eMedicine Specialties > Gastroenterology > Stomach
Peptic Ulcer Disease: Treatment & Medication
Updated: Jul 17, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
- Given the current understanding of the pathogenesis of PUD, most patients with PUD are treated successfully with cure of H pylori infection and/or avoidance of NSAIDs, along with the appropriate use of antisecretory therapy.
- A number of treatment options exist for patients presenting with symptoms suggestive of PUD or ulcerlike dyspepsia, including empiric antisecretory therapy, empiric triple therapy for H pylori infection, endoscopy followed by appropriate therapy based on findings, and H pylori serology followed by triple therapy for patients who are infected. Breath testing for active H pylori infection may be used.
- Computer models have suggested that obtaining H pylori serology followed by triple therapy for patients who are infected is the most cost-effective approach; however, no direct evidence from clinical trials provides confirmation.
- Perform endoscopy early in patients older than 45-50 years and in patients with associated so-called alarm symptoms, such as dysphagia, recurrent vomiting, weight loss, or bleeding.
- See also American College of Gastroenterology Issues Guidelines for Treatment of Helicobacter pylori Infection and Recommendations for Treating Peptic Ulcer Disease Reviewed.
Surgical Care
With the success of medical therapy, surgery has a very limited role in the management of PUD.
- Potential indications for surgery include refractory disease. Complications of PUD include the following:
- Refractory, symptomatic peptic ulcers, though rare with the cure of H pylori infection and the appropriate use of antisecretory therapy, are a potential complication of PUD.
- Perforation usually is managed emergently with surgical repair. However, this is not mandatory for all patients.
- Obstruction can complicate PUD, particularly if PUD is refractory to aggressive antisecretory therapy, H pylori eradication, or avoidance of NSAIDs. Obstruction may persist or recur despite endoscopic balloon dilation.
- Penetration, particularly if not walled off or if a gastrocolic fistula develops, is a potential complication of PUD.
- Bleeding can complicate PUD, particularly in patients with massive hemorrhage and hemodynamic instability, recurrent bleeding on medical therapy, and failure of therapeutic endoscopy to control bleeding.
- The appropriate surgical procedure depends on the location and nature of the ulcer.
- Many authorities recommend simple oversewing of the ulcer with treatment of the underlying H pylori infection or cessation of NSAIDs for bleeding PUD.
- Additional surgical options for refractory or complicated PUD include vagotomy and pyloroplasty, vagotomy and antrectomy with gastroduodenal reconstruction (Billroth I) or gastrojejunal reconstruction (Billroth II), or a highly selective vagotomy.
Consultations
Consult a general surgeon if the clinical presentation suggests a complicated peptic ulcer.
Diet
No special diet is required.
Medication
Treat all patients with peptic ulcers and associated H pylori infection with proton pump inhibitor (PPI)-based triple therapy, which results in a cure rate of infection and healing in approximately 85-90% of cases. Ulcers can relapse in the absence of successful H pylori eradication.
Dual therapies, which are alternative regimens for treating H pylori infection, are usually not recommended as first-line therapy because of a variable cure rate that is significantly less than the cure rate achieved with triple therapy.
Active ulcers associated with NSAID use are treated with an appropriate course of PPI therapy and the cessation of NSAIDs. For patients with a known history of ulcer, and in whom NSAID use is unavoidable, the lowest possible dose and duration of the NSAID and co-therapy with a PPI or misoprostol are recommended.
PPI-based triple therapies for H pylori are considered the first-line therapies for the treatment of H pylori in the United States with a cure rate of 85-90%. These regimens consist of a PPI, amoxicillin, and clarithromycin for 7-14 days. A longer duration of treatment (14 d vs 7 d) appears to be more affective and is currently the recommended duration of treatment. Amoxicillin should only be substituted by metronidazole in penicillin-allergic patients because of the high rate of metronidazole resistance.
In the setting of active ulcers caused by H pylori, treatment with a PPI beyond the 14-day course of antibiotics and until the confirmation for the eradication of H pylori is recommended for complicated ulcers.
PPI-based triple therapies consist of a 14-day treatment of the following:
Omeprazole (Prilosec): 20 mg PO bid or
Lansoprazole (Prevacid): 30 mg PO bid or
Rabeprazole (Aciphex): 20 mg PO bid or
Esomeprazole (Nexium): 40 mg PO qd
Plus:
Clarithromycin (Biaxin): 500 mg PO bid and
Amoxicillin (Amoxil): 1 g PO bid
The alternative combination therapy consists of the following treatments administered for 14 days:
Omeprazole (Prilosec): 20 mg PO bid or
Lansoprazole (Prevacid): 30 mg PO bid or
Rabeprazole (Aciphex): 20 mg PO bid or
Esomeprazole (Nexium): 40 mg PO qd
Plus:
Clarithromycin (Biaxin): 500 mg PO bid and
Metronidazole (Flagyl): 500 mg PO bid
Quadruple therapies for H pylori infection are generally reserved for patients who have failed a course of treatment and are administered for 14 days. The treatment includes the following drugs:
PPI PO bid and
Bismuth 525 mg PO qid and
Metronidazole 500 mg PO qid and
Tetracycline 500 mg PO qid
Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Amoxicillin (Amoxil, Biomox, Trimox)
Derivative of ampicillin and has similar antibacterial spectrum, namely certain gram-positive and gram-negative organisms. Superior bioavailability and stability to gastric acid and has broader spectrum of activity than penicillin. Somewhat less active than that of penicillin against Streptococcus pneumococcus. Penicillin-resistant strains also resistant to amoxicillin, but higher doses may be effective. Interferes with synthesis of cell wall mucopeptides during active multiplication resulting in bactericidal activity against susceptible bacteria. Used in combination with other antimicrobial agents.
If H pylori is identified as the underlying cause of gastritis, subsequent eradication now is almost generally accepted practice. Protocols for H pylori eradication require a combination of antimicrobial agents and antisecretory agents, such as PPIs, ranitidine bismuth citrate, or bismuth subsalicylate. Despite the combinatorial effect of drugs in regimens used to treat H pylori infection, cure rates remain, at best, 80-95%.
Adult
1 g PO bid
Pediatric
Not established
Reduces the efficacy of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; may enhance chance of candidiasis
Clarithromycin (Biaxin)
Semisynthetic macrolide antibiotic that reversibly binds to P site of 50S ribosomal subunit of susceptible organisms and may inhibit RNA-dependent protein synthesis by stimulating dissociation of peptidyl t-RNA from ribosomes, causing bacterial growth inhibition. If H pylori is identified as the underlying cause of gastritis, subsequent eradication now is almost generally accepted practice. Protocols for H pylori eradication require a combination of antimicrobial agents and antisecretory agents, such as PPIs, ranitidine bismuth citrate, or bismuth subsalicylate. Despite the combinatorial effect of drugs in regimens used to treat H pylori infection, cure rates remain, at best, 80-95%.
Adult
500 mg PO bid
Pediatric
Not established
Toxicity increases with coadministration of fluconazole and pimozide; effects decrease and GI adverse effects may increase with coadministration of rifabutin or rifampin; may increase toxicity of anticoagulants, cyclosporine, tacrolimus, digoxin, carbamazepine, ergot alkaloids, triazolam, and HMG-CoA reductase inhibitors; plasma levels of certain benzodiazepines may increase, prolonging CNS depression; arrhythmias and increases in QTc intervals occur with disopyramide; coadministration with omeprazole may increase plasma levels of both agents; decreases metabolism of repaglinide, thus increasing serum levels and effects
Documented hypersensitivity; coadministration of pimozide
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Coadministration with ranitidine or bismuth citrate is not recommended with CrCl <25 mL/min; give half dose or increase dosing interval if CrCl <30 mL/min; diarrhea may be sign of pseudomembranous colitis; superinfections may occur with prolonged or repeated antibiotic therapies
Metronidazole (Flagyl)
Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Used in combination with other antimicrobial agents. If H pylori is identified as the underlying cause of gastritis, subsequent eradication now is almost generally accepted practice. Protocols for H pylori eradication require a combination of antimicrobial agents and antisecretory agents, such as PPIs, ranitidine bismuth citrate, or bismuth subsalicylate. Despite the combinatorial effect of drugs in regimens used to treat H pylori infection, cure rates remain, at best, 80-95%.
Adult
500 mg PO bid
Pediatric
Not established
May increase toxicity of anticoagulants, cyclosporine, lithium, phenytoin, tacrolimus, and carbamazepine; cimetidine may increase toxicity of metronidazole; disulfiram reaction may occur with orally ingested ethanol; coadministration increases amiodarone toxicity (QT prolongation); increases disulfiram toxicity (psychotic symptoms) with concurrent use; phenobarbital and rifampin may increase metabolism of metronidazole
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution with liver impairment, blood dyscrasias, CNS disease; reduce dosage with severe hepatic disease; monitor for seizures and development of peripheral neuropathy
Tetracycline (Sumycin)
Inhibits bacterial growth by binding to the 30S ribosomal unit, preventing protein synthesis.
Component of drug combination therapy that effectively treats duodenal ulcer or gastric ulcer associated with H pylori infection. Treats gram-positive and gram-negative organisms and mycoplasmal, chlamydial, and rickettsial infections. Used in combination with other antimicrobial agents.
If H pylori is identified as the underlying cause of gastritis, subsequent eradication now is almost generally accepted practice. Protocols for H pylori eradication require a combination of antimicrobial agents and antisecretory agents, such PPIs, ranitidine bismuth citrate, or bismuth subsalicylate. Despite the combinatorial effect of drugs in regimens used to treat H pylori infection, cure rates remain, at best, 80-95%.
Adult
500 mg PO qid
Pediatric
Not established
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy; tetracyclines can increase hypoprothrombinemic effects of anticoagulants
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one-half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Proton pump inhibitors (PPIs)
Proton pump inhibitors bind to and inhibit the H+/K+ -adenosine triphosphatase (ATPase) pump of the parietal cell, resulting in a marked decrease in acid secretion. These drugs are an important part of triple therapy, the treatment of choice for H pylori infection. Proton pump inhibitors have some direct antibacterial effect, and their antisecretory properties aid in ulcer healing. Can be used as primary therapy to heal ulcers not associated with H pylori infection.
Lansoprazole (Prevacid)
Decreases gastric acid secretion by inhibiting parietal cell H+/K+ -ATP pump. Might decrease the incidence of NSAID-induced peptic ulcers and can be used to help prevent peptic ulcers in chronic NSAID users at high risk
Adult
15-30 mg PO qd for 4 wk
Pediatric
Not established
May decrease effects of ketoconazole and itraconazole; may increase theophylline clearance
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Consider adjusting dose in liver impairment
Esomeprazole (Nexium)
Inhibits gastric acid secretion by inhibiting H+/K+ -ATPase enzyme system at secretory surface of gastric parietal cells.
Adult
20-40 mg PO qd for 4-8 wk
Pediatric
Not established
None reported
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Symptomatic relief with proton pump inhibitors may mask symptoms of gastric malignancy
Rabeprazole (Aciphex)
Inhibits gastric acid secretion by inhibiting H+/K+ -ATPase enzyme system at secretory surface of gastric parietal cells.
Adult
20 mg PO qd for 4 wk
Pediatric
Not established
None reported
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Symptomatic relief with proton pump inhibitors may mask symptoms of gastric malignancy
Omeprazole (Prilosec)
Decreases gastric acid secretion by inhibiting parietal cell H+/K+ -ATP pump. Might decrease the incidence of NSAID-induced peptic ulcers and can be used in preventing peptic ulcers in high-risk chronic NSAID users
Adult
20 mg PO qd for 4 wk
Pediatric
Not established
May decrease effects of itraconazole and ketoconazole; may increase toxicity of warfarin, digoxin, and phenytoin
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Bioavailability might increase in elderly patients
Cytoprotectants
These agents have the ability to induce prostaglandin synthesis and, thus, cytoprotective effects in the GI tract.
Misoprostol (Cytotec)
Prostaglandin analog can be used to decrease incidence of peptic ulcers and complications in chronic NSAID users
Adult
200 mcg PO qid
Pediatric
Not established
None reported
Documented hypersensitivity; do not use in women of childbearing age unless patient requires NSAID therapy and is at high risk for complications of PUD
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Caution in renal impairment and elderly patients; adverse gastrointestinal effects (eg, abdominal pain, diarrhea) are common; lower doses have fewer adverse effects but are slightly less effective; the dose can be titrated to optimal therapeutic dose
H2-receptor blockers
These agents selectively block H2-receptors on parietal cells, resulting in diminished acid secretion and ulcer healing. Long-term use can have tachyphalaxis.
Cimetidine (Tagamet)
Can be used as primary therapy to heal ulcers not associated with H pylori infection.
Treatment duration is 6-8 wk. A longer treatment course might be required for gastric ulcers
Adult
400 mg PO bid or 800 mg PO qhs for 6-8 wk
Pediatric
Not established
Can increase blood levels of theophylline, warfarin, tricyclic antidepressants, triamterene, phenytoin, quinidine, propranolol, metronidazole, procainamide, and lidocaine
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Elderly patients might experience confusional states; might cause impotence and gynecomastia in young males; might increase levels of many drugs; adjust dose or discontinue treatment if changes in renal function occur
Ranitidine (Zantac)
Inhibits histamine stimulation of the H2 receptor in gastric parietal cells, which, in turn, reduces gastric acid secretion, gastric volume, and reduced hydrogen concentrations
Adult
150 mg PO bid or 300 mg PO qhs
Pediatric
Not established
May decrease effects of ketoconazole and itraconazole; may alter serum levels of ferrous sulfate, diazepam, nondepolarizing muscle relaxants, and oxaprozin
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in renal or liver impairment; if changes in renal function occur during therapy, consider adjusting dose or discontinuing treatment
Famotidine (Pepcid)
Competitively inhibits histamine at H2 receptor of gastric parietal cells, resulting in reduced gastric acid secretion, reduced gastric volume, and reduced hydrogen concentrations
Adult
20 mg PO bid or 40 mg PO qhs
Pediatric
Not established; suggested dose is 1-2 mg/kg/d PO/IV divided q6h; not to exceed 40 mg per dose
May decrease effects of ketoconazole and itraconazole
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
If changes in renal function occur during therapy, consider adjusting dose or discontinuing treatment
Nizatidine (Axid)
Competitively inhibits histamine at the H2 receptor of the gastric parietal cells, resulting in reduced gastric acid secretion, reduced gastric volume, and reduced hydrogen concentrations
Adult
150 mg PO bid or 300 mg PO qhs
Pediatric
Not established
None reported
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in renal or liver impairment (if changes in renal function occur during therapy, consider adjusting dose or discontinuing treatment)
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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Further Reading
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
