Primary Treatment Approach for Peptic Ulcer Disease
The primary treatment for an adult patient with uncomplicated PUD consists of proton pump inhibitor (PPI) therapy combined with mandatory H. pylori testing and eradication if positive, plus immediate discontinuation of NSAIDs/aspirin if applicable. 1, 2, 3
Initial Pharmacological Management
Start PPI therapy immediately upon diagnosis:
- Standard dosing: omeprazole 20 mg once daily, lansoprazole 30 mg once daily, or pantoprazole 40 mg once daily 1, 4
- Administer 30-60 minutes before breakfast for optimal acid suppression 2
- Duration: 4-6 weeks for duodenal ulcers; 6-8 weeks for gastric ulcers 1, 2, 4
- PPIs achieve 95-98% healing rates for duodenal ulcers and 94-96% for gastric ulcers 4, 3
Critical distinction: H2-receptor antagonists should NOT be used as first-line therapy because they are significantly less effective than PPIs for both gastric and duodenal ulcers 4. Similarly, potassium-competitive acid blockers (P-CABs like vonoprazan) should NOT be used first-line due to higher costs, limited availability, and less robust long-term safety data compared to PPIs 1, 4.
Mandatory H. pylori Testing
Test ALL patients with PUD for H. pylori infection before discharge: 5, 1, 2, 3
Preferred testing methods:
- Urea breath test (UBT): 88-95% sensitivity, 95-100% specificity 5
- Stool antigen test: 94% sensitivity, 92% specificity 5
- Endoscopic biopsy if endoscopy performed 5
Critical pitfall: Failure to test for H. pylori leads to recurrence rates of 40-50% over 10 years, whereas successful eradication reduces recurrence from 50-60% to 0-2% 1, 3.
H. pylori Eradication Regimens (If Positive)
First-line therapy in areas with LOW clarithromycin resistance (<15%):
- Standard triple therapy for 14 days: 5, 1, 2, 6, 7
- PPI standard dose twice daily
- Clarithromycin 500 mg twice daily
- Amoxicillin 1000 mg twice daily (or metronidazole 500 mg twice daily if penicillin allergy)
Alternative for HIGH clarithromycin resistance areas:
- Sequential therapy for 10 days: 5, 1
- Days 1-5: PPI twice daily + amoxicillin 1000 mg twice daily
- Days 6-10: PPI twice daily + clarithromycin 500 mg twice daily + metronidazole 500 mg twice daily
Second-line therapy if first-line fails:
- Levofloxacin-based triple therapy for 10 days: 5, 1
- PPI standard dose twice daily
- Levofloxacin 500 mg once daily
- Amoxicillin 1000 mg twice daily
Confirm eradication: Repeat H. pylori testing 4-6 weeks after completing eradication therapy to document cure 1, 3.
NSAID-Associated Ulcer Management
Immediate action required:
- Discontinue ALL NSAIDs and aspirin immediately—this heals 95% of ulcers and reduces recurrence from 40% to 9% 1, 4, 3
- Test for and eradicate H. pylori if present, as eradication in NSAID users reduces peptic ulcer likelihood by 50% 4
If NSAIDs cannot be discontinued:
- Switch to selective COX-2 inhibitor (celecoxib) with lower gastric toxicity 1, 4
- Maintain long-term PPI therapy indefinitely for gastroprotection 1, 2, 4
- Continue PPI co-therapy as long as NSAID use continues 1, 4
Common Pitfalls to Avoid
Critical errors that worsen outcomes:
- Using H2-blockers instead of PPIs as first-line therapy 4
- Failing to test for H. pylori, leading to 40-50% recurrence rates 1, 4
- Not confirming H. pylori eradication after treatment 1, 3
- Continuing NSAIDs without gastroprotection 1, 4
- Assuming all ulcers are acid-related without addressing underlying causes 4
When to Escalate Care
Urgent endoscopy indicated for:
- Signs of active bleeding (hematemesis, melena) 2, 4
- Severe unrelenting pain despite PPI therapy 2
- Alarm symptoms: dysphagia, significant weight loss, recurrent vomiting 2, 4
- Age >55 years with new-onset dyspepsia 1
For bleeding ulcers: High-dose PPI therapy with 80 mg IV bolus followed by 8 mg/hour continuous infusion for 72 hours after endoscopic hemostasis 1, 2.
Follow-Up Strategy
Reassess at 4 weeks: