Peptic ulcer disease: Management
- Nimish B Vakil, MD, AGAF, FACP, FACG, FASGE
Nimish B Vakil, MD, AGAF, FACP, FACG, FASGE
- Clinical Professor of Medicine
- University of Wisconsin School of Medicine and Public Health
A peptic ulcer is a defect in the gastric or duodenal wall that extends through the muscularis mucosa into the deeper layers of the wall. The management of patients with peptic ulcer disease is based on the etiology, ulcer characteristics, and anticipated natural history. This topic will review the initial management of peptic ulcer disease. The management of recurrent and refractory peptic ulcer disease, the complications of peptic ulcer disease, surgical management of peptic ulcer disease, and the clinical manifestations, diagnosis of peptic ulcer disease are discussed separately. (See "Approach to refractory or recurrent peptic ulcer disease" and "Overview of the complications of peptic ulcer disease" and "Surgical management of peptic ulcer disease" and "Peptic ulcer disease: Clinical manifestations and diagnosis".)
Eradication of Helicobacter pylori — All patients with peptic ulcers should be tested for infection with H. pylori and treated [1-4]. In patients treated for H. pylori, eradication of infection should be confirmed four or more weeks after the completion of therapy . Diagnostic evaluation and treatment of H. pylori are discussed in detail, separately. (See "Indications and diagnostic tests for Helicobacter pylori infection" and "Treatment regimens for Helicobacter pylori".)
Eradication of H. pylori in patients with peptic ulcer disease is associated with higher healing rates in patients with duodenal and gastric ulcers. A meta-analysis of 24 randomized trials including 2102 patients with peptic ulcer disease revealed that the 12-month ulcer remission rates for gastric and duodenal ulcers were significantly higher in patients successfully eradicated of H. pylori infection as compared with those with a persistent infection (97 and 98 percent versus 61 and 65 percent, respectively) . In addition, eradication of H. pylori infection is associated with lower ulcer recurrence rates in patients with gastric and duodenal ulcers who are not placed on maintenance antisecretory therapy .
Withdrawal of offending or contributing factors — Patients with peptic ulcers should be advised to avoid nonsteroidal anti-inflammatory drugs (NSAIDs). Contributing factors should be addressed and treated (eg, treating medical comorbidities, poor nutritional status, ischemia). While there are no convincing data that specific foods are associated with an increased risk of peptic ulcer disease, patients should avoid any foods that precipitate dyspeptic symptoms. Given the many benefits of smoking cessation, we advise patients to stop smoking and advise them to limit alcohol intake to one alcoholic beverage a day . (See "Peptic ulcer disease: Genetic, environmental, and psychological risk factors and pathogenesis" and "Unusual causes of peptic ulcer disease".)
Antisecretory therapy — All patients with peptic ulcers should receive antisecretory therapy to facilitate ulcer healing (table 1).
- NIH Consensus Conference. Helicobacter pylori in peptic ulcer disease. NIH Consensus Development Panel on Helicobacter pylori in Peptic Ulcer Disease. JAMA 1994; 272:65.
- Marshall BJ, Goodwin CS, Warren JR, et al. Prospective double-blind trial of duodenal ulcer relapse after eradication of Campylobacter pylori. Lancet 1988; 2:1437.
- Chiorean MV, Locke GR 3rd, Zinsmeister AR, et al. Changing rates of Helicobacter pylori testing and treatment in patients with peptic ulcer disease. Am J Gastroenterol 2002; 97:3015.
- Malfertheiner P, Megraud F, O'Morain CA, et al. Management of Helicobacter pylori infection-the Maastricht V/Florence Consensus Report. Gut 2017; 66:6.
- Leodolter A, Kulig M, Brasch H, et al. A meta-analysis comparing eradication, healing and relapse rates in patients with Helicobacter pylori-associated gastric or duodenal ulcer. Aliment Pharmacol Ther 2001; 15:1949.
- 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 2004; 99:1833.
- Li LF, Chan RL, Lu L, et al. Cigarette smoking and gastrointestinal diseases: the causal relationship and underlying molecular mechanisms (review). Int J Mol Med 2014; 34:372.
- Malfertheiner P, Megraud F, O'Morain CA, et al. Management of Helicobacter pylori infection--the Maastricht IV/ Florence Consensus Report. Gut 2012; 61:646.
- Gudmand-Høyer E, Jensen KB, Krag E, et al. Prophylactic effect of cimetidine in duodenal ulcer disease. Br Med J 1978; 1:1095.
- Gisbert JP, Pajares JM. Systematic review and meta-analysis: is 1-week proton pump inhibitor-based triple therapy sufficient to heal peptic ulcer? Aliment Pharmacol Ther 2005; 21:795.
- Lam SK, Ching CK, Lai KC, et al. Does treatment of Helicobacter pylori with antibiotics alone heal duodenal ulcer? A randomised double blind placebo controlled study. Gut 1997; 41:43.
- Sung JJ, Chung SC, Ling TK, et al. Antibacterial treatment of gastric ulcers associated with Helicobacter pylori. N Engl J Med 1995; 332:139.
- Chey WD, Leontiadis GI, Howden CW, Moss SF. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol 2017; 112:212.
- Lai KC, Lam SK, Chu KM, et al. Lansoprazole for the prevention of recurrences of ulcer complications from long-term low-dose aspirin use. N Engl J Med 2002; 346:2033.
- McColl KE. How I manage H. pylori-negative, NSAID/aspirin-negative peptic ulcers. Am J Gastroenterol 2009; 104:190.
- Yeomans ND, Tulassay Z, Juhász L, et al. A comparison of omeprazole with ranitidine for ulcers associated with nonsteroidal antiinflammatory drugs. Acid Suppression Trial: Ranitidine versus Omeprazole for NSAID-associated Ulcer Treatment (ASTRONAUT) Study Group. N Engl J Med 1998; 338:719.
- Blum AL, Bethge H, Bode JC, et al. Sucralfate in the treatment and prevention of gastric ulcer: multicentre double blind placebo controlled study. Gut 1990; 31:825.
- Hosokawa O, Watanabe K, Hatorri M, et al. Detection of gastric cancer by repeat endoscopy within a short time after negative examination. Endoscopy 2001; 33:301.
- Whiting JL, Sigurdsson A, Rowlands DC, et al. The long term results of endoscopic surveillance of premalignant gastric lesions. Gut 2002; 50:378.
- Gielisse EA, Kuyvenhoven JP. Follow-up endoscopy for benign-appearing gastric ulcers has no additive value in detecting malignancy: It is time to individualise surveillance endoscopy. Gastric Cancer 2015; 18:803.
- ASGE Standards of Practice Committee, Banerjee S, Cash BD, et al. The role of endoscopy in the management of patients with peptic ulcer disease. Gastrointest Endosc 2010; 71:663.
- Eckardt VF, Giessler W, Kanzler G, Bernhard G. Does endoscopic follow-up improve the outcome of patients with benign gastric ulcers and gastric cancer? Cancer 1992; 69:301.
- Stephens MR, Lewis WG, White S, et al. Prognostic significance of alarm symptoms in patients with gastric cancer. Br J Surg 2005; 92:840.
- Bytzer P. Endoscopic follow-up study of gastric ulcer to detect malignancy: is it worthwhile? Scand J Gastroenterol 1991; 26:1193.
- 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 2004; 19:617.
- Dammann HG, Walter TA. Efficacy of continuous therapy for peptic ulcer in controlled clinical trials. Aliment Pharmacol Ther 1993; 7 Suppl 2:17.
- Bianchi Porro G, Parente F. Long term treatment of duodenal ulcer. A review of management options. Drugs 1991; 41:38.
- Lauritsen K, Andersen BN, Laursen LS, et al. Omeprazole 20 mg three days a week and 10 mg daily in prevention of duodenal ulcer relapse. Double-blind comparative trial. Gastroenterology 1991; 100:663.
- Penston JG, Wormsley KG. Review article: maintenance treatment with H2-receptor antagonists for peptic ulcer disease. Aliment Pharmacol Ther 1992; 6:3.
- Penston JG. A decade of experience with long-term continuous treatment of peptic ulcers with H2-receptor antagonists. Aliment Pharmacol Ther 1993; 7 Suppl 2:27.
- Mahadevan U, Kane S. American gastroenterological association institute technical review on the use of gastrointestinal medications in pregnancy. Gastroenterology 2006; 131:283.
- Li L, Li L, Zhou X, et al. Helicobacter pylori Infection Is Associated with an Increased Risk of Hyperemesis Gravidarum: A Meta-Analysis. Gastroenterol Res Pract 2015; 2015:278905.
- Grooten IJ, Den Hollander WJ, Roseboom TJ, et al. Helicobacter pylori infection: a predictor of vomiting severity in pregnancy and adverse birth outcome. Am J Obstet Gynecol 2017; 216:512.e1.
- Gill SK, O'Brien L, Einarson TR, Koren G. The safety of proton pump inhibitors (PPIs) in pregnancy: a meta-analysis. Am J Gastroenterol 2009; 104:1541.
- Marshall JK, Thompson AB, Armstrong D. Omeprazole for refractory gastroesophageal reflux disease during pregnancy and lactation. Can J Gastroenterol 1998; 12:225.
- Plante L, Ferron GM, Unruh M, Mayer PR. Excretion of pantoprazole in human breast. J Reprod Med 2004; 49:825.
- Nava-Ocampo AA, Velázquez-Armenta EY, Han JY, Koren G. Use of proton pump inhibitors during pregnancy and breastfeeding. Can Fam Physician 2006; 52:853.
- Jorde R, Bostad L, Burhol PG. Asymptomatic gastric ulcer: a follow-up study in patients with previous gastric ulcer disease. Lancet 1986; 1:119.
- Howden CW, Hunt RH. The relationship between suppression of acidity and gastric ulcer healing rates. Aliment Pharmacol Ther 1990; 4:25.
- Burget DW, Chiverton SG, Hunt RH. Is there an optimal degree of acid suppression for healing of duodenal ulcers? A model of the relationship between ulcer healing and acid suppression. Gastroenterology 1990; 99:345.
- Kaneko E, Ooi S, Ito G, Honda N. Natural history of duodenal ulcer detected by the gastric mass surveys in men over 40 years of age. Scand J Gastroenterol 1989; 24:165.
- Hopkins RJ, Girardi LS, Turney EA. Relationship between Helicobacter pylori eradication and reduced duodenal and gastric ulcer recurrence: a review. Gastroenterology 1996; 110:1244.
- Laine L, Hopkins RJ, Girardi LS. Has the impact of Helicobacter pylori therapy on ulcer recurrence in the United States been overstated? A meta-analysis of rigorously designed trials. Am J Gastroenterol 1998; 93:1409.
- INITIAL MANAGEMENT
- Eradication of Helicobacter pylori
- Withdrawal of offending or contributing factors
- Antisecretory therapy
- - Choice and duration of therapy
- - Efficacy
- ENDOSCOPY AFTER INITIAL THERAPY
- Duodenal ulcers
- Gastric ulcers
- REFRACTORY ULCERS
- MAINTENANCE THERAPY
- MANAGEMENT OF COMPLICATIONS
- TREATMENT DURING PREGNANCY AND LACTATION
- DISEASE COURSE
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS