Ulcer Therapy: Treatment of Peptic Ulcers

What Is Ulcer Therapy?

Ulcer therapy refers to the full range of medical treatments used to manage a peptic ulcer -- a sore that develops on the inner lining of the stomach (gastric ulcer) or the upper part of the small intestine, called the duodenum (duodenal ulcer). An ulcer forms when the protective mucous layer of the digestive tract breaks down, exposing the underlying tissue to stomach acid.

Causes of a Peptic Ulcer

Identifying the underlying cause is essential for effective treatment. The most common causes include:

• Helicobacter pylori (H. pylori): A bacterial infection that colonizes the stomach lining and is responsible for the majority of peptic ulcers worldwide.
• Non-steroidal anti-inflammatory drugs (NSAIDs): Medications such as ibuprofen and diclofenac inhibit the production of protective prostaglandins in the stomach lining.
• Excess stomach acid production: As seen in rare conditions such as Zollinger-Ellison syndrome.
• Contributing lifestyle factors including smoking, excessive alcohol consumption, and chronic stress.

Symptoms

Common symptoms that may indicate the need for ulcer therapy include:

• Burning or gnawing pain in the upper abdomen, often between meals or at night
• Nausea and vomiting
• Loss of appetite and unintentional weight loss
• Dark, tarry stools (melena), indicating gastrointestinal bleeding
• Heartburn and acid reflux

Diagnosis

The primary diagnostic tool is an upper endoscopy (esophago-gastro-duodenoscopy, EGD), which allows the physician to directly visualize the ulcer, take a biopsy if needed, and test for H. pylori infection. Non-invasive alternatives include the urea breath test and the stool antigen test.

Treatment

Eradication Therapy for H. pylori Infection

If H. pylori is confirmed, eradication therapy is the cornerstone of treatment. The standard approach is a combination regimen lasting 7 to 14 days:

• Proton pump inhibitors (PPIs) such as omeprazole or pantoprazole: Strongly suppress stomach acid production to allow the mucosa to heal.
• Two antibiotics, typically clarithromycin and amoxicillin, forming a triple therapy to eliminate the bacteria.

If first-line therapy fails, a quadruple therapy incorporating bismuth or a different antibiotic combination is used as a second-line regimen.

Acid-Suppressive Therapy

Regardless of the underlying cause, proton pump inhibitors (PPIs) are the foundation of ulcer therapy. By substantially reducing acid levels in the stomach, they create an environment in which the mucosal lining can regenerate. Treatment typically lasts 4 to 8 weeks. H2-receptor antagonists represent an alternative for patients who cannot tolerate PPIs.

Discontinuation of Mucosal-Damaging Medications

If the ulcer is linked to NSAID use, these medications should be stopped or replaced with a more stomach-friendly alternative where clinically possible. When continued NSAID use is unavoidable, a PPI should be co-prescribed for ongoing gastric protection.

Endoscopic and Surgical Treatment

In the case of complications such as an actively bleeding ulcer, immediate endoscopic intervention is performed during the upper endoscopy procedure -- for example, by injection of a hemostatic agent or application of hemostatic clips. In rare cases involving perforation or therapy-refractory ulcers, surgical intervention may be required.

Lifestyle Modifications

In addition to medical treatment, the following lifestyle adjustments are recommended to support healing and reduce the risk of recurrence:

• Cessation of smoking and avoidance of alcohol
• Stress reduction strategies
• Dietary adjustments: avoiding heavily spiced or high-fat foods during symptomatic periods
• Regular follow-up endoscopy to confirm complete healing, particularly for gastric ulcers

Outlook and Prognosis

With appropriate ulcer therapy, the vast majority of peptic ulcers heal completely. Successful eradication of H. pylori dramatically reduces the risk of recurrence. Without addressing the root cause, however, relapse rates remain high.

References

1. Malfertheiner P. et al. - Management of Helicobacter pylori infection: the Maastricht V/Florence Consensus Report. Gut, 2017. DOI: 10.1136/gutjnl-2016-312288
2. Laine L. - Clinical Practice. Upper Gastrointestinal Bleeding Due to a Peptic Ulcer. New England Journal of Medicine, 2016. DOI: 10.1056/NEJMcp1513703
3. Loscalzo J. et al. (Eds.) - Harrison's Principles of Internal Medicine, 21st Edition. McGraw-Hill Education, 2022.