What is the initial management for someone experiencing ulcer symptoms?

Initial Management of Ulcer Symptoms

For patients experiencing ulcer symptoms, start with a proton pump inhibitor (PPI) such as omeprazole 20 mg once daily before meals, test for H. pylori infection using a non-invasive method (urea breath test or stool antigen test), and if positive, initiate eradication therapy with bismuth quadruple therapy or concomitant therapy for 10-14 days. 1, 2, 3

Immediate Assessment and Risk Stratification

Patient Age and Alarm Symptoms

• Patients younger than 60 years without alarm symptoms should receive H. pylori testing as the first step 3
• Patients 60 years and older or those with any alarm symptoms (weight loss, dysphagia, persistent vomiting, evidence of bleeding, anemia) require urgent endoscopy rather than empiric treatment 1, 3
• Alarm symptoms indicating complications or malignancy mandate prompt endoscopic evaluation before initiating treatment 4

Medication History

• Immediately discontinue NSAIDs if the patient is taking them, as this alone heals 95% of NSAID-induced ulcers and reduces recurrence from 40% to 9% 5
• Document aspirin use, as it accounts for approximately 36% of peptic ulcer disease cases 5

H. Pylori Testing Strategy

Testing Method

• Use urea breath test or stool antigen test as the preferred non-invasive methods 3
• Avoid serologic antibody testing as it cannot distinguish active from past infection 3
• Critical pitfall: Ensure the patient has not taken PPIs for at least 2 weeks or antibiotics for 4 weeks before testing, as these can cause false-negative results 3

If H. Pylori Positive

First-line eradication therapy options (choose one):

1. Bismuth quadruple therapy (preferred due to increasing clarithromycin resistance): 3

   • Bismuth + metronidazole + tetracycline + PPI for 10-14 days

2. Concomitant therapy (non-bismuth quadruple therapy): 2, 3

   • Amoxicillin 1000 mg twice daily + clarithromycin 500 mg twice daily + metronidazole + PPI for 10-14 days
   • Use only if local clarithromycin resistance is low (<15%)

3. Standard triple therapy (only if clarithromycin resistance is low): 2

   • Omeprazole 20 mg twice daily + clarithromycin 500 mg twice daily + amoxicillin 1000 mg twice daily for 10 days

After completing eradication therapy, continue omeprazole 20 mg once daily for an additional 18 days if an ulcer was present at diagnosis 6

If H. Pylori Negative

• Treat empirically with omeprazole 20 mg once daily before meals 2, 6, 3
• Continue for 4 weeks for duodenal ulcers or 4-8 weeks for gastric ulcers 6
• If symptoms persist after initial treatment course, refer for endoscopy 2

PPI Dosing and Administration

Standard Dosing

• Omeprazole 20 mg once daily taken before meals is first-line for uncomplicated ulcer symptoms 2, 6
• For active gastric ulcers, use omeprazole 40 mg once daily for 4-8 weeks 6
• Swallow capsules whole; if unable to swallow, open capsule and mix pellets with one tablespoon of applesauce, then swallow immediately without chewing 6

Duration of Therapy

• Duodenal ulcers: 4 weeks (most heal within this timeframe; some require additional 4 weeks) 6
• Gastric ulcers: 4-8 weeks initially; ulcers >2 cm may require 8 weeks 6, 5
• After successful treatment: Consider trial withdrawal of therapy if symptoms are controlled 2

NSAID Users: Special Considerations

If NSAIDs Cannot Be Discontinued

1. Switch to a less gastrotoxic NSAID (e.g., from ketorolac to ibuprofen or use celecoxib) 5, 3
2. Add PPI co-therapy (omeprazole or lansoprazole) 5, 3
3. Test and treat H. pylori if present, as eradication reduces ulcer likelihood by 50% in NSAID users 5, 3
4. The combination of H. pylori infection and NSAID use increases bleeding ulcer risk more than sixfold 3

Follow-Up and Monitoring

Symptom Response

• If symptoms improve: Complete the full PPI course, then attempt withdrawal 2
• If symptoms persist after 4 weeks: Refer for endoscopy to confirm diagnosis and rule out complications or malignancy 2, 4
• On-demand therapy with the successful agent is appropriate for recurrent symptoms 2

Confirmation of H. Pylori Eradication

• Retest 4-6 weeks after completing eradication therapy using urea breath test or stool antigen test 3
• If eradication fails, use levofloxacin-amoxicillin triple therapy for 10 days as second-line treatment 2

Common Pitfalls to Avoid

• Never perform angiography before endoscopy in bleeding cases, as this results in unacceptable rates of negative investigations 1
• Always test for H. pylori in all patients with gastric ulcers; failure to do so is a major pitfall 1
• Do not use antibody testing for H. pylori diagnosis in the acute setting 3
• Ensure medication adherence before labeling treatment as failed 2
• Do not continue NSAIDs without gastroprotection in patients with ulcer history 5, 3