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

Treatment for Stomach Ulcer

All patients with stomach ulcers should receive proton pump inhibitor (PPI) therapy at standard doses (omeprazole 20-40mg once daily) for 6-8 weeks, be tested for H. pylori infection with immediate eradication therapy if positive, and discontinue NSAIDs completely if possible. 1

Initial Assessment and Testing

• Test all patients for H. pylori infection using noninvasive methods—urea breath test or stool antigen test are preferred over serology 2, 1
• Be aware that H. pylori tests have increased false-negative rates during acute bleeding episodes, so repeat testing outside the acute context if initial results are negative 2
• Discontinue all NSAIDs immediately when a stomach ulcer is diagnosed, as this alone heals 95% of ulcers and reduces recurrence from 40% to 9% 1

Primary Pharmacological Treatment

PPI Therapy

• Start PPI therapy immediately at standard doses (omeprazole 20-40mg once daily or lansoprazole 30mg once daily) for 6-8 weeks to allow complete mucosal healing 1, 3
• For bleeding ulcers, use high-dose PPI: 80mg bolus followed by 8mg/hour continuous infusion for 72 hours, then transition to standard oral PPI 1
• PPIs are superior to H2-receptor antagonists, which decrease duodenal ulcer risk but not gastric ulcer risk 2

H. pylori Eradication (if positive)

• First-line therapy: 14-day standard triple therapy consisting of PPI (standard dose twice daily) + clarithromycin 500mg twice daily + amoxicillin 1000mg twice daily, if local clarithromycin resistance is low (<15%) 1, 3
• Alternative for high clarithromycin resistance: Sequential therapy for 10 days (days 1-5: PPI + amoxicillin; days 6-10: PPI + clarithromycin + metronidazole) 1
• Second-line if first-line fails: 10-day levofloxacin-amoxicillin triple therapy (PPI + levofloxacin 500mg once daily + amoxicillin 1000mg twice daily) 1
• Confirm eradication after treatment completion, as this reduces ulcer recurrence from 50-60% to 0-2% 1

NSAID-Associated Ulcers: Special Considerations

• If NSAIDs cannot be discontinued: Switch to a selective COX-2 inhibitor (celecoxib) with lower gastric toxicity AND maintain long-term PPI therapy 1, 4
• Test for and eradicate H. pylori even in NSAID users, as eradication reduces peptic ulcer likelihood by 50% 1, 4
• The combination of H. pylori infection and NSAID use synergistically increases bleeding risk more than sixfold 4
• Consider misoprostol (600mg/day minimum) as an alternative gastroprotective agent, though adverse effects (abdominal pain, diarrhea in ~20% of patients) limit widespread use 2

Management of Bleeding Ulcers

• Endoscopy is first-line for diagnosis and management of bleeding ulcers 1
• Pre-endoscopy erythromycin improves visualization and reduces need for repeat endoscopy 1
• PPI infusion is not a replacement for urgent endoscopy and hemostasis 2, 1
• Most patients requiring endoscopic hemostasis should be hospitalized for at least 72 hours, as 60-76% of rebleeding episodes occur within this timeframe 1

Long-Term Management and Prevention

• After successful H. pylori eradication: Maintenance PPI therapy is generally not necessary 1
• For chronic NSAID users who cannot discontinue: Continue PPI therapy indefinitely for gastroprotection 1
• Patients can be fed within 24 hours if considered low risk for rebleeding after endoscopy 2

Common Pitfalls and Caveats

• Failure to test for H. pylori leads to recurrence rates of 40-50% over 10 years 1
• H2-receptor antagonists are inadequate for NSAID-associated ulcers as they only protect against duodenal ulcers, not gastric ulcers 2, 5
• 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 1
• Combining NSAIDs including low-dose aspirin, other antiplatelet drugs, and anticoagulants should be avoided if possible 2
• Long-term PPI use may carry risks including increased rates of pneumonia, fractures, C. difficile infection, and micronutrient deficiencies 2, 4
• PPIs may reduce absorption of medications requiring an acidic environment 1