Use of proton-pump inhibitors in complicated ulcer disease and upper gastrointestinal tract bleeding

Abstract

The use of proton-pump inhibitors in the management of complicated peptic ulcer disease and upper gastrointestinal bleeding is described. Treatment of peptic ulcers in patients who are Helicobacter pylori positive should include antimicrobial therapy to eradicate the infection; based on considerations of primary antimicrobial resistance and safety, one recommended regimen is the combination of a proton-pump inhibitor (lansoprazole 30 mg or omeprazole 20 mg), clarithromycin 500 mg, and amoxicillin 1 g, each twice daily for 14 days. The proportion of H. pylori-negative ulcers has increased in the United States, now accounting for 39% of patients with ulcers who report no intake of nonsteroidal anti-inflammatory drugs (NSAIDs). Compared with H. pylori-positive ulcers, H. pylori-negative ulcers are more aggressive, characterized by high recurrence rates and increased risk of bleeding and perforation. Long-term therapy with a proton-pump inhibitor may be useful in these patients. Acid suppressants may also have a role in the initial treatment of patients who have a bleeding ulcer, including those associated with NSAID use. For patients who require continuous NSAID therapy, proton-pump inhibitors have been shown to heal a significantly higher percentage of peptic ulcers in eight weeks than histamine H2-receptor antagonists, and maintenance therapy with either lansoprazole or omeprazole reduces ulcer recurrence. Preliminary data suggest a role for proton-pump inhibitors in the prevention of stress ulcers among critically ill patients. Proton-pump inhibitors play an important role in the treatment of both H. pylori-negative and H. pylori-positive peptic ulcers, as well as in upper gastrointestinal tract bleeding. Further study is needed regarding their role in preventing stress ulcers in critically ill patients.