Peptic Ulcer

Description

General Measures

Medicine Treatment

Referral

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ICD-10 code: K25.0-7/K25.9/K26.0-7/K26.9/K27.0-7/K27.9

DESCRIPTION

Ulcer in the stomach mucosa (gastric ulcer: GU) or first few centimetres of the duodenum (duodenal ulcer: DU), which penetrates into, or through the muscularis mucosa. Diagnosis is made after endoscopy as all GUs require biopsy to exclude malignancy.

General Measures

• Advise patient to avoid ulcerogenic medications, e.g. NSAIDs.
• Advise patient to stop smoking and drinking alcohol.
• Dietary advice by dietician.
• Patients with GUs and complicated DUs, those that have bled, perforated or are recurrent, must be rescoped at appropriate intervals until the ulcer has healed. H. pylori can be assessed at scope by rapid urease testing (RUT) or biopsy.

MEDICINE TREATMENT

H. pylori positive 

The vast majority of GUs and DUs are associated with H. pylori infection and eradication therapy is indicated if infection is present. This will greatly reduce the rate of recurrent ulceration. Empiric eradication of H. pylori is not recommended.

H. pylori eradication:

ICD-10 code: K25.0-7/K25.9/K26.0-7/K26.9/K27.0-7/K27.9 + (B98.0)

• Amoxicillin, oral, 1 g 12 hourly for 14 days.

LoE:Ib^xi

OR

For severe penicillin allergy:

ICD-10 code: (Z88.0)

• Azithromycin, oral, 500 mg daily for 3 days.

AND

• Metronidazole, oral, 400 mg 12 hourly for 14 days.

Proton pump inhibitors (PPIs):

• PPI, e.g.:
• Pantoprazole, oral, 40 mg 12 hourly for 14 days.

Continue with PPI therapy as follows:

• PPI, e.g.:

LoE:IIIb^xii

• Pantoprazole, oral, 40 mg daily.
  • Duodenal ulcer: for up to 2 weeks
  • Gastric ulcer: for up to 6 weeks

H. pylori negative:

• These are usually a consequence of NSAID use.
• Stop NSAID until ulcer has healed.
• If patient is unable to stop NSAID, refer to specialist for guidance.
• PPI, e.g.:
• Pantoprazole, oral, 40 mg daily.
  • Duodenal ulcer: for up to 4 weeks
  • Gastric ulcer: for up to 8 weeks.

LoE:IIIb^xiii

Resistant disease

• Ulcer not healing.
• High-risk patients, i.e. poor surgical risk and the elderly or concomitant disease.

Maintenance therapy:

• PPIs, e.g.:

LoE:III^xiv

• Pantoprazole, oral, 40 mg daily. Specialist initiated.

REFERRAL

• Failure of H. pylori eradication: Discuss with specialist.

Click here for the pdf.

Click here for the NEMLC Recommendations for medicine treatement (2020-4 review cycle).

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Standard Treatment Guidelines And Essential Medicines List For South Africa, Adult Hospital level, 2020-4_Version 1_July 2024

Chapter 1: Alimentary tract; 1.1 Gastrointestinal Disorders; 1.1.8 Peptic Ulcer