What is the appropriate treatment for an oesophageal ulcer?

Treatment of Oesophageal Ulcers

Proton pump inhibitors (PPIs) are the cornerstone of oesophageal ulcer treatment and should be initiated immediately to promote healing and prevent complications including strictures. 1

Primary Treatment Approach

First-Line Therapy: Proton Pump Inhibitors

• Initiate high-dose PPI therapy immediately upon diagnosis of oesophageal ulcers, regardless of etiology 1
• PPIs are specifically recommended for treatment of gastro-oesophageal reflux disease (GERD)-related ulcers and prevention of oesophageal strictures 1
• Omeprazole 40 mg once daily or equivalent PPI dosing has demonstrated superior healing rates (85% at 4 weeks, 96% at 8 weeks) compared to H2-receptor antagonists like ranitidine (40% at 4 weeks, 52% at 8 weeks) 2
• Esomeprazole 40 mg once daily provides greater antisecretory activity than other PPIs and effectively heals oesophageal ulcers 3

Treatment Duration and Monitoring

• Continue PPI therapy for 4-8 weeks as the standard treatment course for ulcer healing 2
• After initial treatment, perform follow-up endoscopy at 4 weeks to assess healing; if unhealed, continue therapy and reassess at 8 weeks 2
• For GERD-induced ulcers (which account for approximately 66% of cases), long-term PPI maintenance therapy is often necessary to prevent recurrence 4, 5

Etiology-Specific Considerations

GERD-Related Ulcers (Most Common: ~57-66%)

• These ulcers are typically located in the lower thoracic esophagus (80% of cases) 4
• High-dose PPI therapy is essential as first-line treatment 1
• Be aware that strictures complicate GERD-induced ulcers in approximately 12.5% of cases 4
• If stricture develops, weekly or bi-weekly oesophageal dilatation should be performed until easy passage of a ≥15 mm dilator is achieved 1

Drug-Induced Ulcers (Second Most Common: ~23%)

• Most commonly caused by doxycycline and tetracycline (52% of drug-induced cases), typically in capsule form 6
• These ulcers are usually located in the mid-esophagus (79% in proximal/middle third) 4, 6
• Discontinue the offending medication immediately 6
• Initiate PPI therapy plus sucralfate for mucosal protection 6
• Drug-induced ulcers rarely cause strictures but can cause significant hemorrhage 4

Other Etiologies

• Candidal ulcers: Add antifungal therapy (fluconazole) to PPI treatment 4
• HSV or HIV-related ulcers: Require antiviral therapy in addition to acid suppression 4
• Caustic injury: Requires specialized management with PPI support 4

Management of Complications

Hemorrhage (Occurs in ~34% of Cases)

• Mid-esophageal ulcers have greater bleeding tendency than gastroesophageal junction ulcers 4
• For active bleeding: endoscopic hemostasis using injection therapy (1:10,000 adrenaline solution in quadrants around bleeding point, 4-16 ml total) achieves primary hemostasis in up to 95% of patients 1
• Alternative hemostatic methods include heater probe or multipolar coagulation 1
• Only 4% of patients require endoscopic intervention for bleeding control 4

Stricture Formation (Occurs in ~12.5% of Cases)

• Perform weekly or bi-weekly dilatation sessions until easy passage of ≥15 mm dilator is achieved with symptomatic improvement 1
• Continue PPI therapy after dilatation to reduce stricture recurrence 1
• Esophageal dilatation is effective for most strictures, with only 8% requiring surgery 4

Perforation (Rare: ~3.4% of Cases)

• Suspect perforation if persistent chest pain, fever, breathlessness, or tachycardia develop 1
• Perform CT scan with oral contrast immediately if perforation is suspected 1
• Consider immediate endoscopic stent placement if perforation is confirmed during endoscopy 1

Important Clinical Pitfalls

Common Mistakes to Avoid

• Do not use H2-receptor antagonists (ranitidine) as primary therapy—they are significantly less effective than PPIs for healing oesophageal ulcers 1, 2
• Do not perform routine repeat endoscopy for diagnostic purposes unless clinically indicated, as it rarely changes management 5
• Warn patients about insufficient water intake when taking medications, as 85.5% of drug-induced ulcers relate to inadequate water consumption or taking pills while recumbent 6

Long-Term PPI Considerations

• Regularly review the ongoing indication for PPI use and document the reason for continued therapy 7, 8
• Monitor blood pressure in patients on chronic PPI therapy, especially those also taking NSAIDs 7
• Do not discontinue PPIs based on concerns about unproven risks (dementia, cardiovascular events) when a valid indication exists 8
• Valid indications for long-term PPI therapy include: Barrett's esophagus, severe erosive esophagitis, history of complicated GERD, or recurrent ulceration 8

Adjunctive Therapies

Prokinetic Agents

• Consider adding prokinetic drugs (domperidone, buspirone, or prucalopride) if symptomatic motility disturbances persist despite PPI therapy 1
• Domperidone or alginic acid can improve GERD symptoms in patients with partial response to high-dose PPIs 1

When Surgery Is Required

• Surgery is reserved for refractory strictures or perforation and is needed in only 8% of cases 4
• Mortality from oesophageal ulcers is rare (2.3%), typically from hemorrhage or perforation 4