What is the initial treatment for a patient diagnosed with a peptic ulcer?

Initial Treatment for Peptic Ulcer Disease

Start proton pump inhibitor (PPI) therapy immediately at diagnosis with omeprazole 20mg, lansoprazole 30mg, or pantoprazole 40mg once daily for 6-8 weeks, and test all patients for H. pylori infection to guide eradication therapy. 1, 2

Immediate Pharmacological Management

Standard PPI Therapy

• Initiate PPI therapy as soon as peptic ulcer is diagnosed with standard doses: omeprazole 20mg, lansoprazole 30mg, or pantoprazole 40mg once daily for 6-8 weeks to achieve complete mucosal healing 1, 2
• Take PPIs at the start of a meal to minimize gastrointestinal intolerance 3
• Acid blockers heal peptic ulcers in 80-100% of patients within 4 weeks, though gastric ulcers larger than 2cm may require the full 8 weeks 4

High-Dose PPI for Bleeding Ulcers

• For actively bleeding peptic ulcers, administer 80mg PPI bolus followed by 8mg/hour continuous infusion for 72 hours, then transition to standard oral PPI therapy 1, 2
• Perform urgent endoscopy for diagnosis and hemostasis—PPIs should not replace endoscopy in active bleeding 1, 2
• Pre-endoscopy erythromycin improves visualization and reduces need for repeat procedures 1, 2
• Most patients requiring endoscopic hemostasis should be hospitalized for at least 72 hours, as 60-76% of rebleeding episodes occur within this timeframe 1

Helicobacter pylori Testing and Eradication

Universal Testing

• Test all peptic ulcer patients for H. pylori infection immediately, as failure to eradicate leads to 40-50% recurrence rates over 10 years 1, 2
• H. pylori affects approximately 42% of patients with peptic ulcer disease 4
• Eradication decreases ulcer recurrence from 50-60% to 0-2% 4

First-Line Eradication Regimen (Low Clarithromycin Resistance Areas)

• 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
• This regimen combines amoxicillin 1g, clarithromycin 500mg, and lansoprazole 30mg (or omeprazole 20mg), all given twice daily for 14 days 3, 5

Alternative Regimen (High Clarithromycin Resistance Areas)

• 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, 2

Confirmation of Eradication

• Confirm H. pylori eradication after completing treatment to prevent recurrence 1, 2

NSAID-Associated Ulcers

Discontinuation Strategy

• Discontinue NSAID therapy whenever clinically feasible—this is the most effective intervention, healing 95% of ulcers and reducing recurrence from 40% to 9% 1, 2, 4
• NSAIDs account for approximately 36% of peptic ulcer disease cases 4

If NSAIDs Must Continue

• Maintain PPI therapy long-term to prevent recurrence 1, 2
• Consider switching to a selective COX-2 inhibitor (celecoxib) with lower gastric toxicity 1
• Long-term PPI therapy is necessary for secondary prophylaxis in patients requiring continuous NSAID therapy 1

Critical Pitfalls to Avoid

• Never skip H. pylori testing—this single omission accounts for the majority of treatment failures and recurrences 2
• Do not use PPIs as a substitute for urgent endoscopy in patients with signs of active bleeding (hematemesis, melena, hemodynamic instability) 1, 2
• Avoid H2-receptor antagonists as first-line therapy—standard doses are ineffective for gastric ulcers, and even double doses show limited benefit 2, 6
• Be aware that PPIs may reduce absorption of medications requiring acidic environments (ketoconazole, iron, certain antiretrovirals) 1, 2

Duration and Follow-Up

• Continue treatment for a minimum of 48-72 hours beyond when the patient becomes asymptomatic or evidence of bacterial eradication is obtained 3
• After initial healing, discharge with single daily-dose oral PPI for duration dictated by underlying etiology 1
• Long-term PPI therapy is only indicated for chronic NSAID users who cannot discontinue and patients with recurrent ulcers despite H. pylori eradication 1