What is the recommended treatment for a patient with a duodenal ulcer?

Treatment of Duodenal Ulcer

For uncomplicated duodenal ulcers, initiate omeprazole 20 mg once daily for 4 weeks, test all patients for H. pylori, and if positive, treat with triple therapy (PPI + clarithromycin 500 mg + amoxicillin 1000 mg, all twice daily for 14 days) to prevent recurrence. 1, 2

Initial Pharmacological Management

Standard Acid Suppression Therapy

• Start omeprazole 20 mg once daily for 4 weeks as first-line therapy, which heals 75% of duodenal ulcers at 4 weeks and up to 82-97% by 4-8 weeks 2
• If ulcer persists after 4 weeks, extend treatment for an additional 4 weeks 2
• Omeprazole 20 mg once daily is superior to ranitidine 150 mg twice daily (82% vs 63% healing at 4 weeks, p<0.01) and significantly faster than placebo (75% vs 27% at 4 weeks, p≤0.01) 2
• Do not use potassium-competitive acid blockers (P-CABs) like vonoprazan as first-line therapy due to higher costs, limited availability, and less robust long-term safety data compared to PPIs 3

For Bleeding Duodenal Ulcers

• Administer high-dose PPI therapy: 80 mg omeprazole bolus followed by 8 mg/hour continuous infusion for 72 hours after endoscopic hemostasis for high-risk stigmata 3, 1
• Following the 72-hour infusion, transition to standard oral PPI therapy (omeprazole 20 mg once daily) 3
• Most patients should be hospitalized for at least 72 hours, as 60-76% of rebleeding episodes occur within this timeframe 4

H. pylori Testing and Eradication

Universal Testing Requirement

• Test ALL patients with duodenal ulcers for H. pylori infection, as failure to eradicate leads to 40-50% recurrence rates over 10 years 1, 5
• Testing during acute bleeding may yield false-negatives; repeat testing if initially negative 1

Triple Therapy (First-Line)

• Omeprazole 20 mg twice daily + clarithromycin 500 mg twice daily + amoxicillin 1000 mg twice daily for 14 days 1, 2
• This regimen achieves 77-90% H. pylori eradication rates in clinical trials 2
• For penicillin-allergic patients, substitute metronidazole 500 mg twice daily for amoxicillin 1
• Confirm eradication after completing treatment to prevent recurrence 1, 5

Alternative Regimens

• For areas with high clarithromycin resistance, use sequential therapy: Days 1-5 with PPI twice daily + amoxicillin 1000 mg twice daily, then Days 6-10 with PPI twice daily + clarithromycin 500 mg twice daily + metronidazole 500 mg twice daily 4
• If first-line therapy fails, use levofloxacin-based triple therapy: PPI twice daily + levofloxacin 500 mg once daily + amoxicillin 1000 mg twice daily for 10 days 4

NSAID-Associated Duodenal Ulcers

Immediate Management

• Discontinue NSAIDs immediately if clinically feasible, as this heals 95% of ulcers and reduces recurrence from 40% to 9% 1, 4
• If NSAIDs cannot be discontinued, initiate PPI therapy (omeprazole 20 mg once daily) and continue indefinitely for gastroprotection 1, 4

Long-Term Prevention

• For patients requiring continued NSAID therapy, consider switching to a selective COX-2 inhibitor (celecoxib) with lower gastric toxicity while maintaining PPI co-therapy 4
• Continue PPI therapy long-term in all patients who must remain on NSAIDs 1, 4
• Test for and eradicate H. pylori in addition to PPI therapy to further reduce recurrence risk 1

Common Pitfalls and Clinical Caveats

Critical Errors to Avoid

• Never skip H. pylori testing—this single omission accounts for the majority of treatment failures and recurrences 5
• Do not use H2-receptor antagonists (ranitidine, cimetidine) as first-line therapy; they are significantly less effective than PPIs for duodenal ulcer healing 3, 1
• Avoid all NSAIDs as they significantly increase the risk of ulcer recurrence and complications 1
• Do not use PPIs as a substitute for urgent endoscopy in patients with signs of active bleeding (hematemesis, melena, hemodynamic instability) 5

Monitoring and Follow-Up

• Endoscopic confirmation of ulcer healing is not routinely necessary after H. pylori eradication, unless the patient must continue NSAID therapy 1
• Poor compliance with gastroprotective agents increases the risk of NSAID-induced upper GI adverse events by 4-6 times 1
• PPIs may reduce absorption of medications requiring acidic environments (ketoconazole, iron, certain antiretrovirals) 5

Special Considerations

• For patients with recurrent ulcers despite H. pylori eradication, consider long-term maintenance PPI therapy for up to 12 months 1
• In patients with malabsorption concerns (less than 50 cm of jejunum remaining), omeprazole absorption may be affected and intravenous administration may be required 1