What is the treatment for a duodenal ulcer?

Treatment of Duodenal Ulcer

The cornerstone of duodenal ulcer treatment is H. pylori eradication when present, combined with proton pump inhibitor (PPI) therapy, which heals over 90% of ulcers within 4 weeks and dramatically reduces recurrence risk. 1, 2

Initial Assessment and Testing

Test all patients with duodenal ulcer for H. pylori infection using CLOtest®, histology, or culture, as eradication therapy is essential for preventing recurrent bleeding and ulcer recurrence. 1, 3

Primary Medical Treatment

For H. pylori-Positive Duodenal Ulcers

Triple therapy is the first-line treatment: 1, 2, 3

• PPI (omeprazole 20 mg or lansoprazole 30 mg) twice daily
• Amoxicillin 1000 mg twice daily
• Clarithromycin 500 mg twice daily
• Duration: 10-14 days 1, 2, 3

After completing triple therapy, continue PPI monotherapy (omeprazole 20 mg or lansoprazole 20 mg once daily) for a total of 4 weeks to ensure complete ulcer healing. 2, 3

For patients allergic or intolerant to clarithromycin, or when clarithromycin resistance is suspected, use dual therapy: 2

• PPI (lansoprazole 30 mg) three times daily
• Amoxicillin 1 g three times daily
• Duration: 14 days

For H. pylori-Negative Duodenal Ulcers

Use PPI monotherapy: 2, 3, 4

• Omeprazole 20 mg once daily or lansoprazole 20 mg once daily
• Duration: 4 weeks (heals 75-82% of ulcers) 3
• If not healed at 4 weeks, continue for an additional 4 weeks 2

PPIs are superior to H2-receptor antagonists, with omeprazole showing a median therapeutic gain of 21% at 2 weeks and 15% at 4 weeks compared to ranitidine. 5, 6

NSAID-Associated Duodenal Ulcers

Discontinue NSAIDs immediately if possible. 7, 1 If NSAIDs must be continued: 7

• Use the least damaging agent (ibuprofen)
• Add PPI therapy (omeprazole 20 mg or lansoprazole 30 mg once daily)
• Consider H. pylori eradication therapy (evidence is conflicting but many centers advocate for it) 7

Maintenance Therapy

After successful H. pylori eradication, maintenance PPI therapy is generally not necessary as rebleeding becomes extremely rare. 7 However, maintenance therapy with lansoprazole 15 mg once daily may be considered for up to 12 months in select cases. 2

For patients requiring continued NSAID use after ulcer healing: 7

• Continue PPI therapy indefinitely
• Consider repeat endoscopy to confirm healing

Follow-Up Strategy

Endoscopic confirmation of duodenal ulcer healing is not routinely necessary after H. pylori eradication unless the patient must continue NSAID therapy. 7 In contrast to gastric ulcers, duodenal ulcers do not require routine follow-up endoscopy at 6 weeks. 7

Treatment of Bleeding Duodenal Ulcers

For patients who have bled from duodenal ulcers: 7

• Start intravenous PPI therapy immediately
• Begin H. pylori eradication therapy after 72-96 hours of IV PPI administration 1
• Endoscopic therapy for active bleeding or high-risk stigmata
• Surgery is reserved for refractory bleeding after failed endoscopic treatment 1

Alternative Agents (Second-Line)

H2-receptor antagonists (ranitidine 150 mg twice daily, cimetidine 800 mg daily) are less effective than PPIs but can reduce duodenal ulcer risk, particularly in H. pylori-positive patients. 7 Standard doses reduce duodenal ulcer risk but not gastric ulcer risk; double doses are required for both. 7

Sucralfate is considered a second-line agent, with PPIs preferred as first-line therapy. 8, 4

Common Pitfalls and Caveats

• Failing to test for H. pylori is the most critical error, as untreated infection leads to high recurrence rates 1
• H2-receptor antagonists are inadequate for NSAID-associated ulcers as they only protect against duodenal ulcers, not gastric ulcers 7
• Poor compliance with gastroprotective agents increases NSAID-induced adverse events by 4-6 times 1
• Do not overlook alarm symptoms (hematemesis, melena, significant weight loss, dysphagia) that require urgent endoscopic evaluation 1
• Long-term PPI use carries risks including increased infection risk (pneumonia), requiring ongoing risk-benefit assessment 1
• Avoid all NSAIDs after ulcer healing as they significantly increase recurrence and complication risk 1