What is the initial approach to managing a patient presenting with Peptic Ulcer Disease (PUD)?

Approach to a Patient Presenting with Peptic Ulcer Disease

Start standard-dose PPI therapy immediately (omeprazole 20mg or equivalent once daily, 30-60 minutes before breakfast) and test for H. pylori infection at the initial visit using urea breath test or stool antigen test. 1, 2

Initial Assessment and Risk Stratification

Identify Alarm Features Requiring Urgent Endoscopy

• Active bleeding (hematemesis, melena, hemodynamic instability) 2
• Severe unrelenting pain despite initial therapy 2
• Dysphagia or unintentional weight loss (concern for malignancy) 2, 3
• Age ≥60 years with new-onset symptoms warrants endoscopy rather than empirical treatment 4

For patients without alarm features and age <60 years, proceed with the test-and-treat strategy rather than immediate endoscopy 5, 4

Determine Ulcer Etiology

• H. pylori infection (present in ~42% of PUD cases) 6
• NSAID/aspirin use (present in ~36% of PUD cases) 6
• Both H. pylori and NSAIDs together synergistically increase bleeding risk more than sixfold 4

Pharmacological Management

Acid Suppression Therapy

• Initiate standard-dose PPI as first-line: omeprazole 20mg, lansoprazole 30mg, or pantoprazole 40mg once daily 1, 2
• Duration: 6-8 weeks for gastric ulcers (longer than the 4 weeks needed for duodenal ulcers) 1, 2, 6
• Do NOT use P-CABs (vonoprazan) as first-line therapy due to higher costs, limited availability, and less robust long-term safety data compared to PPIs 5, 1

H. pylori Testing and Eradication

Test ALL patients with gastric ulcers for H. pylori using non-invasive methods 1, 2:

• Urea breath test (sensitivity 88-95%, specificity 92-100%) 2
• Stool antigen test 2, 4

If H. pylori positive, use bismuth quadruple therapy or concomitant therapy as first-line due to increasing clarithromycin resistance 4:

Standard triple therapy (for areas with <15% clarithromycin resistance) 1:

• PPI standard dose twice daily
• Clarithromycin 500mg twice daily
• Amoxicillin 1000mg twice daily
• Duration: 14 days 1

Alternative: Sequential therapy (for high clarithromycin resistance areas) 1:

• Days 1-5: PPI twice daily + amoxicillin 1000mg twice daily
• Days 6-10: PPI twice daily + clarithromycin 500mg twice daily + metronidazole 500mg twice daily

If first-line fails: Levofloxacin-based triple therapy for 10 days 1

Critical: Confirm eradication after treatment completion because failure to eradicate increases recurrence rates to 40-50% over 10 years 1, 2

NSAID-Associated Ulcers

Discontinue NSAID therapy whenever possible 5, 1:

• Discontinuing NSAIDs heals 95% of ulcers and reduces recurrence from 40% to 9% 6

If NSAIDs cannot be discontinued 1, 2:

• Switch to selective COX-2 inhibitor (celecoxib) with lower gastric toxicity 4
• Maintain long-term PPI therapy 5, 1
• Eradicate H. pylori if present (reduces ulcer likelihood by one-half in NSAID users) 4

Management of Complicated PUD

Bleeding Ulcers

For active bleeding with hemodynamic instability 1, 7:

• High-dose PPI therapy: 80mg IV bolus followed by 8mg/hour continuous infusion for 72 hours 1, 7
• Urgent endoscopy is mandatory—PPIs should not replace endoscopy 1
• Pre-endoscopy erythromycin improves visualization and reduces need for repeat endoscopy 1, 7

Perforation or Refractory Cases

• Surgical intervention reserved for life-threatening complications (perforation, refractory bleeding, gastric outlet obstruction) 8
• Graham patch repair for perforated ulcers 8

Follow-Up Strategy

• Reassess symptoms at 4 weeks 2
• Complete full 6-8 week PPI course regardless of symptom resolution 2
• Consider endoscopy if no improvement at 4 weeks 2
• For gastric ulcers specifically, follow-up endoscopy may be needed to exclude malignancy, especially in older patients 3

Common Pitfalls to Avoid

• Do not assume symptom resolution equals cure—gastric malignancy can present similarly 3
• Failure to test for H. pylori leads to 40-50% recurrence rates over 10 years 1, 2
• H. pylori-negative ulcers are more aggressive with higher recurrence and bleeding risk—consider long-term PPI therapy 9
• PPIs may reduce absorption of medications requiring acidic environment and can cause hypomagnesemia with prolonged use (>3 months) 3
• Monitor for PPI-related complications with long-term use: vitamin B12 deficiency (>3 years), bone fractures, acute interstitial nephritis, C. difficile infection 3, 4