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 and 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).
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- INITIAL MANAGEMENT
- Eradication of Helicobacter pylori
- Withdrawal of offending or contributing factors
- Antisecretory therapy
- - Choice and duration of therapy
- - Efficacy
- SURVEILLANCE ENDOSCOPY AFTER INITIAL THERAPY
- Duodenal ulcers
- Gastric ulcers
- MAINTENANCE THERAPY
- REFRACTORY ULCERS
- MANAGEMENT OF COMPLICATIONS
- TREATMENT DURING PREGNANCY AND LACTATION
- DISEASE COURSE
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS