What is the recommended management for peptic ulcers?

Peptic Ulcer Management

Initiate proton pump inhibitor (PPI) therapy immediately upon diagnosis with standard dosing (omeprazole 20mg or lansoprazole 30mg once daily) for 4-8 weeks, test all patients for H. pylori infection, and eradicate if positive using standard triple therapy in areas of low clarithromycin resistance. 1, 2

Initial Pharmacological Treatment

Standard Uncomplicated Ulcers

• Start PPI therapy as soon as possible after diagnosis with typical doses of 20-40mg once daily for 6-8 weeks to allow complete mucosal healing 2
• Duodenal ulcers require 4 weeks of treatment, while gastric ulcers require 4-8 weeks due to slower healing 2, 3
• PPIs heal 80-100% of peptic ulcers within this timeframe 3

Bleeding Peptic Ulcers

• For bleeding ulcers with high-risk stigmata after endoscopic hemostasis, administer 80mg PPI bolus followed by 8mg/hour continuous infusion for 72 hours 1, 2, 4
• After 72 hours of IV therapy, transition to standard oral PPI therapy for 6-8 weeks 2
• PPI therapy should not replace urgent endoscopy in patients with active bleeding 2

H. pylori Testing and Eradication

Testing Strategy

• Test all patients with peptic ulcers for H. pylori infection using urea breath test or stool antigen test (noninvasive methods preferred) 2, 5
• Confirm eradication after treatment completion 2, 6
• H. pylori eradication reduces ulcer recurrence from 50-60% to 0-2% 3

First-Line Eradication Therapy

In areas of low clarithromycin resistance, use standard triple therapy: 1

• PPI standard dose twice daily
• Clarithromycin 500mg twice daily
• Amoxicillin 1000mg twice daily (or Metronidazole 500mg twice daily if penicillin allergic)
• Duration: 14 days 1

For bleeding peptic ulcers specifically, start eradication therapy 72-96 hours after beginning IV PPI therapy 1

Alternative First-Line Therapy

In areas of high clarithromycin resistance, use 10-day sequential therapy: 1

• Days 1-5: PPI standard dose twice daily + Amoxicillin 1000mg twice daily
• Days 6-10: PPI standard dose twice daily + Clarithromycin 500mg twice daily + Metronidazole 500mg twice daily

Second-Line Therapy

If first-line therapy fails, use 10-day levofloxacin-based triple therapy: 1

• PPI standard dose twice daily
• Levofloxacin 500mg once daily (or 250mg twice daily)
• Amoxicillin 1000mg twice daily

NSAID-Associated Ulcers

Immediate Management

• Discontinue NSAID therapy when possible 2
• If NSAIDs cannot be stopped, switch to a more selective COX-2 inhibitor like celecoxib 5
• Eradicating H. pylori in NSAID users reduces peptic ulcer likelihood by 50% 5

Long-Term Prevention

• Maintain PPI therapy long-term if NSAID use must continue 2
• Discontinuing NSAIDs heals 95% of ulcers and reduces recurrence from 40% to 9% 3
• Co-administration of a PPI with NSAIDs significantly reduces ulcer risk 5

Management of Complications

Bleeding Ulcers

• Endoscopy is first-line for diagnosis and management 2, 4
• Pre-endoscopy erythromycin improves visualization and reduces need for repeat endoscopy 2, 4
• Mechanical endoscopic therapy alone or combined with injection is more effective than injection alone 4
• If endoscopic hemostasis fails twice, consider angioembolization in hemodynamically stable patients or surgical intervention 4

Perforated Ulcers

• Surgical consultation is mandatory 1
• Continue high-dose PPI therapy perioperatively 1

Long-Term Management and Monitoring

Duration of PPI Therapy

• Use the shortest duration appropriate to the condition being treated 7, 8
• Continue PPI therapy long-term only in specific populations: chronic NSAID users who cannot discontinue, and patients with recurrent ulcers despite H. pylori eradication 2
• Avoid PPI use beyond one year when possible due to increased risk of fundic gland polyps 7, 8

Monitoring for PPI-Related Complications

For patients on prolonged PPI therapy (>3 months to 1 year), monitor for: 7, 8

• Hypomagnesemia (consider checking magnesium levels periodically, especially in patients on digoxin or diuretics)
• Vitamin B12 deficiency (after >3 years of therapy)
• Osteoporosis-related fracture risk (use lowest effective dose)
• Cutaneous or systemic lupus erythematosus (discontinue if signs develop)

Common Pitfalls and Caveats

Critical Errors to Avoid

• Failure to test for H. pylori leads to recurrence rates of 40-50% over 10 years 2
• Do not use PPIs as a substitute for urgent endoscopy in active bleeding 2
• Avoid omeprazole in patients taking clopidogrel due to significant drug interaction reducing antiplatelet efficacy 8
• Do not use potassium-competitive acid blockers (P-CABs) like vonoprazan as first-line therapy due to higher costs and limited long-term safety data 2

Special Considerations

• Patients 60 years and older with new dyspepsia symptoms require esophagogastroduodenoscopy to exclude malignancy 7, 5
• Consider additional diagnostic testing in patients with suboptimal response to PPI therapy to rule out gastric malignancy 7
• Stop PPI therapy at least 14 days before assessing serum chromogranin A levels to avoid false-positive results for neuroendocrine tumors 7, 8