What is the initial treatment for peptic ulcer disease?

Initial Treatment for Peptic Ulcer Disease

Start proton pump inhibitor (PPI) therapy immediately at standard dose (omeprazole 20mg or equivalent once daily) for 4 weeks for duodenal ulcers or 6-8 weeks for gastric ulcers, while simultaneously testing for H. pylori infection and initiating eradication therapy if positive. 1, 2, 3

Immediate Pharmacological Management

PPI Therapy

• Initiate standard-dose PPI therapy as soon as diagnosis is confirmed 1, 2
• Omeprazole 20mg once daily (or equivalent PPI) taken 30-60 minutes before breakfast 2, 4
• Duration: 4 weeks for duodenal ulcers, 6-8 weeks for gastric ulcers 1, 2, 4
• PPIs heal 80-100% of peptic ulcers within this timeframe 3

H. pylori Testing and Eradication (Concurrent with PPI)

• Test ALL patients with peptic ulcer disease for H. pylori at the initial visit 5, 1, 2
• Use urea breath test or stool antigen test (sensitivity 88-95%, specificity 92-100%) 5
• Failure to test and eradicate H. pylori leads to recurrence rates of 40-50% over 10 years 1, 2

If H. pylori Positive: Standard Triple Therapy

• PPI standard dose twice daily + clarithromycin 500mg twice daily + amoxicillin 1000mg twice daily for 14 days 5, 1
• Alternative if penicillin-allergic: substitute metronidazole 500mg twice daily for amoxicillin 5
• This regimen is first-line therapy in areas with low clarithromycin resistance 5

NSAID Management (Critical Component)

• Discontinue all NSAIDs immediately—this alone heals 95% of ulcers and reduces recurrence from 40% to 9% 1, 3
• If NSAIDs cannot be discontinued, switch to selective COX-2 inhibitor (celecoxib) with lower gastric toxicity and maintain long-term PPI therapy 1, 2
• Suspend aspirin during acute phase unless cardiovascular risk outweighs bleeding risk 6

Why Both PPI and H. pylori Treatment Are Essential

• PPI therapy alone without H. pylori eradication is inadequate treatment 2
• H. pylori eradication decreases recurrence from 50-60% to 0-2% 3
• PPIs provide immediate symptom relief and ulcer healing, while H. pylori eradication prevents long-term recurrence 2, 3

Common Pitfalls to Avoid

• Do not delay H. pylori testing—waiting until after PPI therapy can yield false-negative results 2
• Do not use lifestyle modifications or over-the-counter antacids as primary therapy—these are insufficient for healing and preventing recurrence 2
• Do not use empirical PPI therapy alone without confirming H. pylori status 5, 2
• Be aware that PPIs may reduce absorption of medications requiring acidic environment 1

Follow-Up Strategy

• Reassess symptoms at 4 weeks for duodenal ulcers, 6-8 weeks for gastric ulcers 2
• Gastric ulcers require follow-up endoscopy at 6 weeks to confirm healing and exclude malignancy 6
• Duodenal ulcers do not require routine follow-up endoscopy if symptoms resolve 2
• Complete the full PPI course regardless of symptom resolution 2

Special Considerations for Bleeding Ulcers

• If presenting with active bleeding, use high-dose PPI: 80mg bolus followed by 8mg/hour continuous infusion for 72 hours 1, 6
• After 72 hours, transition to oral PPI 40mg twice daily for 11 days, then continue standard dose for total 6-8 weeks 6