Management of peptic ulcer disease not related to Helicobacter

Abstract

Most peptic ulcers not due to Helicobacter pylori are caused by non-steroidal anti-inflammatory drugs (NSAID), among which an important subset are due to vascular protective ('low-dose') aspirin therapy. Non-steroidal anti-inflammatory drugs ulcers heal quite quickly when treated with a proton pump inhibitor (PPI), even though the NSAID is continued. If the NSAID can be stopped, the ulcers heal readily with either a PPI or a histamine H 2 -receptor antagonist (H 2 -RA). If anti-inflammatory treatment is still needed after ulcers are healed, prophylactic co-therapy with a PPI or misoprostol will reduce the risk of ulcer recurrence by about 60-80%. The alternative of switching to a highly selective cyclooxygenase-2 inhibitor has been shown to reduce the risk of a complicated ulcer by about 50-60%, unless low-dose aspirin treatment needs to be given as well for vascular disease. Idiopathic ulcers are becoming more frequent as H. pylori prevalence falls. Some may be sequelae of previous NSAID ulceration even though the NSAID has been ceased and the original ulcer had healed. These are best treated with an H 2 -RA or a PPI, followed by long-term maintenance with either of these (often in half the healing dosage) to prevent recurrence. Ulcers due to Zollinger-Ellison syndrome and other hypergastrinemia syndromes are rare, and largely beyond the scope of this review.

High Recurrence Rate of Idiopathic Peptic Ulcers in Long-Term Follow-up

“…However, there is no established guideline of management for IPUD at the present time 14-16. This stems from the fact that we do not know the exact pathophysiology of IPUD.…”

Review article: Helicobacter pylori‐negative duodenal ulcer disease

“…Nonsteroidal anti‐inflammatory drugs are classically considered as an important cause of gastroduodenal lesions 110, 111 . Several observations suggest that NSAIDs represent the most relevant factor in DU not associated with H. pylori infection.…”

Management of acute bleeding in the upper gastrointestinal tract

“…The ulcer may then be healed with an H 2 -receptor antagonist or a proton pump inhibitor over a period of six weeks. 9 Current clinical practice favours proton pump inhibitor therapy over H 2 -receptor antagonist for ulcer healing. No further endoscopy is required for duodenal ulcers, but repeat endoscopy at eight weeks is advisable for gastric ulcers to ensure healing and exclude malignancy.…”