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

Treatment for Peptic Ulcer Disease

All patients with peptic ulcer disease should be tested for H. pylori infection, and if positive, receive eradication therapy with standard triple therapy (PPI + amoxicillin 1000 mg twice daily + clarithromycin 500 mg twice daily) for 14 days in areas with low clarithromycin resistance. 1

Initial Diagnostic Testing

Test all patients for H. pylori before initiating treatment, as eradication reduces recurrence rates from 50-60% to 0-2% and prevents rebleeding. 1, 2

• Urea breath test (UBT) or stool antigen testing are the most accurate non-invasive options, with sensitivity of 88-95% for UBT and 94% for stool antigen testing. 1, 3
• Endoscopic tissue biopsy can be used during upper endoscopy if performed. 1
• Serologic tests are less accurate and cannot confirm eradication. 3

Treatment Algorithm Based on H. pylori Status

H. pylori-Positive Patients

First-Line Therapy: Standard Triple Therapy (14 days) 1, 4

Use this regimen in areas with low clarithromycin resistance (<15%):

• PPI (standard dose twice daily) - e.g., omeprazole 20 mg or lansoprazole 30 mg 1, 4
• Amoxicillin 1000 mg twice daily 1, 5
• Clarithromycin 500 mg twice daily 1

Important timing: For bleeding peptic ulcers, start triple therapy after 72-96 hours of intravenous PPI administration. 1

Alternative First-Line: Sequential Therapy (10 days total) 1, 4

Use this in areas with high clarithromycin resistance if patient compliance can be ensured:

• Days 1-5: PPI (standard dose twice daily) + Amoxicillin 1000 mg twice daily 1
• Days 6-10: PPI (standard dose twice daily) + Clarithromycin 500 mg twice daily + Metronidazole 500 mg twice daily 1

Second-Line Therapy (if first-line fails) 1, 4

10-day levofloxacin-based triple therapy:

• PPI (standard dose twice daily) 1
• Levofloxacin 500 mg once daily (or 250 mg twice daily) 1
• Amoxicillin 1000 mg twice daily 1

H. pylori-Negative Patients or NSAID-Induced Ulcers

PPI monotherapy is the treatment of choice for ulcer healing and symptom relief. 4, 2

• Omeprazole 20 mg once daily or equivalent PPI heals 80-100% of ulcers within 4 weeks. 4, 2
• Gastric ulcers >2 cm require 8 weeks of PPI therapy. 2
• Lansoprazole 15 mg daily is effective for duodenal ulcers, with 89-92% healing at 4 weeks. 5

For NSAID-related ulcers: 2, 3

• Discontinuing NSAIDs heals 95% of ulcers and reduces recurrence from 40% to 9%. 2
• If NSAIDs cannot be stopped: Switch to lower-risk NSAID (e.g., ibuprofen instead of ketorolac) + add PPI + eradicate H. pylori if present. 2
• Misoprostol is the only agent proven to prevent NSAID-induced ulcers. 3

Critical Pitfalls to Avoid

Do not use empirical H. pylori eradication therapy without testing, as effectiveness varies by regional bacterial prevalence and resistance patterns. 1

Do not use standard triple therapy in areas with high clarithromycin resistance (>15%), as this significantly reduces eradication rates. 1

Do not rely on serologic testing to confirm H. pylori eradication - only UBT or stool antigen testing are accurate for this purpose. 3

Do not forget to confirm eradication 4-6 weeks after completing therapy using UBT or stool antigen testing. 5

Follow-Up Strategy

• After successful symptom control, consider trial withdrawal of PPI therapy. 4
• On-demand PPI therapy is appropriate for patients with recurrent symptoms after initial healing. 4
• Patients not responding to first-line therapy should be switched to alternative regimens rather than continuing ineffective treatment. 4
• Continue treatment for minimum 48-72 hours beyond symptom resolution. 6

Special Considerations for Bleeding Peptic Ulcers

H. pylori eradication is critical - rebleeding occurs in 26% of H. pylori-positive patients who do not receive eradication therapy. 1

Empirical antimicrobial therapy is NOT recommended for bleeding peptic ulcers without confirmed H. pylori infection. 1