What is the initial treatment for a non-variceal peptic ulcer?

Initial Treatment for Non-Variceal Peptic Ulcer

For patients with bleeding peptic ulcers with high-risk stigmata who undergo successful endoscopic therapy, administer intravenous PPI as an 80 mg bolus followed by continuous infusion at 8 mg/hour for 72 hours. 1, 2

Immediate Resuscitation and Stabilization

• Initiate fluid resuscitation with crystalloids immediately in hemodynamically unstable patients to restore end-organ perfusion 2
• Transfuse red blood cells at hemoglobin <80 g/L in patients without cardiovascular disease; use a higher threshold for those with underlying cardiovascular disease 2
• Start intravenous PPI therapy immediately upon presentation, before endoscopy, to downstage endoscopic lesions and decrease the need for intervention 1, 2

Risk Stratification

• Use the Glasgow Blatchford score to identify very low-risk patients (score ≤1) who may not require hospitalization or inpatient endoscopy 1, 2
• Do not use the AIMS65 score for risk stratification as it is not recommended for identifying low-risk patients 2

Endoscopic Management

• Perform endoscopy within 24 hours of presentation after initial stabilization 1, 2
• Consider earlier endoscopy (within 12 hours) for high-risk patients with hemodynamic instability or ongoing bleeding 2
• For high-risk stigmata (active bleeding or visible vessel), use combination endoscopic therapy with thermocoagulation or sclerosant injection plus clips 1, 2

The 2019 International Consensus Group guidelines provide a strong recommendation (moderate-quality evidence) for combination therapy over monotherapy, as it reduces rebleeding rates more effectively 1. Through-the-scope clips are suggested as part of this combination approach 1.

Post-Endoscopic Pharmacologic Management

The cornerstone of post-endoscopic treatment is high-dose intravenous PPI therapy:

• Administer 80 mg omeprazole (or equivalent PPI) as a bolus immediately after successful endoscopic hemostasis 1, 2
• Follow with continuous infusion at 8 mg/hour for 72 hours 1, 2
• This regimen has been shown to reduce rebleeding rates, blood transfusion requirements, and hospital stay duration 1

After the 72-hour infusion:

• Transition to oral PPI 40 mg twice daily for 11 days (completing 14 days total of high-dose therapy) 1, 2
• Then reduce to once-daily dosing and continue for 6-8 weeks total to allow complete mucosal healing 2, 3

Do not use H2-receptor antagonists as they are not recommended for acute ulcer bleeding and do not reliably increase gastric pH to the level needed for clot stability 1

Post-Endoscopic Monitoring and Care

• Hospitalize patients with high-risk stigmata for at least 72 hours after endoscopic hemostasis 1, 2
• Monitor pulse, blood pressure, and urine output continuously 1
• Low-risk patients can be fed within 24 hours after endoscopy 1, 2
• Patients who are hemodynamically stable 4-6 hours after endoscopy can start a light diet 1

Management of Rebleeding

• If rebleeding occurs, attempt repeat endoscopic therapy as the first approach 1, 2
• Confirm rebleeding endoscopically in most patients before proceeding to surgery 1
• Obtain surgical consultation for patients in whom endoscopic therapy has failed 1, 2
• Consider percutaneous embolization as an alternative to surgery where available 1

Do not perform routine second-look endoscopy as it is not recommended 1

Addressing Underlying Causes

Helicobacter pylori:

• Test all patients with bleeding peptic ulcers for H. pylori using urea breath test or stool antigen test 1, 2, 4
• Provide eradication therapy if positive and confirm eradication after treatment 1, 2
• Negative tests obtained during acute bleeding should be repeated outside the acute setting due to high false-negative rates 1, 3
• Bismuth quadruple therapy or concomitant therapy (nonbismuth quadruple therapy) is preferred first-line treatment due to increasing clarithromycin resistance 4

NSAIDs and Aspirin:

• Discontinue all NSAIDs immediately if they are the causative factor 3, 4, 5
• For patients requiring cardiovascular prophylaxis with aspirin, restart as soon as cardiovascular risk outweighs bleeding risk (typically within 1-7 days, often earlier) 1, 2
• When aspirin is restarted, continue PPI therapy indefinitely 1, 2

Common Pitfalls to Avoid

• Do not delay endoscopy for PPI administration—start PPI immediately but proceed with endoscopy within 24 hours 1, 2
• Do not use somatostatin or octreotide routinely as they are not recommended for acute ulcer bleeding 1
• Do not rely on a single negative H. pylori test during acute bleeding—repeat testing is essential 1, 3
• Do not discharge high-risk patients before 72 hours of observation post-hemostasis 1, 2
• For gastric ulcers specifically, perform follow-up endoscopy at 6 weeks to confirm healing and exclude malignancy 3