---
title: Peptic Ulcer Disease Treatment
description: A comprehensive clinical reference on the diagnosis and management of peptic ulcer disease.
keywords: 
  - peptic ulcer
  - H. pylori
  - proton pump inhibitor
  - antibiotics
  - gastrointestinal
category: clinical
---

## Diagnostic Criteria

Peptic ulcer disease (PUD) is characterized by the presence of mucosal defects in the stomach (gastric ulcers) or duodenum (duodenal ulcers) that extend through the muscularis mucosae. The diagnosis of PUD is confirmed by endoscopic visualization of an ulcer crater ≥5 mm in diameter with unequivocal depth. Key diagnostic criteria include:

- Abdominal pain that may be relieved by food, antacids, or acid suppressants
- Positive Helicobacter pylori testing (e.g. urea breath test, stool antigen, or endoscopic biopsy)
- Presence of an ulcer crater ≥5 mm in diameter on endoscopy
- Exclusion of other potential causes (e.g. NSAIDs, malignancy)

## Etiology and Risk Factors

The primary etiologies of PUD include:

1. Helicobacter pylori infection: This gram-negative bacterium is the leading cause of PUD, responsible for up to 60-80% of gastric ulcers and 90-100% of duodenal ulcers.

2. Nonsteroidal anti-inflammatory drugs (NSAIDs): Chronic NSAID use can disrupt the gastric mucosal barrier, leading to ulceration.

3. Zollinger-Ellison syndrome: This rare condition involves gastrin-secreting tumors that cause severe, recurrent peptic ulcers.

Other risk factors for PUD include smoking, excessive alcohol use, stress, and a family history of the disease.

## Treatment Approach

The primary goals of PUD treatment are to:

1. Eradicate H. pylori infection (if present)
2. Provide symptomatic relief through acid suppression
3. Promote ulcer healing
4. Prevent ulcer recurrence

The treatment approach is guided by the underlying etiology and involves a combination of antimicrobial therapy, acid-suppressing medications, and lifestyle modifications.

### H. pylori Eradication

For patients with H. pylori-positive PUD, eradication of the infection is the cornerstone of treatment. The recommended first-line regimen is a 14-day course of:

- Proton pump inhibitor (PPI) (e.g., omeprazole 20 mg BID)
- Amoxicillin 1 g BID
- Clarithromycin 500 mg BID

Alternative regimens include:

- Bismuth quadruple therapy (PPI, bismuth, metronidazole, tetracycline)
- Concomitant therapy (PPI, amoxicillin, clarithromycin, metronidazole)

Eradication success rates should be monitored, and rescue therapy should be offered if initial treatment fails.

### Acid Suppression

Adequate acid suppression is essential for ulcer healing and symptom relief. Proton pump inhibitors (PPIs) are the mainstay of acid-suppressing therapy, with the following dosing recommendations:

- Gastric ulcers: Omeprazole 20-40 mg daily for 4-8 weeks
- Duodenal ulcers: Omeprazole 20 mg daily for 4 weeks

H2-receptor antagonists (e.g., ranitidine, famotidine) are less potent but may be used as an alternative.

### Lifestyle Modifications

Patients with PUD should be counseled on the following lifestyle changes:

- Smoking cessation
- Reduction of alcohol intake
- Avoidance of NSAIDs and aspirin
- Stress management techniques

### Monitoring and Follow-up

Patients should undergo endoscopic re-evaluation 4-8 weeks after the initiation of treatment to confirm ulcer healing. Subsequent monitoring should include:

- H. pylori testing (if previously positive)
- Assessment of symptom resolution
- Evaluation for complications (bleeding, perforation, obstruction)

## Complicated Peptic Ulcers

Complicated PUD, such as bleeding, perforation, or obstruction, requires prompt medical or surgical intervention.

### Bleeding Ulcers

Patients with suspected upper gastrointestinal bleeding should be evaluated with urgent endoscopy. Endoscopic hemostatic techniques (e.g., thermal, mechanical, or injection therapy) should be employed for active bleeding or high-risk stigmata. Intravenous PPI therapy should be initiated, followed by high-dose oral PPI maintenance.

### Perforated Ulcers

Patients with signs of peritonitis or free air on imaging should undergo immediate surgical exploration and repair. Postoperative management includes broad-spectrum antibiotics, acid suppression, and H. pylori eradication (if applicable).

### Obstructive Ulcers

Gastric outlet obstruction due to a duodenal or pyloric ulcer may require endoscopic dilation or surgical intervention (e.g., gastrojejunostomy, pyloroplasty) to restore gastric emptying.

## Special Considerations

### Nonsteroidal Anti-inflammatory Drug (NSAID)-Induced Ulcers

Patients on chronic NSAID therapy should be co-prescribed a PPI to reduce the risk of ulcer development. If an NSAID-induced ulcer is diagnosed, the NSAID should be discontinued, and PPI therapy should be initiated.

### Elderly Patients

Older adults are at increased risk of PUD complications, such as bleeding and perforation. They should be promptly evaluated and treated, with particular attention to medication reconciliation and avoidance of high-risk medications (e.g., NSAIDs, anticoagulants).

### Recurrent or Refractory Ulcers

Patients with recurrent or refractory PUD should undergo thorough investigation, including:

- Repeat endoscopy to rule out malignancy
- Evaluation for Zollinger-Ellison syndrome
- Consideration of alternative eradication regimens for H. pylori
- Assessment of medication adherence and potential interactions

In these cases, consultation with a gastroenterologist is recommended.

## Conclusion

Peptic ulcer disease is a common gastrointestinal condition that requires a comprehensive, evidence-based approach to management. Effective treatment involves the eradication of H. pylori infection, adequate acid suppression, and addressing underlying risk factors. Careful monitoring and prompt recognition of complications are essential for optimal patient outcomes.