What is the treatment for a duodenal ulcer?

Treatment of Duodenal Ulcer

All patients with duodenal ulcer should receive proton pump inhibitor (PPI) therapy and be tested for H. pylori, with eradication therapy given if positive. 1

Initial Assessment and Testing

• Test all patients for H. pylori infection using CLOtest®, histology, or culture, as eradication therapy is strongly recommended to prevent recurrent bleeding and ulcer recurrence. 1
• Discontinue NSAIDs immediately if possible in patients with NSAID-associated duodenal ulcers; if NSAIDs must be continued, add PPI therapy for gastroprotection. 1
• Evaluate for alarm symptoms including hematemesis (vomiting blood), melena (black, tarry stools), recurrent vomiting suggesting gastric outlet obstruction, significant weight loss, or dysphagia, which require prompt endoscopic evaluation. 1

First-Line Medical Therapy

PPI Monotherapy (H. pylori-negative or while awaiting test results)

• Start omeprazole 20 mg daily, lansoprazole 30 mg daily, or pantoprazole 40 mg daily as first-line treatment. 2
• PPIs achieve 95-98% healing rates for duodenal ulcers after 4-6 weeks of treatment. 2
• Standard treatment duration is 4 weeks for uncomplicated duodenal ulcers. 3
• Omeprazole 20 mg once daily heals 75% of duodenal ulcers at 4 weeks and provides significantly faster complete daytime and nighttime pain relief compared to placebo. 4

H. pylori Eradication Therapy (if positive)

• Triple therapy is the recommended first-line regimen: PPI (omeprazole 20 mg or lansoprazole 30 mg) twice daily + amoxicillin 1000 mg twice daily + clarithromycin 500 mg twice daily for 14 days. 1
• For bleeding ulcers, start eradication therapy after 72-96 hours of intravenous PPI administration. 1
• Dual therapy (PPI + amoxicillin) is reserved for patients allergic or intolerant to clarithromycin, or when clarithromycin resistance is known or suspected. 3
• H. pylori eradication with triple therapy (omeprazole/clarithromycin/amoxicillin) achieves 77-90% eradication rates and significantly reduces duodenal ulcer recurrence. 4

NSAID-Associated Duodenal Ulcers

• Discontinue NSAIDs immediately if possible; if NSAIDs must be continued, use the least damaging agent and add PPI therapy. 1
• Continue PPI therapy indefinitely for gastroprotection in patients who cannot discontinue NSAIDs. 1
• Consider switching to a COX-2 selective inhibitor plus PPI in high-risk patients. 1
• H2-receptor antagonists are inadequate for NSAID-associated ulcers as they only protect against duodenal ulcers, not gastric ulcers. 1

Maintenance Therapy

• After successful H. pylori eradication, maintenance PPI therapy is generally not necessary, but may be considered for up to 12 months in select cases. 1
• For patients requiring continued NSAID use after ulcer healing, continue PPI therapy indefinitely and consider repeat endoscopy to confirm healing. 1
• Lansoprazole 15 mg daily is effective for maintenance therapy with endoscopic relapse rates of only 3.3% at 12 months. 5
• Controlled studies for maintenance therapy do not extend beyond 12 months. 3

Follow-Up Strategy

• Endoscopic confirmation of duodenal ulcer healing is not routinely necessary after H. pylori eradication, unless the patient must continue NSAID therapy. 1
• For patients who do not heal with 8 weeks of PPI therapy, an additional 8 weeks of treatment may be helpful. 3

Alternative Agents (Second-Line Only)

• H2-receptor antagonists (ranitidine, cimetidine) are less effective than PPIs and should not be used as first-line therapy. 2
• H2-receptor antagonists decrease the risk of NSAID-associated duodenal ulcers but not gastric ulcers, making them less effective overall than PPIs. 1
• Sucralfate is recommended as a second-line agent only, with PPIs preferred as first-line therapy. 6
• Misoprostol can be effective for preventing NSAID-related ulcers but has significant side effects that limit its use. 1

Surgical Indications

• Surgery is indicated for complications including bleeding refractory to endoscopic treatment, perforation, or gastric outlet obstruction. 1
• For bleeding duodenal ulcers requiring surgery, the bleeding vessel (often the gastroduodenal artery) can be oversewn via duodenotomy. 1
• Vagotomy with drainage procedures has been associated with lower mortality than local ulcer oversew alone for intractable bleeding. 1

Common Pitfalls to Avoid

• Failing to test for H. pylori in all patients with duodenal ulcer leads to missed opportunities for eradication and prevention of recurrence. 1
• Using H2-receptor antagonists for NSAID-associated ulcers is inadequate as they only protect against duodenal ulcers, not gastric ulcers. 1
• Poor compliance with gastroprotective agents can increase the risk of NSAID-induced upper GI adverse events by 4-6 times. 1
• Overlooking alarm symptoms such as hematemesis, melena, or dysphagia can lead to delayed diagnosis and treatment of complications. 1
• Long-term PPI use may be associated with increased risks of certain adverse events, requiring risk-benefit assessment for maintenance therapy. 1