Treatment for Gastric Ulceration
Start proton pump inhibitor (PPI) therapy immediately at standard doses (omeprazole 20mg, lansoprazole 30mg, or pantoprazole 40mg once daily) for 6-8 weeks to achieve complete mucosal healing. 1
Initial Pharmacological Management
Standard Gastric Ulcer Treatment
- Initiate PPI therapy as soon as gastric ulceration is diagnosed, using standard doses: omeprazole 20mg, lansoprazole 30mg, or pantoprazole 40mg once daily for 6-8 weeks. 1, 2
- PPIs demonstrate superior healing rates compared to H2-receptor antagonists, with omeprazole 20mg achieving 83% healing at 8 weeks versus 64% with ranitidine. 3
- Lansoprazole 30mg once daily produces significantly faster healing than ranitidine 300mg, with 78% healing at 4 weeks versus 61%, and 99% versus 91% at 8 weeks. 4
Bleeding Gastric Ulcers
- For actively bleeding ulcers, administer high-dose PPI therapy: 80mg bolus followed by 8mg/hour continuous infusion for 72 hours, then transition to standard oral PPI therapy. 1
- Perform urgent endoscopy for diagnosis and hemostasis—PPIs should not replace endoscopy in active bleeding. 1
- Pre-endoscopy erythromycin improves visualization and reduces need for repeat procedures. 1
Helicobacter pylori Testing and Eradication
Universal Testing Requirement
- Test all gastric ulcer patients for H. pylori infection, as failure to eradicate leads to 40-50% recurrence rates over 10 years. 1
- Confirm eradication after completing treatment to prevent recurrence. 1
First-Line Eradication Regimens
For areas with low clarithromycin resistance:
- 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
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
Second-Line Therapy
- If first-line eradication fails, use 10-day levofloxacin-amoxicillin triple therapy: PPI twice daily + levofloxacin 500mg once daily + amoxicillin 1000mg twice daily. 1
NSAID-Associated Gastric Ulcers
Immediate Management
- Discontinue NSAID therapy whenever clinically feasible, as this is the most effective intervention. 1
- If NSAIDs must be continued, maintain PPI therapy long-term to prevent recurrence. 1, 2
Treatment Efficacy
- Omeprazole 20mg once daily heals 82-83% of NSAID-associated gastric ulcers at 8 weeks, superior to ranitidine (64%) and comparable to misoprostol (74%) but with better tolerability. 3
- Standard dose omeprazole (20mg) is optimal—higher doses (40mg) show no additional benefit. 3
Long-Term Prevention
- For patients with documented gastric ulcer history requiring chronic NSAID use, continue PPI therapy indefinitely for risk reduction. 1, 2
- PPIs are better tolerated than misoprostol, which causes more diarrhea and abdominal pain leading to treatment discontinuation. 5
Common Pitfalls and Clinical Caveats
Critical Errors to Avoid
- Never skip H. pylori testing—this single omission accounts for the majority of treatment failures and recurrences. 1
- Do not use PPIs as a substitute for urgent endoscopy in patients with signs of active bleeding (hematemesis, melena, hemodynamic instability). 1
- Avoid H2-receptor antagonists as first-line therapy—standard doses are ineffective for gastric ulcers (only work for duodenal ulcers), and even double doses show limited benefit primarily in H. pylori-positive patients. 6
Drug Interactions and Absorption
- PPIs may reduce absorption of medications requiring acidic environments (e.g., ketoconazole, iron, certain antiretrovirals). 1
- Monitor for these interactions and adjust timing or formulations as needed. 1