Peptic ulcers: treatment

There are treatments available that can heal peptic ulcers and stop them from coming back. Specific treatments for peptic ulcers depends on the cause of the ulcer and whether there are any complications.

Most people with peptic ulcers will be prescribed medicines to reduce the amount of acid in the stomach, which helps the ulcer to heal and relieves symptoms.

If your peptic ulcer is associated with an infection with Helicobacter pylori, your doctor will recommend antibiotics to eradicate the H. pylori bacteria. Treating the infection helps the ulcer heal and helps prevent new ulcers developing in the future.

If your ulcer was caused by use of nonsteroidal anti-inflammatory drugs (NSAIDs), the NSAIDs should be stopped, if possible. If NSAIDs cannot be stopped, they should be taken together with acid-suppressing medicines.

People with peptic ulcers associated with H. pylori infection should also avoid or stop taking NSAID medicines, if possible.

Treatment of peptic ulcers associated with H. pylori

Most people with ulcers (or suspected ulcers) will be tested to see if they are infected with H. pylori. That’s because the majority of duodenal ulcers and a large percentage of stomach ulcers are caused by H. pylori.

Eradication therapy is used to treat peptic ulcers associated with H. pylori infection. This therapy includes:

  • a medicine that suppresses the production of stomach acid (usually a proton pump inhibitor), which helps the ulcer to heal and relieves peptic ulcer pain; plus
  • antibiotics to eradicate (get rid of) the H. pylori bacteria.

Eradication therapy has revolutionised the treatment of peptic ulcers worldwide. Depending on the medicines used, it can have a success rate of 85 to 90 per cent in eradicating H. Pylori and treating peptic ulcers. Eradicating H. pylori also significantly reduces the chance of relapse.

Triple therapy to eradicate H. pylori

Because no single antibiotic is effective against H. pylori, combination therapy is given. The first-choice treatment for eradicating H. pylori in Australia is called triple therapy, and includes:

  • a proton pump inhibitor (esomeprazole); plus
  • 2 antibioticsclarithromycin and amoxicillin.

These medicines need to be taken twice daily for 7 days.

Convenient ‘combination packs’ containing all the medicines for the treatment are available (Brand name Nexium Hp7 Combination pack).

It is vital that you follow the treatment exactly according to your doctor’s instructions — the success rate is much lower if the tablets are not taken as directed.

Side effects commonly associated with triple therapy include nausea, diarrhoea and taste disturbance. Side effects are usually mild.

Alternative eradication therapies

There are other combinations of medicines that can be used if you are allergic to amoxicillin/penicillin or if first-line therapy is not effective in eradicating H. pylori. Your doctor will advise you which combination will be most likely to work for you.

Side effects will depend on which medicines you take for eradication therapy. Your doctor should let you know about common side effects and what to do about them.

Ongoing acid-suppression treatment

Some people (for example, those with complicated, recurrent or large ulcers) may need ongoing treatment with a proton pump inhibitor (PPI) for a period of time after completing the antibiotic course. Histamine H2-receptor antagonists (a different type of medicine that reduces stomach acid secretion) can be used but are less effective than proton pump inhibitors.

Sometimes, long-term treatment with PPIs is recommended to prevent a relapse in people who are at high risk.

Treatment of NSAID-induced ulcers

Treatment for NSAID-induced ulcers involves stopping the NSAID (if possible) and taking a medicine to suppress acid secretion and promote healing.

Acid-suppressing medicines are usually given for 8-12 weeks, depending on whether it is a duodenal or gastric ulcer. Proton pump inhibitors are usually used, as they are effective and heal ulcers faster than H2-receptor antagonists.

In people who cannot stop taking NSAIDs, taking them in combination with a proton pump inhibitor can reduce the risk of peptic ulcers. Some people at high risk may be offered long-term treatment with PPIs to prevent a recurrence. There are some risks associated with using PPIs long-term that need to be weighed up against the risk of having another peptic ulcer - your doctor will talk you through this.

Your doctor will also recommend testing for H. pylori infection and eradication treatment if necessary.

Antacids

Antacids neutralise the stomach’s acid and so usually give temporary relief from ulcer pain. There are many varieties available without a prescription. Ask your pharmacist for advice about which one would be best for you.

If you are being treated for H. pylori infection, you should check with your doctor before taking an antacid, because some of the antibiotics used in eradication therapy for H. pylori don’t work as well when combined with an antacid.

Lifestyle changes

Your doctor may give you dietary guidelines to follow, such as reducing or eliminating alcohol, as it can worsen ulcers and prevent healing. It’s a good idea to avoid any foods that tend to aggravate your symptoms.

If you are a smoker, your doctor will also recommend you stop smoking as it has been shown that smokers have a higher incidence of ulcer complications and recurrence.

Stress relief may be important for reducing your symptoms, because being stressed can increase stomach acid production. It might be easier said than done, but you should try to get enough sleep and exercise and make time to do things you enjoy, such as reading or seeing friends and family. Meditation or relaxation exercises may be an good option for you. Talk to your doctor if you are worried about your stress levels.

Treating ulcer complications

If you develop peptic ulcer complications, you may need to have a procedure or surgery.

Bleeding ulcers can usually be treated endoscopically (during a gastroscopy) by sealing the blood vessels using a special instrument that is fed down the endoscopy tube. Sometimes surgery is needed if the bleeding cannot be stopped this way.

Perforated peptic ulcers usually need to be treated surgically.

References

1. Gastric disorders (published March 2016). In: eTG complete. Melbourne: Therapeutic Guidelines Limited; 2018 Jul. https://tgldcdp.tg.org.au/ (accessed Oct 2018).
2. BMJ Best Practice. Peptic ulcer disease (updated Jan 2018; reviewed Sep 2018). https://bestpractice.bmj.com/topics/en-gb/80 (accessed Oct 2018).
3. Drini M. Peptic ulcer disease and non-steroidal anti-inflammatory drugs. Aust Prescr 2017;40:91-3. DOI: 10.18773/austprescr.2017.037. https://www.nps.org.au/australian-prescriber/articles/peptic-ulcer-disease-and-non-steroidal-anti-inflammatory-drugs (accessed Oct 2018).
4. Mitchell H, Katerlaris P. Epidemiology, clinical impacts and current clinical management of Helicobacter pylori infection. Med J Aust 2016; 204 (10): 376-380. || doi: 10.5694/mja16.00104. https://www.mja.com.au/journal/2016/204/10/epidemiology-clinical-impacts-and-current-clinical-management-helicobacter (accessed Oct 2018).
5. Ng JCH, Yeomans ND. Helicobacter pylori infection and the risk of upper gastrointestinal bleeding in low dose aspirin users: systematic review and meta-analysis. Med J Aust 2018;209(7):306-11. doi: 10.5694/mja17.01274. https://www.mja.com.au/journal/2018/209/7/helicobacter-pylori-infection-and-risk-upper-gastrointestinal-bleeding-low-dose (accessed Oct 2018).
6. Yaxley J, Chakravaerty B. Helicobacter pylori eradication - an update on the latest therapies. AFP 2014;43(5):301-5. https://www.racgp.org.au/afp/2014/may/helicobacter-pylori-eradication/ (accessed Oct 2018).
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