What is the recommended management for peptic ulcers?

Management of Peptic Ulcer Disease

Start proton pump inhibitor (PPI) therapy immediately upon diagnosis at standard doses (omeprazole 20-40mg or lansoprazole 30mg once daily) for 6-8 weeks, test all patients for H. pylori infection, and discontinue NSAIDs if possible. 1

Initial Pharmacological Treatment

Standard Peptic Ulcers

• Initiate PPI therapy as soon as possible after diagnosis with standard dosing: omeprazole 20-40mg once daily or lansoprazole 30mg once daily for 6-8 weeks to achieve complete mucosal healing 1, 2
• Gastric ulcers larger than 2 cm require 8 weeks of treatment rather than the standard 4 weeks 2
• PPIs heal 80-100% of peptic ulcers within 4 weeks and are superior to H2-receptor antagonists 2, 3

Bleeding Peptic Ulcers

• For bleeding ulcers with high-risk stigmata after endoscopic hemostasis, administer an 80mg PPI bolus followed by 8mg/hour continuous infusion for 72 hours 1, 4
• After the 72-hour infusion, transition to standard oral PPI therapy for 6-8 weeks 1
• Pre-endoscopy erythromycin improves visualization and reduces the need for repeat endoscopy 1, 4

Critical caveat: PPI therapy should not replace or delay urgent endoscopy in patients with active bleeding 1

H. pylori Testing and Eradication

Testing Strategy

• Test all patients with peptic ulcers for H. pylori infection, as it affects approximately 42% of patients with peptic ulcer disease 1, 2
• Confirm eradication after treatment completion 1
• Failure to test for H. pylori leads to recurrence rates of 40-50% over 10 years, while successful eradication reduces recurrence from 50-60% to 0-2% 1, 2

First-Line Eradication Therapy

• Start standard triple therapy after 72-96 hours of intravenous PPI administration for bleeding ulcers 5, 6
• Standard triple therapy for 14 days (if low clarithromycin resistance): 5, 6
  • PPI standard dose twice daily
  • Clarithromycin 500mg twice daily
  • Amoxicillin 1000mg twice daily (or metronidazole 500mg twice daily)

Alternative First-Line Therapy (High Clarithromycin Resistance)

• Sequential therapy for 10 days if high clarithromycin resistance is detected and compliance can be maintained: 5, 6
  • 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-amoxicillin triple therapy: 5, 6
  • PPI standard dose twice daily
  • Levofloxacin 500mg once daily (or 250mg twice daily)
  • Amoxicillin 1000mg twice daily

NSAID-Associated Ulcers

• Discontinue NSAID therapy whenever possible, as this heals 95% of ulcers and reduces recurrence from 40% to 9% 1, 2
• If NSAID continuation is necessary: 1
  • Maintain long-term PPI therapy
  • Consider changing to a less ulcerogenic NSAID (e.g., from ketorolac to ibuprofen) 2
  • Eradicate H. pylori if present 2

Long-Term Management and Maintenance Therapy

• Continue PPI therapy long-term only in specific populations: 1
  • Chronic NSAID users who cannot discontinue
  • Patients with recurrent ulcers despite H. pylori eradication
  • H. pylori-negative ulcers (which are more aggressive with high recurrence rates) 7
• Use the shortest duration of PPI therapy appropriate to the condition being treated to minimize risks 1, 8

Important Safety Considerations with Long-Term PPI Use

Monitor for Complications

• Hypomagnesemia: Monitor magnesium levels in patients on prolonged treatment (>3 months) or taking digoxin/diuretics 8, 9
• Vitamin B12 deficiency: Consider monitoring after >3 years of therapy 8, 9
• Bone fracture risk: Increased with high-dose, long-term use (≥1 year); manage osteoporosis risk appropriately 8
• C. difficile-associated diarrhea: Consider this diagnosis in patients with diarrhea that does not improve 8

Drug Interactions

• Avoid omeprazole with clopidogrel due to reduced antiplatelet activity 9
• Temporarily stop PPI at least 14 days before assessing chromogranin A levels for neuroendocrine tumor workup 8, 9

Endoscopic Management

• Endoscopy is first-line for diagnosis and management of bleeding ulcers 1
• In bleeding ulcers, mechanical endoscopic therapy alone or combined with injection is more effective than injection alone 4
• Consider repeat endoscopy, angioembolization, or surgical intervention for refractory bleeding 4

Special Populations

Exclude Malignancy

• In adults with suboptimal response or early symptomatic relapse after PPI treatment, consider additional diagnostic testing 8
• In older patients, consider endoscopy to exclude gastric malignancy 8