What is the treatment for a patient with a stomach ulcer, possibly caused by H. pylori infection, and with a history of bleeding or high risk for complications?

Treatment of Stomach Ulcers

For stomach ulcers, initiate high-dose PPI therapy (omeprazole 20-40mg once daily or equivalent) for 6-8 weeks, test all patients for H. pylori infection, and provide 14-day triple eradication therapy (PPI twice daily + clarithromycin 500mg twice daily + amoxicillin 1000mg twice daily) if positive, while immediately discontinuing all NSAIDs. 1, 2, 3

Initial Assessment and Risk Stratification

Test for H. pylori infection in all patients using non-invasive methods—urea breath test (sensitivity 88-95%, specificity 95-100%) or stool antigen testing (sensitivity 94%, specificity 92%) are preferred over serology. 1, 2

Important caveat: In bleeding ulcers, H. pylori testing has increased false-negative rates during acute bleeding episodes, so repeat testing outside the acute context if initial results are negative. 1, 4

Immediately discontinue all NSAIDs and aspirin when stomach ulcer is diagnosed, as this alone heals 95% of ulcers and reduces recurrence from 40% to 9%. 2, 4

PPI Therapy Based on Clinical Presentation

For Uncomplicated (Non-Bleeding) Stomach Ulcers:

• Start standard-dose PPI: omeprazole 20-40mg once daily, lansoprazole 30mg once daily, or pantoprazole 40mg once daily for 6-8 weeks to allow complete mucosal healing. 2, 5
• PPIs heal >90% of gastric ulcers after 6 weeks of treatment. 6

For Bleeding Stomach Ulcers (High-Risk):

• Administer high-dose IV PPI regimen: 80mg bolus followed by 8mg/hour continuous infusion for 72 hours after successful endoscopic hemostasis. 1, 2, 4
• Transition to oral therapy: Switch to PPI 40mg twice daily for days 4-14 (completing 14 days total of high-dose therapy), then continue 40mg once daily for a total duration of 6-8 weeks. 2, 4

H. pylori Eradication Therapy

If H. pylori testing is positive, start triple therapy after completing 72-96 hours of IV PPI (in bleeding cases) or immediately (in non-bleeding cases). 1

First-Line Regimen (Low Clarithromycin Resistance <15%):

14-day standard triple therapy: 1, 2, 3

• PPI standard dose (omeprazole 20mg, lansoprazole 30mg, or pantoprazole 40mg) twice daily
• Clarithromycin 500mg twice daily
• Amoxicillin 1000mg twice daily

This regimen achieves H. pylori eradication rates of 82-92% and reduces ulcer recurrence from 50-60% to 0-2%. 1, 7

Alternative Regimen (High Clarithromycin Resistance):

10-day sequential therapy: 1

• Days 1-5: PPI twice daily + amoxicillin 1000mg twice daily
• Days 6-10: PPI twice daily + clarithromycin 500mg twice daily + metronidazole 500mg twice daily

Second-Line Therapy (If First-Line Fails):

10-day levofloxacin-based triple therapy: 1

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

NSAID-Associated Ulcer Management

If NSAIDs cannot be discontinued for valid medical reasons: 1, 2, 3

• Switch to selective COX-2 inhibitor (celecoxib) with lower gastric toxicity
• Maintain long-term PPI therapy as secondary prophylaxis
• Test for and eradicate H. pylori if present, as eradication in NSAID users reduces peptic ulcer likelihood by 50%

Avoid H2-receptor antagonists for NSAID-associated gastric ulcers, as they only protect against duodenal ulcers, not gastric ulcers. 1

Consider misoprostol 600mg/day as an alternative gastroprotective agent if PPIs are contraindicated, though adverse effects (abdominal pain, diarrhea, nausea in ~20%) limit widespread use. 1

Mandatory Follow-Up for Gastric Ulcers

Perform follow-up endoscopy at 6 weeks after hospital discharge to confirm ulcer healing and exclude malignancy—this is mandatory for gastric ulcers (unlike duodenal ulcers) due to risk of underlying malignancy. 4

Document H. pylori eradication after treatment completion using urea breath test or stool antigen testing, as eradication is crucial to prevent recurrence. 1, 2

Long-Term Management Beyond 8 Weeks

Discontinue PPI after documented H. pylori eradication in uncomplicated cases, as rebleeding becomes extremely rare. 4

Maintain indefinite PPI therapy only in specific populations: 2

• Chronic NSAID users who cannot discontinue therapy
• Patients with recurrent ulcers despite H. pylori eradication
• Aspirin users requiring cardiovascular prophylaxis (restart aspirin within 1-7 days once hemostasis achieved, along with PPI therapy) 4

Common Pitfalls to Avoid

Failure to test for H. pylori leads to recurrence rates of 40-50% over 10 years. 2 Empirical PPI therapy alone without H. pylori testing results in inadequate treatment and high recurrence rates. 8

Do not rely on initial negative H. pylori testing during acute bleeding—false-negative rates are significantly elevated in this context. 1, 4

Combining NSAIDs with low-dose aspirin, other antiplatelet drugs, or anticoagulants synergistically increases bleeding risk more than sixfold—avoid these combinations if possible. 1, 3

PPIs may reduce absorption of medications requiring acidic environment and carry risks including increased pneumonia rates, though these considerations should not prevent appropriate use. 1