What is the recommended treatment for a patient with peptic ulcer disease, possibly caused by H. pylori infection or NSAID (Non-Steroidal Anti-Inflammatory Drug) use?

Treatment of Peptic Ulcer Disease

For peptic ulcer disease, initiate a proton pump inhibitor (PPI) immediately—omeprazole 20-40mg daily or lansoprazole 30mg daily—and test all patients for H. pylori infection, treating positive cases with triple therapy (PPI + amoxicillin 1000mg + clarithromycin 500mg, all twice daily for 14 days), while discontinuing NSAIDs permanently if they are the causative agent. 1, 2

Immediate Management Based on Etiology

H. pylori-Positive Ulcers

• Test all patients with peptic ulcer disease for H. pylori infection using urea breath test or stool antigen test, as these are more accurate than serology 3, 4
• Initiate triple therapy eradication regimen: PPI (omeprazole 20mg or lansoprazole 30mg) + amoxicillin 1000mg + clarithromycin 500mg, all twice daily for 14 days 2, 1
• Alternative regimens include bismuth quadruple therapy or concomitant therapy (non-bismuth quadruple therapy) in areas with high clarithromycin resistance 3
• H. pylori eradication reduces ulcer recurrence from 50-60% to 0-2%, making it essential for long-term outcomes 5

NSAID-Induced Ulcers

• Discontinue all NSAIDs immediately—this heals 95% of ulcers and reduces recurrence from 40% to 9% 5, 1
• If NSAIDs cannot be discontinued, switch to a less ulcerogenic agent (ibuprofen or celecoxib) and add PPI therapy 6, 3
• For patients requiring continued NSAID use, combine a COX-2 selective inhibitor (celecoxib) with a PPI for lowest recurrence risk 7, 8

Bleeding Ulcers

• Administer high-dose PPI therapy: 80mg omeprazole bolus followed by 8mg/hour continuous infusion for 72 hours after endoscopic hemostasis 1
• Start H. pylori eradication therapy when oral feeding resumes (after 72-96 hours of IV PPI), as delaying treatment reduces compliance 6
• Transition to standard oral PPI therapy (omeprazole 20mg once daily) after the 72-hour infusion 1

PPI Therapy Duration

Duodenal Ulcers

• Treat for 4 weeks initially; most patients heal within this timeframe 2, 9
• If unhealed, extend treatment for an additional 4 weeks 2
• After successful H. pylori eradication, maintenance PPI is generally unnecessary 1

Gastric Ulcers

• Treat for 4-8 weeks, as gastric ulcers require longer acid suppression than duodenal ulcers 6, 9
• Endoscopic follow-up is required to confirm complete gastric ulcer healing and rule out malignancy 6
• Continue PPI until healing is documented 6

Gastroprotection Strategies for High-Risk Patients

Patients Requiring Continued NSAIDs

• PPIs are superior to H2-receptor antagonists, reducing endoscopic NSAID-related ulcers by 90% 6
• H2-receptor antagonists only protect against duodenal ulcers, not gastric ulcers, making them inadequate 6, 1
• Misoprostol 600mg/day reduces NSAID complications by 40% but causes diarrhea and abdominal pain in 20% of patients, limiting its use 6, 10

Patients on Antiplatelet Therapy

• Test for and eradicate H. pylori before starting chronic antiplatelet therapy in patients with ulcer history 6
• H. pylori infection increases upper GI bleeding risk 4.7-fold in low-dose aspirin users 6
• PPI therapy plus H. pylori eradication is superior to eradication alone in preventing recurrent bleeding (1.6% vs 14.8% recurrence) 6
• Combining a PPI with clopidogrel reduces GI bleeding without clinically significant drug interactions 6

Confirmation of Treatment Success

• Confirm H. pylori eradication using urea breath test or stool antigen test 4-6 weeks after completing therapy 1, 3
• Do not use serology to confirm cure, as antibodies persist after eradication 4
• Endoscopic confirmation of healing is not routinely necessary for duodenal ulcers after H. pylori eradication, unless NSAIDs must be continued 1
• Gastric ulcers require endoscopic confirmation of healing to exclude malignancy 6

Critical Pitfalls to Avoid

• Never restart NSAIDs without gastroprotection in patients with prior ulcer complications—this significantly increases mortality and recurrence risk 7, 8
• Poor compliance with PPI therapy increases NSAID-induced adverse events 4-6 fold, emphasizing the need for patient education 8, 7
• Testing for H. pylori during acute bleeding may yield false negatives; repeat testing if initially negative 1
• Avoid combining NSAIDs with low-dose aspirin, antiplatelet drugs, or anticoagulants whenever possible, as this synergistically increases bleeding risk more than sixfold 6, 3
• H2-receptor antagonists at standard doses do not prevent gastric ulcers, only duodenal ulcers—double doses are required for both 1

Alarm Symptoms Requiring Urgent Evaluation

• Hematemesis, melena, significant weight loss, dysphagia, or recurrent vomiting require immediate endoscopy to rule out complications such as perforation, gastric outlet obstruction, or malignancy 1, 8, 7
• Patients over 60 years with new dyspeptic symptoms should undergo esophagogastroduodenoscopy rather than empiric treatment 3, 4