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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 in 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. Clarithromycin-based triple therapy is no longer preferred 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 recommended dosages of misoprostol and superior to the 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 IV administration of a PPI loading dose followed by a 72-hour continuous infusion.

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

  • imageSince there are limited data to support the selection of a PPI over an IV H2RA for SRMB prophylaxis, agent selection should be based on appropriate individual patient characteristics (eg, nothing by mouth, presence of nasogastric tube, thrombocytopenia, renal failure).


Patient Care Process for Peptic Ulcer Disease (PUD)



  • Patient characteristics (eg, age, sex, pregnant)

  • Patient medical history (personal and family) especially prior history of H. pylori infection, previous peptic ulcers, or previous upper GI disorders (see Table 50-4)

  • Social history (eg, tobacco and ethanol use) as well as recent medical procedures and stress levels (see Table 50-2)

  • Current medications, especially NSAIDS (nonprescription and prescription) use of nonprescription proton pump inhibitors (PPIs), other acid reflux treatments, anticoagulants, and antiplatelet medications. If prior NSAID use, note medication, dosage, and duration of use

  • Pain: presence or absence, rating (1-10), quality, and location (see Table 50-5)

  • Objective Data

    • Blood pressure (BP), heart rate (HR), respiratory rate (RR), height, weight, O2-saturation

    • Labs including hemoglobin ...

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