Management of peptic ulcer

The aim of treatment:

The main aim of treatment of peptic ulcer is to provide symptomatic relief to the patient in the short term, induce ulcer healing and to prevent relapse in the long run. If H. pylori are found, attempt should be made to eradicate with appropriate antibiotic therapy

General measures:

 General measures for management of peptic ulcer are avoidance of smoking as it has a causative role in peptic ulcer and also smoking cause delay in ulcer healing. So smoking should be strongly discouraged. Aspirin and other NSAIDs (non-steroidal anti inflammatory drugs) should be avoided as far as possible because of the injurious effect they have on gastric and duodenal mucosa. If NSAIDs are required for pain relief of some other pain like toothache, a selective COX2-inhibitor NSAID (e.g. valdecoxib, celecoxib etc.) should be given or they can be given with proton pump inhibitor drugs (e.g. omeprazole, pantoprazole etc.) or with prostaglandin analogues like misoprostol. Alcohol should be avoided (although alcohol in moderation does no harm) as well as excess tea and coffee.

Medical Management:

Short term management of peptic ulcer is done with H2-receptor antagonist (e.g. ranitidine, famotidine etc.), proton pump inhibitor drugs (e.g. omeprazole, pantoprazole, rabeprazole, etc.), sucralfate, and prostaglandin analogues (e.g. misoprostol) or with antacids. All the above mentioned medications are equally effective in treatment of peptic ulcer.

Maintenance therapy is done with proton pump inhibitor drugs (e.g. omeprazole) or with H2-receptor antagonist like ranitidine (either of the group of drugs is safe and effective in long term maintenance).

Eradication of H. pylori is important if found in biopsy. For eradication of H. pylori 14 day treatment is given with omeprazole 20 mg, metronidazole (or tinidazole) 400 mg and clarithromycine 250 mg (available as kit which contains all 3 medicines). One kit is to be taken 2 times a day for 14 days. Other combination kits are also available where clarithromycine is replaced with amoxicillin 750 mg.

Surgical treatment:

If none of the above mentioned treatment regimens including eradication of H. pylori fails, surgical treatment should be considered. Indication of surgical intervention is strengthened by the younger age of the patient, complications like hemorrhage or perforation of intestine, strong family history of peptic ulcer, frequent relapses, if ulcer is causing obstruction to gastric outflow or produced an hour glass stomach due to fibrosis. There are also patients who do not comply with prolonged medical management, can be treated with elective surgical intervention. But in case of elderly patients surgical operation should be avoided.

Finally every ulcer should be viewed with seriousness, especially long standing gastric ulcer as it can turn malignant although rarely. As peptic ulcer is a common problem in the modern life, it should be appropriately treated and doctor’s advice followed strictly.   

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