What is the initial step in managing a patient with a duodenal ulcer, nausea, vomiting, and abdominal pain that worsens after meals, and a history of chronic Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) use for arthritis?

Initial Management of NSAID-Induced Duodenal Ulcer

The correct answer is C: Start a proton pump inhibitor (PPI) immediately. This patient has an endoscopically confirmed duodenal ulcer with chronic NSAID use, and PPI therapy should be initiated immediately for symptom control and ulcer healing 1, 2.

Rationale for PPI as First-Line Therapy

Immediate PPI initiation is the priority because it directly addresses ulcer healing and symptom relief, which are the most urgent clinical needs. The evidence strongly supports this approach:

• PPIs are superior to all other agents for healing NSAID-associated duodenal ulcers, including H2-receptor antagonists 3, 4
• Standard dosing is omeprazole 20 mg once daily, which heals 75% of duodenal ulcers by 4 weeks and provides faster pain relief than placebo 5
• The FDA label for omeprazole demonstrates 82% healing rates at 4 weeks for duodenal ulcers, significantly superior to ranitidine 5

Why Not the Other Options?

Option A (Diet changes and antacids): Inadequate

• Over-the-counter antacids are insufficient for healing established duodenal ulcers and do not address the underlying pathophysiology 6
• Dietary modifications alone have no proven efficacy for ulcer healing 6

Option B (Treat H. pylori first): Premature

• While H. pylori testing should be performed, it is not the immediate first step 1, 3
• In NSAID-induced ulcers, H. pylori may not even be present—studies show only 36-41% of NSAID users with duodenal ulcers are H. pylori positive 7, 8
• PPI therapy should be started immediately while awaiting H. pylori test results 1, 2

Option D (Surgery): Not indicated

• Surgery is reserved for complications such as perforation, bleeding refractory to endoscopic treatment, or gastric outlet obstruction 1
• This patient has an uncomplicated ulcer on endoscopy

Complete Initial Management Algorithm

Step 1: Immediate Actions (Day 1)

• Discontinue NSAIDs immediately if possible—this is critical as NSAIDs significantly increase ulcer recurrence and mortality even with PPI therapy 1, 2, 3
• Start omeprazole 20 mg once daily (or equivalent PPI) taken 30 minutes before meals 1, 2, 5
• Order H. pylori testing using urea breath test or stool antigen test 1, 3

Step 2: Address Pain Management

• Switch to acetaminophen for arthritis pain as an alternative to NSAIDs 3
• If NSAIDs are absolutely required, this decision should be deferred until after ulcer healing is confirmed 1, 2

Step 3: H. pylori Management (Once Results Available)

• If H. pylori positive: Add triple therapy (PPI + amoxicillin 1000 mg twice daily + clarithromycin 500 mg twice daily for 14 days) 1, 5
• If H. pylori negative: Continue PPI monotherapy for 8 weeks to ensure complete healing 1, 3

Step 4: Long-Term Strategy (After 8 Weeks)

• If NSAIDs must be resumed: Continue PPI indefinitely plus consider switching to a COX-2 selective inhibitor 1, 2, 3
• If NSAIDs can be avoided: Discontinue PPI after confirming ulcer healing (especially if H. pylori was eradicated) 1, 2

Critical Clinical Caveats

Beware of false-negative H. pylori testing during acute bleeding—if initial testing is negative but clinical suspicion remains high, repeat testing after the acute phase 1, 3

H2-receptor antagonists are inadequate for NSAID-induced ulcers because they only protect against duodenal ulcers, not gastric ulcers, and are significantly less effective than PPIs 1, 4

Poor compliance with PPI therapy increases NSAID-induced adverse events 4-6 fold—emphasize the importance of taking the medication 30 minutes before meals daily 2, 3

The combination of NSAID use plus H. pylori infection creates independent and additive risk—both must be addressed for optimal outcomes 2, 8