patients 2
• The combination of H. pylori infection and NSAID use synergistically increases bleeding risk more than sixfold 4

If NSAIDs cannot be discontinued:

• Switch to less gastrotoxic agent (e.g., celecoxib or ibuprofen instead of ketorolac) 2, 4
• Add PPI for gastroprotection 2, 4
• Eradicate H. pylori if present (reduces ulcer likelihood by 50% in NSAID users) 4

Endoscopic Evaluation

Perform upper endoscopy in specific situations:

• Patients ≥60 years with new dyspepsia symptoms 4
• Any patient with alarm symptoms (bleeding, weight loss, dysphagia, anemia) 4
• All gastric ulcers require follow-up endoscopy at 6 weeks to confirm healing and exclude malignancy 7
• Endoscopy is the gold standard for definitive diagnosis 5, 2

For younger patients (<60 years) without alarm symptoms: Use H. pylori test-and-treat strategy without initial endoscopy 4

Special Considerations for Bleeding Ulcers

If peptic ulcer presents with bleeding:

• Administer high-dose PPI: 80 mg bolus followed by 8 mg/hour continuous infusion for 72 hours 3, 1, 7
• Urgent endoscopy is first-line management for diagnosis and hemostasis 3
• Pre-endoscopy erythromycin improves visualization and reduces need for repeat endoscopy 3
• Continue oral PPI for 6-8 weeks after endoscopic hemostasis 3, 1

Common Pitfalls to Avoid

Failure to test for H. pylori leads to recurrence rates of 40-50% over 10 years 1

Do not use PPIs as substitute for urgent endoscopy in active bleeding 3, 1

Be aware of false-negative H. pylori tests during acute bleeding—repeat testing outside the acute context if initial test negative 7

Long-term PPI use (>3 years) carries risks: vitamin B12 deficiency, hypomagnesemia, bone fractures, C. difficile infection, and potential drug interactions 8, 9, 4

Use the shortest duration and lowest effective PPI dose appropriate for the condition 8, 9