What is the recommended management for ulcers?

Management of Peptic Ulcers

Start standard-dose PPI therapy immediately upon diagnosis (omeprazole 20mg once daily or equivalent) for 4 weeks for duodenal ulcers and 6-8 weeks for gastric ulcers, while simultaneously testing for H. pylori and discontinuing NSAIDs if possible. 1, 2

Initial Pharmacological Management

PPI Therapy

• Initiate omeprazole 20mg once daily (or equivalent PPI) taken 30-60 minutes before breakfast as soon as peptic ulcer is confirmed 1
• Duodenal ulcers require 4 weeks of treatment, while gastric ulcers require 6-8 weeks due to slower healing rates 1, 2
• PPIs heal 80-100% of peptic ulcers within the specified timeframe and are superior to H2-receptor antagonists like ranitidine 3, 4

Bleeding Ulcers Require Intensified Therapy

• For high-risk bleeding ulcers after endoscopic hemostasis, administer 80mg PPI bolus followed by 8mg/hour continuous infusion for 72 hours, then transition to standard oral PPI 2, 5
• Pre-endoscopy PPI administration is safe and may improve outcomes, but PPI therapy does not replace urgent endoscopy in actively bleeding patients 5, 2

Mandatory H. pylori Testing and Eradication

Why Both PPI and H. pylori Treatment Are Essential

• Test all patients with peptic ulcers for H. pylori at the initial visit using urea breath test or stool antigen test (sensitivity 88-95%, specificity 92-100%) 1, 5
• Failure to eradicate H. pylori leads to recurrence rates of 40-50% over 10 years, while successful eradication reduces recurrence to 0-2% 1, 3
• H. pylori eradication is preventative medicine that addresses the root cause, not just symptom relief 1

H. pylori Eradication Regimens

• If H. pylori 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, 2, 6
• For high clarithromycin resistance areas, use sequential therapy: 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 2
• If first-line therapy fails, use levofloxacin-amoxicillin triple therapy for 10 days 2
• Confirm H. pylori eradication after treatment completion 2, 5

Critical Testing Caveat

• Acute bleeding causes false-negative H. pylori test results; if initial testing during bleeding is negative, repeat testing after stabilization 5, 7

NSAID Management

• Discontinuing NSAIDs immediately heals 95% of ulcers and reduces recurrence from 40% to 9%—this is the single most effective intervention for NSAID-associated ulcers 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
• For chronic NSAID users who cannot discontinue, long-term PPI therapy is necessary for secondary prophylaxis 2

Special Considerations for Gastric Ulcers

Mandatory Biopsy to Exclude Malignancy

• All gastric ulcers require biopsy from the ulcer margin and base to exclude malignancy, as benign and malignant ulcers cannot be reliably distinguished by appearance alone 5, 7
• This is the most critical step that distinguishes gastric ulcer management from duodenal ulcer management 7

Mandatory Follow-Up Endoscopy

• All gastric ulcers require repeat endoscopy at approximately 6 weeks to confirm healing and exclude malignancy 7
• Continue PPI therapy until repeat endoscopy confirms complete healing 7

Follow-Up and Long-Term Management

• Reassess symptoms at 4 weeks; if symptoms persist despite PPI therapy and H. pylori eradication, perform repeat endoscopy to evaluate for complications or alternative diagnoses 1
• Complete the full PPI course (4 weeks for duodenal, 6-8 weeks for gastric) regardless of symptom resolution 1, 2
• Patients can be fed within 24 hours if considered low-risk after endoscopy 5
• Most patients can be discharged with single daily-dose oral PPI after the initial healing period 2

When to Continue Long-Term PPI Therapy

• Chronic NSAID users who cannot discontinue therapy 2
• Patients with recurrent ulcers despite H. pylori eradication 2
• H. pylori-negative ulcers, which are more aggressive with higher recurrence and bleeding risk 8

Management of Bleeding Ulcers

Initial Resuscitation and Risk Stratification

• Maintain hemoglobin >7 g/dL, target systolic blood pressure 90-100 mmHg, normalize lactate and base deficit, and correct coagulopathy 7
• Use Blatchford score for risk stratification to determine timing of endoscopy 7

Endoscopic and Interventional Management

• Endoscopy is first-line for diagnosis and treatment of bleeding ulcers, with dual modality endoscopic hemostasis recommended for spurting ulcers, oozing ulcers, and ulcers with non-bleeding visible vessels 7, 5
• Pre-endoscopy erythromycin improves visualization and reduces need for repeat endoscopy 2, 7
• If endoscopic hemostasis fails in hemodynamically stable patients, use transcatheter angioembolization as an alternative 5, 7
• Most patients who undergo endoscopic hemostasis for high-risk stigmata should be hospitalized for at least 72 hours, as 60-76% of rebleeding episodes occur within this timeframe 2

Surgical Intervention

• Emergency surgery is indicated for recurrent bleeding from ulcers >2cm after failed endoscopic treatment 5
• Intraoperative endoscopy should be planned to facilitate localization of the bleeding site 5

Common Pitfalls to Avoid

• Do not use lifestyle modifications or over-the-counter antacids as primary therapy—these are insufficient for healing peptic ulcers and preventing recurrence 1
• Do not delay H. pylori testing until after PPI therapy, as PPIs can cause false-negative results 1
• Do not use PPIs alone without addressing H. pylori status—this leads to high recurrence rates 1
• Failing to biopsy gastric ulcers is the most critical error, as malignancy cannot be excluded without histology 7
• Do not use H2-receptor antagonists (ranitidine) instead of PPIs—they result in inferior healing rates 7, 4
• Do not perform angiography before endoscopy, as this results in unacceptably high rates of negative investigations 7
• Be aware that PPIs may reduce absorption of medications requiring an acidic environment 1, 2