An etiologic approach to management of duodenal and gastric ulcers

With rare exception, peptic ulcers can now be classified as either Helicobacter pylori-related, induced by nonsteroidal anti-inflammatory drugs (NSAIDs), or related to Zollinger-Ellison syndrome. Helicobacter pylori-related ulcers can be treated by eradication of H pylori or by traditional therapies, including antisecretory drugs or sucralfate. Successful eradication of H pylori requires compliance with a multidrug regimen. Therefore, candidates should demonstrate substantial motivation. In general, the greater the degree of ulcer recurrence or resistance, the stronger the indication for H pylori eradication. Sucralfate is effective in healing H pylori-related duodenal ulcers, and H2 receptor antagonists heal H pylori-related duodenal and gastric ulcers. Omeprazole provides faster healing of H pylori-related ulcers, and is particularly useful in treating large gastric ulcers. Dyspepsia induced by NSAIDs and NSAID-related endoscopic erosions are managed by stopping NSAID use or reducing the dosage; administering NSAIDs with meals; and administering H2 receptor antagonists in full split-doses. NSAID-induced duodenal ulcers and small gastric ulcers can be healed with full split-doses of H2 receptor antagonists, even while the NSAID is continued. Large (> 5 mm) NSAID-induced gastric ulcers are most efficiently treated with omeprazole, particularly if the patient continues to take the NSAID.