What is the treatment for peptic ulcers?

Treatment of Peptic Ulcers

Initiate proton pump inhibitor (PPI) therapy immediately upon diagnosis with standard doses (omeprazole 20mg, lansoprazole 30mg, or pantoprazole 40mg once daily) for 6-8 weeks, test all patients for H. pylori infection and eradicate if present, and discontinue NSAIDs whenever clinically feasible. 1

Initial Pharmacological Management

Standard Uncomplicated Ulcers

• Start PPI therapy as soon as gastric or duodenal ulceration is diagnosed using standard doses: omeprazole 20mg, lansoprazole 30mg, or pantoprazole 40mg once daily 1
• Continue treatment for 6-8 weeks to achieve complete mucosal healing 1, 2
• PPIs heal peptic ulcers in 80-100% of patients within 4 weeks for duodenal ulcers, though gastric ulcers larger than 2 cm may require the full 8 weeks 3

Actively Bleeding Ulcers

• Administer high-dose PPI therapy: 80mg IV bolus followed by 8mg/hour continuous infusion for exactly 72 hours after endoscopic hemostasis 1, 4
• This regimen reduces mortality (OR 0.56), rebleeding rates (OR 0.43), and need for surgery compared to no PPI or H2-receptor antagonists 4
• After 72 hours, transition to oral PPI 40mg twice daily for days 4-14, then 40mg once daily from day 15 onward 4
• Perform urgent endoscopy for diagnosis and hemostasis—PPIs are adjunctive therapy and should never replace endoscopy in active bleeding 1, 4
• Pre-endoscopy erythromycin (250mg IV) improves gastric visualization and reduces need for repeat procedures 1, 2

Helicobacter pylori Testing and Eradication

Universal Testing Requirement

• Test all gastric and duodenal ulcer patients for H. pylori infection—failure to do this accounts for the majority of treatment failures 1, 2
• H. pylori is present in approximately 42% of peptic ulcer patients, and failure to eradicate leads to 40-50% recurrence rates over 10 years 1, 3
• Confirm eradication after completing treatment to prevent recurrence 1, 2

First-Line 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 1, 2
• For penicillin-allergic patients: substitute metronidazole 500mg twice daily for amoxicillin 1
• This regimen achieves 77-90% eradication rates in clinical trials 5

For areas with high clarithromycin resistance (>15%):

• Sequential therapy for 10 days 1, 2:
  • Days 1-5: PPI twice daily + amoxicillin 1000mg twice daily
  • Days 6-10: PPI twice daily + clarithromycin 500mg twice daily + metronidazole 500mg twice daily

Second-Line Therapy

• If first-line therapy fails, use 10-day levofloxacin-amoxicillin triple therapy: PPI twice daily + levofloxacin 500mg once daily + amoxicillin 1000mg twice daily 2

NSAID-Associated Ulcers

Primary Intervention

• Discontinue NSAID therapy whenever clinically feasible—this is the most effective intervention, healing 95% of ulcers and reducing recurrence from 40% to 9% 1, 3

When NSAIDs Must Continue

• Maintain PPI therapy long-term to prevent recurrence 1, 2
• Consider changing to a less ulcerogenic NSAID (e.g., from ketorolac to ibuprofen) 3
• Test for and eradicate H. pylori if present, as dual pathology increases ulcer risk 3
• PPIs heal significantly more NSAID-associated ulcers in 8 weeks than H2-receptor antagonists 6

Critical Pitfalls to Avoid

• Never skip H. pylori testing—this single omission causes most treatment failures and recurrences 1, 2
• Do not use PPIs as a substitute for urgent endoscopy in patients with hematemesis, melena, or hemodynamic instability 1, 4
• Avoid H2-receptor antagonists as first-line therapy—they are ineffective for gastric ulcers at standard doses and show limited benefit even at double doses 1
• Do not discontinue PPI therapy before 6-8 weeks, as this does not allow adequate time for mucosal healing 4
• Be aware that PPIs reduce absorption of medications requiring acidic environments (ketoconazole, iron, certain antiretrovirals) 1

Long-Term Management

• Continue PPI therapy long-term only in specific populations: chronic NSAID users who cannot discontinue, and patients with recurrent ulcers despite H. pylori eradication 2
• Eradication of H. pylori decreases recurrence rates from 50-60% to 0-2% 3
• For H. pylori-negative ulcers (39% of non-NSAID ulcers in the US), consider long-term PPI therapy as these ulcers are more aggressive with higher recurrence and bleeding risk 6