What is the recommended treatment for a gastric ulcer in patients of all ages?

Treatment of Gastric Ulcer in Patients of All Ages

All patients with gastric ulcers should undergo H. pylori testing and receive eradication therapy if positive, combined with proton pump inhibitor (PPI) therapy continued until complete healing is endoscopically confirmed, as gastric ulcers require longer acid suppression than duodenal ulcers and mandate biopsy to exclude malignancy. 1, 2

Initial Diagnostic Approach

Age-Based Triage

• Patients ≥45 years with gastric ulcer symptoms or any patient with alarm symptoms (anemia, weight loss, dysphagia, palpable mass) must undergo endoscopy with biopsy to exclude gastric malignancy, as the standardized incidence of gastric cancer is 19 per 100,000 for men and 9 per 100,000 for women in this age group 1
• Patients with known gastric ulcer history require repeat endoscopy with biopsy until complete healing is documented, as malignancy may be present 1
• Younger patients (<45 years) without alarm symptoms may be managed with H. pylori testing first, though gastric ulcers still warrant endoscopic evaluation 1

H. Pylori Testing

• All gastric ulcer patients must be tested for H. pylori infection using urea breath test (sensitivity 88-95%, specificity 95-100%) or stool antigen test (sensitivity 94%, specificity 92%) 1, 2
• Endoscopic biopsy for H. pylori testing is available during diagnostic endoscopy 1

Treatment Protocol for H. Pylori-Positive Gastric Ulcers

First-Line Eradication Therapy

In areas with low clarithromycin resistance (<20%):

• Standard triple therapy for 14 days: PPI (standard dose twice daily) + clarithromycin 500 mg twice daily + amoxicillin 1000 mg twice daily, achieving eradication rates of 77-90% 1, 2
• Start therapy 72-96 hours after intravenous PPI administration in bleeding ulcer cases 1

In areas with high clarithromycin resistance (>20%):

• Bismuth-based quadruple therapy for 14 days is recommended as first-line treatment 2
• Alternative: Concomitant therapy (non-bismuth quadruple therapy) with PPI + amoxicillin 1000 mg twice daily + clarithromycin 500 mg twice daily + metronidazole 500 mg twice daily for 5-10 days, achieving approximately 90% eradication 1, 3

Second-Line Therapy

• If first-line therapy fails, switch to levofloxacin-amoxicillin triple therapy without waiting for culture results: PPI (standard dose twice daily) + levofloxacin 500 mg once daily (or 250 mg twice daily) + amoxicillin 1000 mg twice daily for 10-14 days 1, 2
• Bismuth-based quadruple therapy is an alternative second-line option 2

Third-Line Therapy

• Culture and antibiotic susceptibility testing should guide treatment selection 2
• Tailor therapy based on identified resistance patterns 2

Acid Suppression Duration

Critical distinction for gastric ulcers:

• PPI therapy must be continued after H. pylori eradication until complete endoscopic healing is confirmed, as gastric ulcers require longer acid inhibition than duodenal ulcers 2
• This differs from uncomplicated duodenal ulcers, which heal in >90% of cases without additional acid suppression after successful eradication 2
• Prolonged PPI beyond healing confirmation is unnecessary and increases costs 2

Confirmation of Eradication

• Testing for eradication is mandatory for gastric ulcers at least 4 weeks after completing therapy and at least 2 weeks after stopping PPI 2
• Use urea breath test or stool antigen test for confirmation 2
• Eradication results in cure in over 90% of patients and prevents recurrence 1

Special Considerations

NSAID-Associated Gastric Ulcers

• H. pylori eradication reduces peptic ulcer likelihood by one-half in NSAID users 4
• The combination of H. pylori infection and NSAID use synergistically increases bleeding ulcer risk more than sixfold 4
• In long-term NSAID users with gastric ulcers, eradication therapy should still be administered, though healing rates are similar regardless of H. pylori status when NSAIDs are continued 5
• Consider PPI co-administration or switching to celecoxib for ongoing NSAID therapy 4

H. Pylori-Negative Gastric Ulcers

• Treat with PPI therapy (e.g., omeprazole 20 mg twice daily) for 4-8 weeks 5
• Healing rate approaches 100% in H. pylori-negative patients 6
• Investigate for NSAID use, malignancy, or other causes 7, 4

Common Pitfalls to Avoid

• Never delay H. pylori eradication therapy until after hospital discharge in bleeding ulcer cases, as this significantly reduces treatment compliance; start when oral feeding is reintroduced 2
• Do not use serology to assess early treatment success or failure, as antibody titers take up to 6 months to decline 1
• Avoid stopping PPI therapy prematurely in gastric ulcers—continue until endoscopic healing is confirmed, unlike duodenal ulcers 2
• Do not skip endoscopic follow-up with biopsy for gastric ulcers, as malignancy must be excluded even with symptom resolution 1, 7
• Recognize that rapid office serological tests have disappointing accuracy (sensitivity 63-97%, specificity 68-92%) and should not be relied upon 1