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

Treatment of Peptic Ulcer Disease

The treatment of peptic ulcer disease requires proton pump inhibitor (PPI) therapy combined with H. pylori eradication when infection is present, immediate discontinuation of NSAIDs/aspirin when feasible, and follow-up endoscopy for gastric ulcers to exclude malignancy. 1, 2

Initial Management and Diagnosis

Testing for H. pylori

• All patients with peptic ulcers must be tested for H. pylori infection, as eradication reduces ulcer recurrence from 50-60% to 0-2% 1, 3
• Use urea breath test or stool antigen test for non-invasive diagnosis, as these have the highest accuracy 1
• Critical pitfall: Tests for H. pylori show 25-55% false-negative rates during acute bleeding episodes, so repeat testing outside the acute context if initially negative 2, 4
• Serologic tests are less accurate and cannot confirm eradication 5

Immediate Medication Review

• Stop all NSAIDs and aspirin immediately if medically feasible, as discontinuing NSAIDs heals 95% of ulcers and reduces recurrence from 40% to 9% 3, 2
• The combination of H. pylori infection and NSAID use synergistically increases bleeding risk more than sixfold 6

Pharmacologic Treatment

PPI Therapy for Uncomplicated Ulcers

• Initiate high-dose PPI therapy immediately: omeprazole 40 mg twice daily or equivalent for 14 days 1, 2
• Continue PPI for 4 weeks for duodenal ulcers, 6-8 weeks for gastric ulcers to ensure complete healing 2, 7, 3
• PPIs heal peptic ulcers in 80-100% of patients within this timeframe 3

PPI Therapy for Bleeding Ulcers (High-Risk Stigmata)

• Administer IV PPI bolus of 80 mg followed by continuous infusion at 8 mg/hour for 72 hours after successful endoscopic hemostasis 1, 2
• Transition to oral PPI 40 mg twice daily for 11 additional days (completing 14 days total of high-dose therapy) 2
• Continue oral PPI for total duration of 6-8 weeks 2

H. pylori Eradication Regimens

• First-line treatment: Bismuth quadruple therapy or concomitant therapy (non-bismuth quadruple therapy) due to increasing clarithromycin resistance 6
• Alternative: Triple therapy with PPI + amoxicillin 1000 mg + clarithromycin 500 mg, all twice daily for 14 days, only in areas with low clarithromycin resistance 1, 4, 8
• Start eradication therapy as soon as oral feeding is reintroduced after stabilization, rather than waiting for discharge, to improve compliance 4
• Confirm eradication in all patients using urea breath test or stool antigen test at least 4 weeks after completing therapy 1, 4

Management Based on Etiology

H. pylori-Positive Ulcers

• Eradication of H. pylori is mandatory and sufficient for cure in most cases 1, 7
• After confirmed eradication, maintenance PPI therapy is unnecessary for uncomplicated duodenal ulcers 4
• For gastric ulcers, continue PPI until healing is confirmed on follow-up endoscopy 7

NSAID-Associated Ulcers

• If NSAIDs must be continued: Use the least harmful agent (ibuprofen) combined with PPI therapy 1, 2
• Consider switching to COX-2 selective inhibitor (celecoxib) plus PPI, which reduces complicated ulcer risk by 50-60% 1, 9
• H. pylori eradication is beneficial before starting NSAID treatment and mandatory in patients with peptic ulcer history 1
• However, in chronic NSAID users, eradication appears less effective than maintenance PPI for preventing ulcers 1

Aspirin Users with Cardiovascular Disease

• For patients requiring aspirin for cardiovascular prophylaxis: Test for H. pylori and eradicate if present 1
• After successful eradication, the residual risk of peptic ulcer bleeding is very low even without gastroprotective treatment 1
• Restart aspirin within 1-7 days (ideally 1-3 days) once hemostasis is achieved, along with PPI therapy 1, 2
• Continue indefinite PPI therapy for aspirin users with previous ulcer bleeding 1, 2

Follow-Up and Monitoring

Endoscopic Follow-Up

• Mandatory follow-up endoscopy at 6 weeks for all gastric ulcers to confirm healing and exclude malignancy 2, 4
• This is not required for duodenal ulcers unless symptoms persist 2
• Obtain biopsies during initial endoscopy if H. pylori testing not previously performed 4

Post-Treatment PPI Management

• Discontinue PPI after documented H. pylori eradication in uncomplicated cases, as rebleeding becomes extremely rare 2
• Continue indefinite PPI only if: ongoing NSAID/aspirin use, recurrent ulcers despite eradication, or other indications like GERD 2, 7

Special Considerations and Pitfalls

Common Pitfalls to Avoid

• Do not delay H. pylori eradication therapy beyond 96 hours of IV PPI administration in bleeding ulcers 4
• Do not skip confirmation of eradication testing—assume success without verification leads to treatment failures 1, 4
• Do not use H2-receptor antagonists for acute ulcer bleeding—they are not recommended 1
• Be aware that long-term PPI use carries potential risks including fractures, C. difficile infection, and micronutrient deficiencies, though these remain relatively uncommon 6

Refractory or Complicated Ulcers

• For refractory ulcers, only maximal acid inhibition offers advantage; cure of H. pylori facilitates healing 10
• Seek surgical consultation for patients in whom endoscopic therapy has failed 1
• Consider percutaneous embolization as alternative to surgery where available 1