What is the recommended treatment for a duodenal ulcer?

Treatment of Duodenal Ulcer

For uncomplicated duodenal ulcers, initiate omeprazole 20 mg once daily for 4 weeks, with mandatory H. pylori testing and eradication therapy if positive. 1, 2

Initial Pharmacological Management

Proton Pump Inhibitor Therapy

• Start omeprazole 20 mg once daily immediately upon diagnosis, as this achieves 75% healing at 4 weeks and over 90% healing by 8 weeks 2
• Most patients heal within 4 weeks; if not healed, continue for an additional 4 weeks 2
• Omeprazole 20 mg is superior to H2-receptor antagonists (ranitidine 150 mg twice daily), with significantly faster healing rates: 82% vs 63% at 4 weeks 2
• Do not use H2-receptor antagonists as first-line therapy—they are less effective and heal only about 90% of duodenal ulcers over 6-8 weeks compared to PPIs 3

For Bleeding Duodenal Ulcers

• Administer high-dose omeprazole: 80 mg IV bolus followed by 8 mg/hour continuous infusion for 72 hours after successful endoscopic hemostasis 4
• This regimen reduces rebleeding rates, blood transfusion requirements, and hospital stay duration 4
• Transition to standard oral PPI therapy (20 mg once daily) after the 72-hour infusion 4

H. pylori Testing and Eradication (Critical Step)

Mandatory Testing

• Test ALL duodenal ulcer patients for H. pylori infection—failure to test and eradicate is the single most common cause of treatment failure and recurrence 1, 5
• H. pylori eradication reduces duodenal ulcer recurrence risk from 40-50% over 10 years to less than 10% 1, 5

First-Line Eradication Regimen

In areas with low clarithromycin resistance (<20%):

• Triple therapy for 14 days: PPI (omeprazole 20 mg) twice daily + clarithromycin 500 mg twice daily + amoxicillin 1000 mg twice daily 1, 2
• This achieves H. pylori eradication rates of 77-90% 1
• For the omeprazole/clarithromycin/amoxicillin combination, eradication rates were 69-83% in intent-to-treat analysis 2

In areas with high clarithromycin resistance (>20%):

• Bismuth-based quadruple therapy for 14 days 1

Second-Line Eradication (If First-Line Fails)

• Switch to levofloxacin-amoxicillin triple therapy or bismuth-based quadruple therapy without waiting for culture results 1
• Levofloxacin-based triple therapy: PPI + levofloxacin + amoxicillin for 10-14 days 1

Confirmation of Eradication

• Test for eradication at least 4 weeks after completing therapy and at least 2 weeks after stopping PPI 1
• Use urea breath test (sensitivity 88-95%) or stool antigen test (sensitivity 94%) 1

Duration of PPI Therapy After H. pylori Eradication

• For uncomplicated duodenal ulcers: discontinue PPI after successful H. pylori eradication—prolonged therapy is unnecessary with healing rates >90% without additional acid suppression 1
• For complicated duodenal ulcers (bleeding, perforation): continue PPI until complete healing is confirmed 1

NSAID-Associated Duodenal Ulcers

• Discontinue NSAID therapy if clinically feasible—this is the most effective intervention 5
• If NSAIDs must be continued, maintain long-term PPI therapy to prevent recurrence 4, 5
• Consider switching to COX-2 inhibitors with careful CV risk assessment, or use lowest effective NSAID dose for shortest duration 4
• Add PPI cotherapy to reduce NSAID-associated ulcer risk by approximately 90% 4

Maintenance Therapy

• For H. pylori-negative patients with frequent relapses (≥3 episodes in 2 years): omeprazole 20 mg daily maintains 94% remission at 12 months vs 9% with placebo 6
• For H. pylori-positive patients: maintenance therapy is generally unnecessary after successful eradication 1

Critical Pitfalls to Avoid

• Never skip H. pylori testing—this accounts for the majority of treatment failures and recurrences 1, 5
• Do not use sucralfate as first-line therapy—PPIs are superior and recommended by modern guidelines 7
• Avoid combining multiple NSAIDs, low-dose aspirin, antiplatelet drugs, or anticoagulants when possible 4
• Do not delay H. pylori eradication therapy—start immediately when oral feeding is reintroduced, not at discharge, to improve compliance 1