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  • imagePsychological stress, cigarette smoking, nonsteroidal anti-inflammatory drug (NSAID) use, and certain foods/beverages can exacerbate ulcer symptoms and should be avoided.

  • imageEradication of Helicobacter pylori (H. pylori) is recommended for all patients who test positive, especially in those patients with an active ulcer, a documented history of a prior ulcer, or a history of ulcer-related complications.

  • imageThe selection of an H. pylori eradication regimen should be based on several factors, including efficacy, safety, antibiotic resistance, cost, and the likelihood of medication adherence. The recommended initial treatment options with the strongest level of evidence include bismuth quadruple and concomitant therapy, both administered for 10 to 14 days. Empiric clarithromycin-based triple therapy is no longer recommended due to increasing resistance and reduced eradication rates.

  • imageWhen first-line therapy fails, salvage treatment for H. pylori should contain different antibiotics due to potential resistance. Patients with reported penicillin allergy should be considered for penicillin skin testing after failing first-line therapy since many can safely be treated with amoxicillin containing salvage regimens.

  • imagePPI co-therapy reduces the risk of NSAID-related gastric and duodenal ulcers and is at least as effective as misoprostol and superior to histamine-2 receptor antagonists (H2RAs).

  • imageStandard PPI dosages and a nonselective NSAID are as effective as a selective cyclooxygenase-2 (COX-2) inhibitor in reducing the risk of NSAID-induced ulcers and upper gastrointestinal (GI) complications.

  • imagePatients with peptic ulcer disease (PUD), especially those receiving H. pylori eradication or misoprostol co-therapy, require patient education regarding their disease and drug treatment to successfully achieve a positive therapeutic outcome.

  • imageTreatment for severe peptic ulcer bleeding after appropriate endoscopic treatment includes administration of a PPI either orally or parenterally via intermittent or continuous infusion targeting cumulative daily doses of 80 to 160 mg.

  • imageCoagulopathy and respiratory failure requiring mechanical ventilation are the most notable risk factors for developing stress-related mucosal bleeding (SRMB). Prophylactic drug therapy should be administered to critically ill patients with either of these risk factors.

  • imageSelection of a PPI over an IV H2RA for SRMB prophylaxis should be based on individual patient characteristics (eg, nothing by mouth, presence of nasogastric tube, thrombocytopenia, renal failure).



Create a table with two columns, one titled PPI and one titled H2RA. Create rows for Prevention of NSAID-induced ulcer disease and Stress Ulcer Prophylaxis. In each new cell, list advantages and disadvantages of using each medication class for these conditions. The purpose of this exercise is to familiarize students with the relative safety and efficacy for medications commonly used to treat PUD.


Gastric acid is a critical component of upper gastrointestinal (GI) tract complications including gastritis, erosions, and peptic ulcer.2-4 Peptic ulcer disease (PUD) differs from gastritis and erosions in that ulcers are larger (greater than or equal to 5 mm) and extend deeper into the muscularis mucosa. The three common forms ...

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