Management of Duodenal Peptic Ulcer
Start PPI therapy immediately and simultaneously test for H. pylori, then treat the infection if positive—both interventions are essential and should be initiated together, not sequentially. 1
Initial Pharmacological Management
Begin standard-dose PPI therapy as soon as the diagnosis is confirmed:
- Administer omeprazole 20mg once daily (or equivalent: lansoprazole 30mg, pantoprazole 40mg, or rabeprazole 20mg) for 4 weeks for duodenal ulcers 1, 2
- PPIs should be taken 30-60 minutes before meals, preferably before breakfast, for optimal acid suppression 3
- PPIs heal >90% of duodenal ulcers within 4 weeks and are superior to H2-receptor antagonists 2, 4
Concurrent H. pylori Testing and Eradication
Test all patients with duodenal ulcers for H. pylori infection at the initial visit:
- Use urea breath test or stool antigen test (sensitivity 88-95%, specificity 92-100%) 3
- Failure to test and eradicate H. pylori leads to recurrence rates of 40-50% over 10 years 1, 3
If H. pylori is positive, initiate 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
- This regimen is appropriate for areas with low clarithromycin resistance (<15%) 1, 3
- For high clarithromycin resistance areas, use sequential therapy: days 1-5 with PPI + amoxicillin, then days 6-10 with PPI + clarithromycin + metronidazole 1
- Confirm eradication after completing treatment 1, 5
NSAID Management
If the patient is taking NSAIDs:
- Discontinue NSAID therapy immediately—this heals 95% of ulcers and reduces recurrence from 40% to 9% 1
- If NSAIDs cannot be discontinued, switch to a selective COX-2 inhibitor (celecoxib) with lower gastric toxicity and maintain long-term PPI therapy 1, 3
- Over-the-counter NSAIDs should be replaced with acetaminophen for pain management 6
Why Both PPI and H. pylori Treatment Are Essential
The evidence strongly supports addressing both acid suppression and H. pylori eradication simultaneously rather than choosing one over the other:
- PPIs provide rapid symptom relief and promote ulcer healing within 4 weeks 2, 7
- H. pylori eradication prevents long-term recurrence and is considered "preventative medicine" even in the absence of immediate symptomatic benefit 8
- Empirical PPI therapy alone without H. pylori testing results in inadequate treatment of peptic ulcer disease 8
- The test-and-treat strategy is now the recommended initial approach for uninvestigated dyspepsia and confirmed peptic ulcers 8, 6
Follow-Up Strategy
Reassess symptoms at 4 weeks:
- If symptoms persist despite PPI therapy and H. pylori eradication, consider repeat endoscopy to evaluate for complications or alternative diagnoses 3
- Complete the full 4-week PPI course regardless of symptom resolution 3
- Most patients can be discharged with single daily-dose oral PPI after the initial healing period 1
Common Pitfalls to Avoid
- Do not use lifestyle modifications or over-the-counter antacids as primary therapy—these are insufficient for healing duodenal ulcers and preventing recurrence 8, 6
- Do not delay H. pylori testing—waiting to test after PPI therapy can yield false-negative results 3
- Do not use PPIs alone without addressing H. pylori status—this leads to high recurrence rates 1, 3
- Be aware that PPIs may reduce absorption of medications requiring an acidic environment 1