Describe the treatment approach.
Nonpharmacological measures: e.g., avoid NSAIDs, restrict alcohol.
Follow-up to confirm treatment success; possibly endoscopic surveillance
H. pylori test-and-treat strategy
H. pylori eradication therapy with antibiotics and a PPI
Continue acid suppression medication (i.e., PPIs) for 4–8 weeks.
Negative: Trial of acid suppression medication (i.e., PPIs) for 4–8 weeks, followed by reevaluation
Failure of medical treatment : Consider elective surgery.
Describe the general medical treatment of PUD.
Pharmacologic therapies for uncomplicated PUD include a trial of acid suppression therapy and, if H. pylori is detected, eradication therapy. These may be complemented with antacids for rapid symptom relief, and in some cases with cytoprotective agents for mucosal protection. All patients should also be counseled on lifestyle and risk factor modification.
List and describe the drugs for medical treatment of PUD.
Acid suppression medications and antacids are covered in detail in “Treatment of dyspepsia.”
Cytoprotective agents (gastrointestinal mucosal protection)
Sucralfate : a sucrose sulfate-aluminum complex that reacts with HCl in an acidic environment to create a protective barrier over the gastric/duodenal mucosa
Acts as an acid buffer and promotes HCO3 production
Should not be taken simultaneously with a PPI or H2 blocker
Antibiotics: e.g., clarithromycin triple therapy (combined with amoxicillin and a PPI). See “H. pylori eradication therapy” for other treatment regimens.
Restrict alcohol, smoking, and caffeine, and avoid stress.
Avoid medications that may cause or worsen PUD (e.g., discontinue NSAIDs, reduce or stop corticosteroids if possible).
Avoid eating before bedtime.
Describe the general elective surgical treatment.
Surgical management of uncomplicated peptic ulcers is rarely necessary because they usually respond well to medical treatment. When malignancy is confirmed or complications such as massive bleeding or gastrointestinal perforation occur, surgery specific to these complications must be performed.
List indications for elective surgical treatment.
(consider after thorough evaluation)
Refractory symptoms or recurrence of disease despite appropriate medical treatment
Diseases that require the continuation of NSAIDs
Inability to tolerate medical treatment
Describe the surgical procedures.
Vagotomy: surgical division of the anterior and posterior vagal trunk of the vagus nerve (truncal vagotomy), both located along the lower esophagus. Denervation through truncal vagotomy results in ∼ 70% reduction of acid production.
Complications include delayed gastric emptying, postvagotomy diarrhea , postvagotomy hypergastrinemia, and dumping syndrome.
To improve results, truncal vagotomy is combined with one of the following drainage procedures:
Partial gastrectomy (Billroth) and reconstruction
Billroth I: distal gastrectomy with end-to-end or side-to-end gastroduodenostomy
Billroth II: resection of the distal two-thirds of the stomach with a blind-ending duodenal stump and end-to-side gastrojejunostomy
Total gastrectomy and reconstruction: Roux-en-Y
The anterior and posterior branches of the vagus nerve (CN X) are also known as nerves of Latarjet, which divide into terminal branches that innervate the stomach and the pylorus. The terminal branches on the antropyloric area are sometimes referred to as “crow's foot.”
Describe the indications for endoscopic follow-up.
Gastric ulcer in patients with ≥ 1 of the following :
Ulcer of unknown etiology
Ulcer that appears malignant in initial EGD (even if biopsies are negative)
No biopsies taken in initial EGD (e.g., due to active bleeding)
Ulcer diagnosed via radiological imaging
Duodenal ulcer: if symptoms persist after an appropriate course of antisecretory treatment
Bleeding peptic ulcer requiring initial emergency endoscopy: endoscopic control on the following day
Dysplasia: endoscopy every 6–12 months depending on the degree of dysplasia
Refractory ulcer: Consider repeated EGD until the ulcer heals or etiology is identified.
New onset of symptoms after successful H. pylori eradication
Surveillance method: Repeat endoscopy and obtain new biopsies.
Describe the H. pylori eradication confirmation.
Indication: H. pylori-associated ulcer
Performed 4 weeks or more after H. pylori eradication therapy
PPIs need to be paused at least 2 weeks prior to this test.
Urea breath testing
Stool antigen assay
Endoscopic biopsies with rapid urea testing (only if endoscopy is indicated; see indications above)