Treatment has three aims at once: heal the ulcer, remove the cause that keeps it there, and prevent it from returning. Acid suppression heals the mucosal defect, eradicating H. pylori or stopping an injurious drug removes the trigger, and a smaller group of patients needs long-term or surgical treatment.
Healing the ulcer
Proton pump inhibitors (PPIs) are the mainstay of acid suppression and heal the great majority of ulcers. A duodenal ulcer usually heals within 4 weeks of adequate treatment, while a gastric ulcer heals more slowly, taking about 8 weeks. The ulcer must also be protected from reinjury for as long as it is healing: a patient who continues to take the drug that caused the ulcer is likely to heal poorly whatever acid suppression is used.
Eradicating H. pylori
H. pylori infection is formally recognised as an infectious disease, and current consensus is that infected patients should be treated. Eradication heals most ulcers linked to the infection and greatly reduces the chance of recurrence, so it is the definitive step for that group. Treatment combines an acid suppressant with two or more antibiotics, and the choice of regimen is driven by clarithromycin resistance:
- PPI-clarithromycin triple therapy — a PPI with clarithromycin and amoxicillin (metronidazole for patients allergic to penicillin) for 14 days — is used where local clarithromycin resistance is low and the regimen reliably cures.
- Bismuth quadruple therapy — a PPI with bismuth, tetracycline and metronidazole for 14 days — is preferred where clarithromycin resistance exceeds about 15% or is unknown, because clarithromycin-containing triple therapy rarely succeeds against a resistant strain.
Because resistance is rising, the regimen that works in one region may fail in another, and eradication success should be confirmed rather than assumed. A test of cure — usually a urea breath test or a stool antigen test — is done at least four weeks after treatment ends, with PPIs stopped for one to two weeks beforehand so that the result is not falsely negative.
Ulcers caused by NSAIDs or aspirin
When an ulcer is linked to an NSAID or to low-dose aspirin, stopping the drug is the most effective step if it is safe to do so. If the drug has to continue, a PPI is given alongside it for protection, and any H. pylori infection is tested for and treated, because the two risks add together. For patients at high risk of bleeding who cannot stop the NSAID, the options include a COX-2 selective agent combined with a PPI, and misoprostol, a prostaglandin analogue, as an alternative protective drug.
Maintenance and refractory disease
Most ulcers heal and stay healed once the cause is removed. Long-term maintenance acid suppression is reserved for ulcers that keep coming back, for those that fail to heal, and for patients who must continue an injurious drug and are at high risk. An ulcer that remains unhealed, or that recurs despite eradication and effective acid suppression, calls for a review of adherence and drug causes, and for assessment for rare causes such as Zollinger-Ellison syndrome. Surgery is now uncommon and is reserved for complications — such as perforation or obstruction — or for the occasional ulcer that will not heal with medical treatment.