What is the appropriate diagnosis and treatment approach for a patient suspected of having Peptic Ulcer Disease (PUD), potentially complicated by a history of NSAID use?

Diagnosis and Management of Peptic Ulcer Disease (PUD)

Initial Diagnostic Approach

For patients under age 60 without alarm symptoms (weight loss, bleeding, anemia, dysphagia, recurrent vomiting, palpable mass), proceed with H. pylori testing and treatment rather than immediate endoscopy. 1

When to Perform Immediate Endoscopy

• Age ≥60 years with new-onset dyspeptic symptoms (age cutoff may be lowered to 45-50 years in regions with higher gastric cancer incidence) 1
• Any patient with alarm symptoms regardless of age 1
• All patients on chronic NSAID therapy presenting with dyspeptic symptoms due to risk of life-threatening complications like bleeding 1
• Perform endoscopy when symptoms are present and after minimum one month off antisecretory therapy 1

H. pylori Testing Strategy

Use non-invasive testing with urea breath test or stool antigen test (NOT serology) as these have sensitivity and specificity ≥90%. 1, 2

• Serologic tests are less accurate and cannot confirm eradication 2
• Tests have increased false-negative rates during acute bleeding episodes, so repeat testing outside acute context if initially negative 3
• All patients with confirmed peptic ulcer must be tested for H. pylori 3, 4

Pharmacological Treatment

Acid Suppression Therapy

Start PPI therapy immediately at standard dose (omeprazole 20mg or lansoprazole 30mg once daily) for 4-8 weeks. 3, 5

• Duodenal ulcers: 4 weeks of PPI therapy is sufficient 5
• Gastric ulcers: Require 8 weeks of PPI therapy for complete healing 3, 5
• Gastric ulcers >2cm: May require full 8 weeks of treatment 4
• After initial healing, continue PPI until H. pylori eradication is confirmed in gastric ulcers 1

H. pylori Eradication Regimens

For areas with low clarithromycin resistance (<20%), use standard triple therapy for 14 days: 1, 3

• PPI standard dose twice daily
• Clarithromycin 500mg twice daily
• Amoxicillin 1000mg twice daily (or metronidazole 500mg twice daily if penicillin allergic)

For areas with high clarithromycin resistance (>20%), use sequential therapy for 10 days: 3

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

If first-line therapy fails, use levofloxacin-based triple therapy for 10 days: 3

• PPI twice daily
• Levofloxacin 500mg once daily
• Amoxicillin 1000mg twice daily

Confirm H. pylori eradication 4-6 weeks after completing treatment using urea breath test or stool antigen test. 1, 3 Eradication reduces ulcer recurrence from 50-60% to 0-2% 3, 4

NSAID-Associated Ulcers

Immediate Management

Discontinue all NSAIDs and aspirin immediately when peptic ulcer is diagnosed. 3, 4

• Stopping NSAIDs heals 95% of ulcers and reduces recurrence from 40% to 9% 3, 4
• Test for and eradicate H. pylori if present, as eradication in NSAID users reduces peptic ulcer likelihood by 50% 3
• Start PPI therapy for 8 weeks even if NSAID is discontinued 1, 5

When NSAIDs Must Be Continued

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

1. Switch to selective COX-2 inhibitor (celecoxib) which has lower gastric toxicity 1, 3
2. Add PPI prophylaxis (omeprazole 20mg or lansoprazole 30mg daily) 1
3. Eradicate H. pylori if present 1, 3

Risk factors requiring prophylactic PPI therapy with continued NSAID use: 1

• Previous history of peptic ulcer disease
• Age >60 years (risk increases with advancing age)
• Concurrent glucocorticosteroid use
• Concurrent anticoagulant use

PPI therapy is superior to misoprostol and ranitidine for both healing and prophylaxis of NSAID-associated gastroduodenal damage. 1

Management of Complicated PUD

Bleeding Peptic Ulcers

For bleeding ulcers with high-risk stigmata after endoscopic hemostasis: 3

1. Administer 80mg PPI bolus followed by 8mg/hour continuous IV infusion for 72 hours 1, 3
2. Switch to oral PPI 40mg twice daily for days 4-14 (reduces rebleeding risk by 63% compared to once-daily dosing) 3
3. Continue PPI 40mg once daily after completing 14 days total 3
4. Start H. pylori eradication treatment immediately when oral feeding is reintroduced 1
5. Hospitalize for at least 72 hours as 60-76% of rebleeding episodes occur within this timeframe 3

Perforated Peptic Ulcers

Patients with significant pneumoperitoneum, extraluminal contrast extravasation, or signs of peritonitis require immediate operative treatment. 1

• Perform surgery as soon as possible, especially in patients with delayed presentation and those >70 years old 1
• Each hour of surgical delay beyond hospital admission is associated with 2.4% decreased probability of survival 1
• In stable patients, laparoscopic approach is preferred; in unstable patients, open surgery is mandatory 1

Common Pitfalls and Caveats

Critical errors to avoid: 3, 6

• Failure to test for H. pylori leads to recurrence rates of 40-50% over 10 years 3
• Do not use serology for H. pylori testing as it cannot confirm eradication 2
• PPIs should not replace urgent endoscopy in patients with active bleeding 3
• Gastric ulcers require endoscopic follow-up to ensure complete healing and exclude malignancy 1
• 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 3, 6

Important considerations: 3, 6

• PPIs may reduce absorption of medications requiring acidic environment 3
• Pre-endoscopy erythromycin improves visualization and reduces need for repeat endoscopy in bleeding ulcers 3
• After successful H. pylori eradication, PPI continuation is not required for uncomplicated duodenal ulcers 1
• Long-term PPI therapy should only be continued in chronic NSAID users who cannot discontinue and patients with recurrent ulcers despite H. pylori eradication 3