What is the initial treatment for a patient presenting with a gastric ulcer and severe epigastric pain?

Initial Treatment for Gastric Ulcer with Severe Epigastric Pain

Start proton pump inhibitor (PPI) therapy immediately with omeprazole 20-40 mg once daily, taken 30-60 minutes before breakfast, for 6-8 weeks to achieve complete mucosal healing. 1, 2

Immediate Management

Acid Suppression Therapy

• Initiate standard-dose PPI therapy as first-line treatment: omeprazole 20 mg once daily or equivalent (lansoprazole 30 mg, pantoprazole 40 mg) 3, 1, 2
• PPIs provide superior healing rates compared to H2-receptor antagonists, with gastric ulcer healing rates of 82-83% at 8 weeks versus 64% with ranitidine 4, 5, 6
• Administer PPIs 30-60 minutes before meals (preferably breakfast) for optimal acid suppression 7, 2
• Treatment duration should be 6-8 weeks for gastric ulcers, which is longer than the 4 weeks typically needed for duodenal ulcers 1, 2, 4

Pain Management Considerations

• Severe epigastric pain (ulcer-like dyspepsia) is the cardinal symptom and responds well to acid suppression therapy 8, 7
• Antacids may be used concomitantly with PPIs for additional symptom relief 2
• Most patients experience symptom improvement within days, though complete healing requires the full treatment course 3, 1

Essential Testing During Initial Visit

H. pylori Testing

• Test all gastric ulcer patients for H. pylori infection using urea breath test or stool antigen test (sensitivity 88-95%, specificity 92-100%) 3, 1
• If endoscopy is performed, obtain tissue biopsies for H. pylori testing 3
• Confirming H. pylori status is critical because failure to eradicate increases recurrence rates to 40-50% over 10 years 1

Medication History

• Document all NSAID use, including over-the-counter medications and aspirin 1, 5
• NSAID-associated ulcers require different management strategies than H. pylori-associated ulcers 3, 1

H. pylori Eradication (If Positive)

Standard Triple Therapy (First-Line)

Use this regimen in areas with low clarithromycin resistance (<15%): 3, 1

• PPI standard dose (omeprazole 20 mg) twice daily
• Clarithromycin 500 mg twice daily
• Amoxicillin 1000 mg twice daily (or metronidazole 500 mg twice daily if penicillin-allergic)
• Duration: 14 days 3, 1, 2

Alternative Regimens

• Sequential therapy for high clarithromycin resistance areas: Days 1-5 with PPI + amoxicillin, followed by days 6-10 with PPI + clarithromycin + metronidazole 3, 1
• Second-line therapy if first-line fails: 10-day levofloxacin 500 mg once daily + amoxicillin 1000 mg twice daily + PPI twice daily 3, 1

Timing of Eradication Therapy

• Continue PPI monotherapy for 72-96 hours before starting eradication therapy if bleeding is present 3, 1
• After completing eradication, continue PPI for additional 18 days if ulcer was present at therapy initiation 2
• Confirm eradication success 4-6 weeks after completing antibiotics 3, 1

NSAID-Associated Ulcers

Immediate Actions

• Discontinue NSAID therapy whenever possible 1, 5
• If NSAIDs cannot be stopped, switch to selective COX-2 inhibitors and maintain long-term PPI therapy 8, 1
• Omeprazole 20 mg once daily is the optimal dose for NSAID-associated gastric ulcers, with 83% healing at 8 weeks 5

When to Escalate Care

Red Flags Requiring Urgent Endoscopy

• Signs of active bleeding: hematemesis (coffee-ground or bright red) or melena 8, 1
• Severe, unrelenting pain suggesting perforation 3
• Age >55 years with new-onset dyspepsia 7
• Alarm symptoms: dysphagia, unintentional weight loss, anemia, recurrent vomiting 7

High-Dose PPI for Bleeding

• If bleeding is confirmed: 80 mg IV bolus followed by 8 mg/hour continuous infusion for 72 hours after endoscopic hemostasis 8, 1
• Then transition to standard oral PPI therapy 1

Common Pitfalls to Avoid

• Do not use potassium-competitive acid blockers (P-CABs) like vonoprazan as first-line therapy due to higher costs, limited availability, and less robust long-term safety data compared to PPIs 3, 1
• Do not assume symptom relief equals healing: gastric ulcers require 6-8 weeks of therapy even if pain resolves earlier 1, 2, 4
• Do not forget to biopsy gastric ulcers during endoscopy to exclude malignancy, as gastric cancer can present as ulceration 9
• Do not delay H. pylori testing: empirical eradication without confirmation is less cost-effective than test-and-treat strategies 3
• PPIs may reduce absorption of medications requiring acidic environment (e.g., ketoconazole, atazanavir) 1

Follow-Up Strategy

• Reassess symptoms at 4 weeks; if no improvement, consider endoscopy 3, 1
• Complete full 6-8 week PPI course regardless of symptom resolution 1, 2
• If H. pylori was eradicated, confirm success with non-invasive testing 3, 1
• For recurrent symptoms after initial healing, repeat 4-8 week PPI course may be considered 2