What is the recommended treatment for a patient with peptic ulcer disease, possibly caused by Helicobacter pylori (H. pylori) infection?

Treatment of Peptic Ulcer Disease

For peptic ulcer disease, initiate standard-dose PPI therapy (omeprazole 20mg daily or equivalent) immediately upon diagnosis, test all patients for H. pylori infection using urea breath test or stool antigen test, and if positive, start 14-day triple therapy with PPI twice daily, clarithromycin 500mg twice daily, and amoxicillin 1000mg twice daily, while discontinuing all NSAIDs if present. 1, 2, 3

Immediate Pharmacological Management

PPI Therapy Based on Ulcer Type

Duodenal Ulcers (Uncomplicated):

• Start omeprazole 20mg once daily (or equivalent PPI) for 4 weeks, taken 30-60 minutes before breakfast 2, 4
• After successful H. pylori eradication, prolonged PPI therapy beyond 4 weeks is NOT recommended 5
• Healing rates exceed 90% with appropriate treatment 5, 6

Gastric Ulcers:

• Require longer treatment duration of 6-8 weeks with standard-dose PPI 1, 4
• Continue PPI until complete healing is confirmed on follow-up endoscopy 5, 1
• Mandatory follow-up endoscopy at 6 weeks to exclude malignancy 1

Complicated or Bleeding Ulcers:

• Initiate high-dose IV PPI: 80mg bolus followed by 8mg/hour continuous infusion for 72 hours 1, 7
• Transition to oral PPI 40mg twice daily for 11 days, then 40mg once daily 1
• Continue for total 6-8 weeks regardless of H. pylori status 1

H. Pylori Testing and Eradication

Testing Strategy

• Test ALL patients with peptic ulcers using urea breath test or stool antigen test (sensitivity 88-95%, specificity 92-100%) 2, 8
• Critical pitfall: Tests show 25-55% false-negative rates during acute bleeding—repeat testing outside acute context if initially negative 1, 7
• Do NOT use serology for follow-up or confirmation of eradication 5

Eradication Regimen

Standard Triple Therapy (14 days): 5, 2, 3

• PPI standard dose twice daily (e.g., omeprazole 20mg BID)
• Clarithromycin 500mg twice daily
• Amoxicillin 1000mg twice daily (or metronidazole 500mg BID if penicillin-allergic)

Timing of Eradication

• Start eradication treatment immediately when oral feeding is reintroduced after bleeding ulcer stabilization 5, 7
• Do NOT delay until discharge—this reduces compliance and is less cost-effective 7
• Eradication has no effect on early rebleeding, so waiting provides no benefit 5, 7

Confirmation of Eradication

• Confirm eradication using urea breath test or monoclonal stool antigen test at least 4 weeks after completing therapy 5, 2
• Confirmation is mandatory in all complicated ulcers and gastric ulcers 5, 1
• Successful eradication reduces recurrence from 50-60% to 0-2% 6

NSAID Management

Immediate Actions

• Discontinue ALL NSAIDs and aspirin immediately upon diagnosis 1, 7
• Discontinuing NSAIDs heals 95% of ulcers and reduces recurrence from 40% to 9% 2, 6

If NSAIDs Cannot Be Discontinued

• Switch to selective COX-2 inhibitor (celecoxib) with lower gastric toxicity 2
• Use the least harmful nsNSAID (ibuprofen, etodolac, or diclofenac) 5
• Maintain continuous PPI therapy (omeprazole or lansoprazole) 5, 6
• Eradicate H. pylori if present, though eradication alone is insufficient—must combine with gastroprotection 5

High-Risk Patients Requiring NSAIDs

• Institute gastroprotection with misoprostol 600mg/day (if tolerated) or PPIs 5
• Test for and treat H. pylori, particularly in those with previous ulcer history 5
• Warning: Adding gastroprotection significantly reduces but does not eliminate risk 5

Follow-Up Strategy

Duodenal Ulcers

• Reassess symptoms at 4 weeks 2
• If symptoms persist despite treatment, consider repeat endoscopy 2
• No routine endoscopic follow-up needed if asymptomatic after H. pylori eradication 5

Gastric Ulcers

• Mandatory follow-up endoscopy at 6 weeks to confirm healing and exclude malignancy 1
• Continue PPI until complete healing documented 5, 1
• Confirm H. pylori eradication in all cases 5

Bleeding Ulcers

• Perform repeat endoscopy at 6 weeks post-discharge for gastric ulcers 7
• Confirm H. pylori eradication at least 4 weeks after completing therapy 7

Critical Pitfalls to Avoid

• Do NOT use PPI monotherapy without testing for H. pylori—this leads to recurrence rates of 40-50% over 10 years 2
• Do NOT delay H. pylori testing—waiting until after PPI therapy yields false-negative results 2
• Do NOT rely on initial negative H. pylori tests during acute bleeding—false-negative rates reach 25-55% 1, 7
• Do NOT use H2-receptor antagonists for gastroprotection in high-risk patients—they are inadequate 5
• Do NOT skip follow-up endoscopy for gastric ulcers—malignancy must be excluded 1
• Do NOT use lifestyle modifications or antacids as primary therapy—these are insufficient for healing 2