eMedicine Specialties > Gastroenterology > Stomach

Peptic Ulcer Disease: Follow-up

Author: Tri H Le, MD, Assistant Professor of Medicine, Division of Gastroenterology and Hepatology, Penn State Milton S Hershey Medical Center
Coauthor(s): George T Fantry, MD, Director of Clinical Gastroenterology, Department of Internal Medicine, Division of Gastroenterology, Associate Professor, University of Maryland School of Medicine
Contributor Information and Disclosures

Updated: Jul 17, 2008

Follow-up

Further Outpatient Care

  • Endoscopy is required to document healing of gastric ulcers and to rule out gastric cancer. This usually is performed 6-8 weeks after the initial diagnosis of PUD.
  • Documentation of H pylori cure with a noninvasive test, such as the urea breath test or fecal antigen test, is appropriate in patients with complicated ulcers.

Inpatient & Outpatient Medications

  • Consider maintenance therapy with half standard doses of H2-receptor antagonists at bedtime in patients with recurrent, refractory, or complicated ulcers, particularly if cure of H pylori has not been documented or if an H pylori -negative ulcer is present.

Deterrence/Prevention

  • Primary prevention of NSAID-induced ulcers includes the following:
    • Avoid unnecessary use of NSAIDs.
    • Use acetaminophen or nonacetylated salicylates when possible.
    • Use the lowest effective dose of an NSAID and switch to less toxic NSAIDs, such as the newer NSAIDs or cyclooxygenase-2 (COX-2) inhibitors, in high-risk patients without cardiovascular disease.
  • Consider prophylactic or preventive therapy for the following patients:
    • Patients with NSAID-induced ulcers who require chronic, daily NSAID therapy
    • Patients older than 60 years
    • Patients with a history of PUD or a complication such as gastrointestinal bleeding
    • Patients taking concomitant steroids or anticoagulants or patients with significant comorbid medical illnesses
  • Prophylactic regimens that have been shown to dramatically reduce (prevent) the risk of NSAID-induced gastric and duodenal ulcers include the use of a prostaglandin analogue or a PPI.
    • Misoprostol 100-200 mcg PO 4 times per day
    • Omeprazole 20-40 mg PO every day
    • Lansoprazole 15-30 mg PO every day

Complications

  • Perforation
  • Penetration
  • Obstruction
  • Bleeding

Prognosis

    • When the underlying cause is addressed, the prognosis is excellent. Most patients are treated successfully with the cure of H pylori infection, avoidance of NSAIDs, and the appropriate use of antisecretory therapy.
    • Cure of H pylori infection changes the natural history of the disease, with a decrease in the ulcer recurrence rate from 60-90% to approximately 10-20%. However, this is a higher recurrence rate than previously reported, suggesting an increased number of ulcers not caused by H pylori infection.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to assess for H pylori infection in patients with PUD is a potential pitfall.
  • Choosing an inadequate treatment regimen for patients with H pylori infection, such as the wrong combination of drugs, wrong dosage, or too short duration of treatment, is a potential pitfall.
  • Failure to obtain a detailed medical history regarding potential NSAID use is a potential pitfall.
 


More on Peptic Ulcer Disease

Overview: Peptic Ulcer Disease
Differential Diagnoses & Workup: Peptic Ulcer Disease
Treatment & Medication: Peptic Ulcer Disease
Follow-up: Peptic Ulcer Disease
References
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References

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  2. Conn HO, Poynard T. Corticosteroids and peptic ulcer: Meta-analysis of adverse events during steroid therapy. J Intern Med. 1994;236:619. [Medline].

  3. Ford AC, Delaney BC, Forman D, Moayyedi P. Eradication therapy in Helicobacter pylori positive peptic ulcer disease: systematic review and economic analysis. Am J Gastroenterol. Sep 2004;99(9):1833-55. [Medline].

  4. Gisbert JP, Khorrami S, Carballo F, et al. Meta-analysis: Helicobacter pylori eradication therapy vs. antisecretory non-eradication therapy for the prevention of recurrent bleeding from peptic ulcer. Aliment Pharmacol Ther. Mar 15 2004;19(6):617-29. [Medline].

  5. Hawkey CJ, Karrasch JA, Szczepanski L, et al. Omeprazole compared with misoprostol for ulcers associated with nonsteroidal anti-inflammatory drugs. Omeprazole versus Misoprostol for NSAID-induced Ulcer Management (OMNIUM) Study Group. N Engl J Med. 338(11):727-34. [Medline].

  6. Jyotheeswaran S, Shah AN, Jin HO, et al. Prevalence of Helicobacter pylori in peptic ulcer patients in greater Rochester, NY: is empirical triple therapy justified?. Am J Gastroenterol. Apr 1998;93(4):574-8. [Medline].

  7. Piper JM, Ray WA, Daugherty JR, Griffin MR. Corticosteroid use and peptic ulcer disease: role of nonsteroidal anti-inflammatory drugs. Ann Intern Med. May 1 1991;114(9):735-40. [Medline].

  8. Quan C, Talley NJ. Management of peptic ulcer disease not related to Helicobacter pylori or NSAIDs. Am J Gastroenterol. Dec 2002;97(12):2950-61. [Medline].

  9. Rautelin H, Lehours P, Megraud F. Diagnosis of Helicobacter pylori infection. Helicobacter. 2003;8 Suppl 1:13-20. [Medline].

  10. Salcedo JA, Al-Kawas F. Treatment of Helicobacter pylori infection. Arch Intern Med. Apr 27 1998;158(8):842-51. [Medline].

  11. Silverstein FE, Graham DY, Senior JR, et al. Misoprostol reduces serious gastrointestinal complications in patients with rheumatoid arthritis receiving nonsteroidal anti-inflammatory drugs. A randomized, double-blind, placebo-controlled trial. Ann Intern Med. 123(4):241-9. [Medline].

  12. Soll AH. Consensus conference. Medical treatment of peptic ulcer disease. Practice guidelines. Practice Parameters Committee of the American College of Gastroenterology. JAMA. Feb 28 1996;275(8):622-9. [Medline].

  13. Wolfe MM, Lichtenstein DR, Singh G. Gastrointestinal toxicity of nonsteroidal antiinflammatory drugs. N Engl J Med. Jun 17 1999;340(24):1888-99. [Medline].

  14. Yeomans ND, Tulassay Z, Juhasz L, et al. A comparison of omeprazole with ranitidine for ulcers associated with nonsteroidal anti-inflammatory drugs. Acid Suppression Trial: Ranitidine versus Omeprazole for NSAID-associated Ulcer Treatment (ASTRONAUT) Study Group. N Engl J Med. 338(11):719-26. [Medline].

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Further Reading

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Keywords

PUD, Helicobacter pylori infection, H pylori infection, nonsteroidal anti-inflammatory drugs, NSAIDs, mucosal break, dyspepsia, heartburn, smoking, stress, epigastric pain, belching, bloating, distention, fatty food intolerance, hematemesis, melena, gastrointestinal bleeding, Guaiac-positive stool, occult blood loss, succussion splash, gastric outlet obstruction, duodenal ulcers, perforation, gastrinoma, Zollinger-Ellison syndrome, multiple endocrine neoplasia syndrome, MEN-I, antral G cell hyperplasia, systemic mastocytosis, basophilic leukemias, cirrhosis, chronic pulmonary disease, renal failure, renal transplantation, radiation-induced ulcers, chemotherapy-induced ulcers, vascular insufficiency, crack cocaine, duodenal obstruction

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Contributor Information and Disclosures

Author

Tri H Le, MD, Assistant Professor of Medicine, Division of Gastroenterology and Hepatology, Penn State Milton S Hershey Medical Center
Tri H Le, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, American Society of Gastrointestinal Endoscopy, and Crohns and Colitis Foundation of America
Disclosure: Nothing to disclose.

Coauthor(s)

George T Fantry, MD, Director of Clinical Gastroenterology, Department of Internal Medicine, Division of Gastroenterology, Associate Professor, University of Maryland School of Medicine
George T Fantry, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Medical Editor

Terence David Lewis, MBBS, FRACP, FRCPC, FACP, Program Director, Internal Medicine Residency, & Assistant Chairman, Associate Professor, Department of Internal Medicine, Division of Gastroenterology, Loma Linda University Medical Center
Terence David Lewis, MBBS, FRACP, FRCPC, FACP is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Medical Association, California Medical Association, Royal College of Physicians and Surgeons of Canada, and Sigma Xi
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Noel Williams, MD, Professor Emeritus, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Professor, Department of Internal Medicine, Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
Noel Williams, MD is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Assistant Dean for Medical Curriculum, Associate Professor of Medicine, Division of General Internal Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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