Overview of the management of the adult patient with peptic ulcer disease

PPI: proton pump inhibitor; H. pylori: Helicobacter pylori; NSAID: non steroidal anti-inflammatory drug; IV: intravenous.
* Patients with complicated peptic ulcers should receive initial acid suppressive therapy with an IV PPI. In general, once patients are tolerating oral medications, they should be switched to an oral PPI. However, in patients with bleeding peptic ulcers the duration of IV PPI and timing of transition to oral PPI is based on the risk of rebleeding. Refer to UpToDate text on treatment of bleeding peptic ulcers.
¶ In patients with bleeding duodenal or gastric ulcer on upper endoscopy, we perform a gastric mucosal biopsy at the time of the initial endoscopy unless it is impractical or difficult, such as with a blood-filled stomach. A negative biopsy result does not exclude H. pylori in the setting of an active upper gastrointestinal bleed, and another test for active H. pylori infection should be performed to confirm a negative result.
Δ A repeat upper endoscopy is indicated in patients with any one of the following:

• Persistent symptoms or recurrent symptoms after discontinuation of PPI therapy
• Complicated ulcer (bleeding) with evidence of ongoing bleeding
• Giant gastric ulcer (>2 cm)
• Ulcer with features of malignancy at index endoscopy
• Gastric ulcer that was not biopsied or inadequately sampled on the index upper endoscopy (for adequate sampling we suggest 4 biopsies obtained from four quadrants of the ulcer and additional biopsies of the edges with jumbo forceps if there are endoscopic features of a malignant gastric ulcer)
• Gastric ulcers in a patient with risk factors for gastric cancer (Refer to UpToDate text on the management of peptic ulcer disease)
• Gastric ulcer of unclear etiology

◊ Refer to UpToDate text on rare causes of peptic ulcer disease.
§ Examples of typical maintenance doses for PPI include omeprazole 20 mg daily, lansoprazole 30 mg daily, esomeprazole 20 mg daily, and pantoprazole 40 mg daily.