Initial Treatment for Duodenal Ulcer
Start all patients with duodenal ulcer on standard-dose PPI therapy (omeprazole 20 mg once daily or lansoprazole 15-30 mg once daily) for 4 weeks, and immediately test for H. pylori infection using urea breath test or stool antigen test—if positive, initiate 14-day triple therapy with PPI twice daily, clarithromycin 500 mg twice daily, and amoxicillin 1000 mg twice daily. 1
Immediate First Steps
- Test all duodenal ulcer patients for H. pylori infection using urea breath test or stool antigen testing, which have sensitivity of 88-95% and specificity of 92-100%. 1
- Start PPI therapy immediately while awaiting H. pylori results—administer 30-60 minutes before breakfast for optimal acid suppression. 2
- Immediately discontinue all NSAIDs, as this alone heals 95% of NSAID-associated ulcers and reduces recurrence from 40% to 9%. 1
H. pylori-Positive Duodenal Ulcer Treatment
If H. pylori is confirmed positive, the treatment algorithm is:
- Administer 14-day standard triple therapy if local clarithromycin resistance is low (<15%): PPI standard dose twice daily + clarithromycin 500 mg twice daily + amoxicillin 1000 mg twice daily. 1, 3, 4
- Alternative 10-day triple therapy is equivalent to 14-day therapy for H. pylori eradication (84% vs 85% cure rates). 3
- After completing triple therapy, continue PPI monotherapy for a total of 4 weeks for uncomplicated duodenal ulcers. 1
- H. pylori eradication is essential because it reduces ulcer relapse rates from >60% per year to 2.6%, essentially abolishing recurrent bleeding. 1
H. pylori-Negative or Dual Therapy Alternative
- If the patient is allergic or intolerant to clarithromycin, use dual therapy: lansoprazole 30 mg three times daily + amoxicillin 1000 mg three times daily for 14 days (70-77% eradication rate). 3, 4
- For H. pylori-negative ulcers, continue PPI monotherapy alone for 4 weeks. 1
NSAID-Associated Ulcers
- If NSAIDs cannot be discontinued, switch to a selective COX-2 inhibitor (celecoxib) with lower gastric toxicity and maintain long-term PPI therapy. 1
- H2-receptor antagonists are inadequate for NSAID-associated ulcers as they only protect against duodenal ulcers, not gastric ulcers. 1
Bleeding Duodenal Ulcers (Complicated Cases)
- For bleeding duodenal ulcers, start with high-dose IV PPI: 80 mg bolus followed by 8 mg/hour continuous infusion for 72-96 hours. 1
- Begin triple therapy after completing the 72-96 hour IV PPI course. 1
- Extend total PPI therapy duration to 6-8 weeks (instead of 4 weeks) to ensure complete mucosal healing. 1
- Important caveat: H. pylori testing during acute bleeding has high false-negative rates—if initial testing is negative during bleeding, repeat testing outside the acute context to confirm true H. pylori status. 1, 5
Follow-Up Strategy
- Reassess symptoms at 4 weeks after completing initial therapy. 1
- Endoscopic confirmation of healing is not routinely necessary for duodenal ulcers after H. pylori eradication, unlike gastric ulcers which require mandatory follow-up endoscopy. 1, 5
- After successful H. pylori eradication, maintenance PPI therapy is generally not necessary as rebleeding becomes extremely rare. 1, 5
Why This Approach Matters
- Empirical PPI therapy alone without H. pylori testing results in inadequate treatment and high recurrence rates—the infection must be addressed to alter the natural history of the disease. 1
- Triple therapy achieves >90% H. pylori eradication rates and is significantly more effective than all possible dual therapy combinations. 3
- Standard-dose PPIs (omeprazole 20 mg, lansoprazole 15-30 mg) heal 89-92% of duodenal ulcers at 4 weeks, significantly superior to placebo (46%) and comparable to ranitidine. 3, 6