What is the recommended treatment for duodenal ulcers?

Treatment of Duodenal Ulcers

Proton pump inhibitors (PPIs) are the first-line treatment for duodenal ulcers, with omeprazole 20 mg once daily achieving 75% healing at 4 weeks and 95-98% healing at 4-6 weeks, combined with mandatory H. pylori testing and eradication therapy if positive. 1, 2, 3

Initial Medical Management

PPI Therapy

• Start omeprazole 20 mg once daily (or equivalent: lansoprazole 30 mg daily, pantoprazole 40 mg daily) immediately upon diagnosis 1, 2
• Continue treatment for 4-6 weeks for uncomplicated duodenal ulcers 1, 2
• PPIs are superior to H2-receptor antagonists, with omeprazole showing significantly higher healing rates than ranitidine 150 mg twice daily (82% vs 63% at 4 weeks, p<0.01) 3
• After ulcer healing, maintenance PPI therapy is generally not necessary unless the patient requires continued NSAID use 1

H. pylori Testing and Eradication

All patients with duodenal ulcers must be tested for H. pylori infection 4, 1, 2

• If H. pylori positive, initiate triple therapy: PPI (omeprazole 20 mg twice daily) + amoxicillin 1000 mg twice daily + clarithromycin 500 mg twice daily for 14 days 1, 3
• This regimen achieves 77-90% eradication rates in clinical trials 3
• H. pylori eradication is the single most important intervention to prevent ulcer recurrence and rebleeding 4, 1
• After successful eradication, maintenance PPI therapy is not required 1

Important caveat: Tests for H. pylori may have increased false-negative rates during acute bleeding, so if initial testing is negative, perform confirmatory testing after the acute bleeding episode 4

NSAID-Associated Duodenal Ulcers

Immediate Management

• Discontinue all NSAIDs immediately if possible 1, 2, 5
• Start PPI therapy at standard doses 1, 2
• Test for H. pylori and treat if positive, as eradication reduces recurrence risk even in NSAID-associated ulcers 1

If NSAIDs Must Be Continued

• Continue PPI co-therapy indefinitely for gastroprotection 1, 2
• Use the least ulcerogenic NSAID available 1
• Consider switching to a COX-2 selective inhibitor plus PPI in high-risk patients 1
• Confirm ulcer healing with repeat endoscopy before continuing NSAIDs 1

Bleeding Duodenal Ulcers

Pharmacological Management

• Administer high-dose PPI: 80 mg esomeprazole bolus followed by 8 mg/hour continuous infusion for 72 hours after endoscopic hemostasis 4
• This regimen significantly reduces rebleeding (5.9% vs 10.3%, p=0.03) and need for endoscopic retreatment 4
• Consider pre-endoscopy erythromycin to improve visualization 4
• After the initial 72 hours, continue PPI for 6-8 weeks following endoscopic treatment 4

H. pylori Management in Bleeding Ulcers

• Start H. pylori eradication therapy after 72-96 hours of intravenous PPI administration 1
• Post-treatment H. pylori infection status is an independent predictor of rebleeding 4

Alternative Agents (Not Recommended as First-Line)

H2-Receptor Antagonists

• H2-receptor antagonists should not be used as first-line therapy because they are significantly less effective than PPIs 1, 2
• They only reduce duodenal ulcer risk, not gastric ulcer risk, making them inadequate for NSAID-associated ulcers 1
• Ranitidine 150 mg twice daily achieves only 63% healing at 4 weeks compared to 82% with omeprazole 20 mg daily 3

Sucralfate

• Sucralfate is a second-line agent only, with PPIs preferred as first-line treatment 5
• If used, must be combined with H. pylori eradication therapy for H. pylori-associated ulcers 5

Treatment Duration and Follow-Up

• Uncomplicated duodenal ulcers: 4-6 weeks of PPI therapy 1, 2
• After H. pylori eradication: No maintenance PPI needed 1
• NSAID-associated ulcers requiring continued NSAID use: Indefinite PPI therapy 1, 2
• Endoscopic confirmation of healing is not routinely necessary after H. pylori eradication unless NSAIDs must be continued 1

Common Pitfalls to Avoid

• Failing to test for H. pylori in all duodenal ulcer patients - this is the most critical error, as eradication prevents recurrence 4, 1, 2
• Using H2-receptor antagonists instead of PPIs for first-line treatment 1, 2
• Overlooking alarm symptoms (hematemesis, melena, recurrent vomiting, significant weight loss, dysphagia) that require prompt endoscopic evaluation 1, 2
• Poor compliance with gastroprotective agents increases risk of NSAID-induced adverse events by 4-6 times 1
• Assuming all ulcers are acid-related without testing for H. pylori 2
• Continuing NSAIDs without adequate PPI co-therapy 1, 2