What is the recommended management for peptic ulcer disease?

Management of Peptic Ulcer Disease

Initial Pharmacological Treatment

Start proton pump inhibitor (PPI) therapy immediately upon diagnosis with standard dosing of 20-40mg once daily for 6-8 weeks to achieve complete mucosal healing. 1

• For uncomplicated peptic ulcers: Omeprazole 20mg daily, lansoprazole 30mg daily, or pantoprazole 40mg daily for 4 weeks for duodenal ulcers and 6-8 weeks for gastric ulcers 1, 2
• For bleeding peptic ulcers with high-risk stigmata after endoscopic hemostasis: Administer 80mg PPI bolus followed by 8mg/hour continuous infusion for 72 hours, then transition to standard oral PPI therapy 1, 3
• PPIs heal 80-100% of peptic ulcers within 4 weeks, though gastric ulcers larger than 2cm may require 8 weeks of treatment 4

Critical caveat: PPI therapy should not delay urgent endoscopy in patients with active bleeding 1, 3

Helicobacter pylori Testing and Eradication

Test all patients with peptic ulcer disease for H. pylori infection using breath test, stool antigen test, or endoscopic biopsy, as this is present in approximately 42% of cases. 1, 2, 4

First-Line H. pylori Eradication Regimens

For areas with low clarithromycin resistance (<15%):

• Standard triple therapy for 14 days: PPI standard dose twice daily + clarithromycin 500mg twice daily + amoxicillin 1000mg twice daily (or metronidazole 500mg twice daily if penicillin allergic) 1, 2
• Begin eradication therapy 72-96 hours after starting IV PPI therapy in bleeding ulcers 2

For areas with high clarithromycin resistance:

• Sequential therapy for 10 days: Days 1-5 with PPI twice daily + amoxicillin 1000mg twice daily, then days 6-10 with PPI twice daily + clarithromycin 500mg twice daily + metronidazole 500mg twice daily 1

For treatment failure:

• Levofloxacin-based triple therapy for 10 days: PPI twice daily + levofloxacin 500mg once daily + amoxicillin 1000mg twice daily 1

Always confirm eradication after completing treatment, as failure to eradicate H. pylori leads to recurrence rates of 40-50% over 10 years, while successful eradication reduces recurrence from 50-60% to 0-2%. 1, 4

NSAID-Associated Ulcer Management

Discontinue NSAID therapy immediately when possible, as this heals 95% of ulcers and reduces recurrence from 40% to 9%. 4

When NSAID discontinuation is not feasible:

• Switch to a more selective COX-2 inhibitor (e.g., from ketorolac to ibuprofen) 2, 4
• Continue long-term PPI therapy at standard doses 1
• Test for and eradicate H. pylori if present 4

Management of Bleeding Peptic Ulcers

Endoscopy is the first-line diagnostic and therapeutic intervention for bleeding ulcers. 1, 3

Pre-Endoscopy Optimization

• Administer erythromycin as a prokinetic agent before endoscopy to improve visualization and reduce need for repeat endoscopy 1, 3
• Stabilize blood pressure and restore intravascular volume before proceeding 3

Endoscopic Therapy

• Mechanical endoscopic therapy alone or combined with injection is more effective than injection alone 3
• After successful endoscopic hemostasis, initiate high-dose PPI therapy (80mg bolus + 8mg/hour infusion for 72 hours) 1, 3

Refractory Bleeding Management Algorithm

1. First attempt: Repeat endoscopic therapy 3
2. Second failure: Consider angioembolization in hemodynamically stable patients 3
3. Persistent bleeding: Surgical intervention with open surgery 3
4. Bridge therapy: Balloon tamponade may be used temporarily (maximum 24 hours) while arranging definitive treatment 3

Long-Term Management and Prevention

Continue PPI therapy long-term only in specific high-risk populations:

• Chronic NSAID users who cannot discontinue therapy 1
• Patients with recurrent ulcers despite H. pylori eradication 1
• H. pylori-negative ulcers, which are more aggressive with higher recurrence and bleeding risk 5

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. 1, 2

Common Pitfalls to Avoid

• Never assume H. pylori testing is unnecessary: Failure to test leads to 40-50% recurrence rates over 10 years 1
• Do not delay endoscopy for PPI therapy in active bleeding: PPIs are adjunctive, not replacement therapy 1, 3
• Remember PPI drug interactions: PPIs reduce absorption of medications requiring acidic environment 1
• Recognize H. pylori-negative ulcers are more aggressive: These require more vigilant follow-up and often long-term PPI therapy 5
• Confirm eradication success: Always verify H. pylori eradication after treatment completion 1, 2