What is the first-line management for peptic ulcer?

First-Line Management for Peptic Ulcer Disease

Proton pump inhibitor (PPI) therapy at standard doses (omeprazole 20-40 mg or equivalent once daily) for 4-8 weeks is the first-line pharmacological treatment for uncomplicated peptic ulcers, combined with H. pylori testing and eradication therapy if positive. 1, 2

Immediate Diagnostic and Treatment Steps

Acid Suppression Therapy

• Start PPI therapy immediately upon diagnosis with standard dosing: omeprazole 20-40 mg once daily or equivalent 1, 2
• Duodenal ulcers typically require 4 weeks of treatment, while gastric ulcers require 6-8 weeks due to slower healing rates 2, 3
• PPIs heal 80-100% of peptic ulcers within this timeframe 2
• Gastric ulcers larger than 2 cm may require the full 8 weeks of treatment 2

H. pylori Testing and Eradication

• Test all patients with peptic ulcer disease for H. pylori infection using urea breath test, stool antigen test, or endoscopic biopsy 1, 4
• H. pylori is present in approximately 42% of peptic ulcer cases and eradication is critical to prevent recurrence 2
• If H. pylori positive, initiate eradication therapy with bismuth quadruple therapy or concomitant therapy (nonbismuth quadruple therapy) as first-line due to increasing clarithromycin resistance 4
• Standard triple therapy option (in areas with low clarithromycin resistance): PPI standard dose twice daily + clarithromycin 500 mg twice daily + amoxicillin 1000 mg twice daily for 14 days 3
• Eradication reduces ulcer recurrence from 50-60% down to 0-2% 2
• Confirm eradication success after completing therapy 3

NSAID Management

• Immediately discontinue all NSAIDs and aspirin if present, as they account for approximately 36% of peptic ulcer cases 2, 5
• Discontinuing NSAIDs heals 95% of ulcers and reduces recurrence from 40% to 9% 2
• If NSAID continuation is medically necessary, switch to the least harmful agent (ibuprofen preferred over ketorolac), maintain PPI therapy long-term, and eradicate H. pylori if present 1, 2
• The combination of H. pylori infection and NSAID use synergistically increases bleeding risk more than sixfold 4

Special Considerations for Bleeding Ulcers

High-Dose PPI Protocol

• For bleeding peptic ulcers with high-risk stigmata after endoscopic hemostasis: administer 80 mg PPI bolus followed by 8 mg/hour continuous infusion for 72 hours 1, 5, 3
• This high-dose regimen should be followed by standard oral PPI therapy for 6-8 weeks 6, 1
• Endoscopy is the first-line treatment for diagnosis and management of bleeding ulcers, not PPI therapy alone 1, 5

Critical Pitfall

• PPI therapy should not replace urgent endoscopy in patients with active bleeding 6, 1
• Pre-endoscopy erythromycin (not metoclopramide) improves visualization and reduces need for repeat endoscopy, though it does not impact mortality 6, 1

Follow-Up Requirements

Gastric Ulcers

• Mandatory follow-up endoscopy at 6 weeks to confirm healing and exclude malignancy 5
• This is essential for gastric ulcers (unlike duodenal ulcers) due to risk of underlying malignancy 5

Duodenal Ulcers

• Follow-up endoscopy is not routinely required for uncomplicated duodenal ulcers if symptoms resolve 3
• Confirm H. pylori eradication success after treatment completion 3

Role of Newer Agents

Potassium-competitive acid blockers (P-CABs) like vonoprazan should NOT be used as first-line therapy due to higher costs, limited availability, and less robust long-term safety data compared to PPIs 6, 3

• P-CABs may be useful in PPI treatment failures, assuming ulcers are not secondary to non-acid causes (cancer, infections, vasculitis, ischemia) 6

Long-Term Prevention Strategy

• Continue PPI therapy long-term only in specific populations: chronic NSAID users who cannot discontinue, and patients with recurrent ulcers despite H. pylori eradication 6
• After successful H. pylori eradication and NSAID discontinuation, most patients do not require indefinite PPI therapy 6
• Patients with H. pylori-negative ulcers have more aggressive disease with higher recurrence and bleeding risk, potentially warranting long-term PPI therapy 7