NICE guidance - management of duodenal ulcer (DU) in primary care

Management of Duodenal Ulcer in Primary Care

Step (A) Stop NSAIDs if used - note that if NSAID continuation is necessary, after ulcer healing offer long-term gastric protection or consider substitution to a newer Cox-2-selective NSAID

Step (B) Test of H.pylori (use a carbon-13 urea breath test, stool antigen test or, when performance has been validated, laboratory-based serology)

1. if test positive, ulcer associated with NSAID use then full-dose PPI for two months then (C)
2. if test positive, ulcer not associated with NSAID use then (C)
3. if test negative then full-dose PPI for one or two months
   1. if response after treatment then offer low-dose treatment, possibly on an as-required basis, with a limited number of repeat prescriptions then (D)
   2. if no response then exclude other causes of duoedenal ulcer 
      • consider: non-adherence with treatment, possible malignancy, failure to detect H. pylori infection due to recent PPI or antibiotic ingestion, inadequate testing or simple misclassification; surreptitious or inadvertent NSAID or aspirin use; ulceration due to ingestion of other drugs; Zollinger Ellison syndrome, Crohn's disease
      • review care annually, to discuss symptoms, promote stepwise withdrawal of therapy when appropriate and provide lifestyle advice.

Step (C) Eradication Therapy - triple therapy as per linked item

1. if response then return to self-care
2. if no response or relapse then re-test for H.pylori (use carbon-13 urea breath test or stool antigen test or when performance has been validated, laboratory-based serology)
   1. if positive then eradication therapy - as per linked item
   2. if negative then offer low-dose treatment, possibly on an as-required basis, then (D)
3. if no response or relapse after second course of eradication therapy then offer low-dose treatment, possibly on an as-required basis, with a limited number of repeat prescriptions then (D)

Step (D) Assessment of response to low-dose treatment

• if no response to low-dose treatment then exclude other causes of duoedenal ulcer
  • consider: non-adherence with treatment, possible malignancy, failure to detect H. pylori infection due to recent PPI or antibiotic ingestion, inadequate testing or simple misclassification; surreptitious or inadvertent NSAID or aspirin use; ulceration due to ingestion of other drugs; Zollinger Ellison syndrome, Crohn's disease
• if response then review care annually, to discuss symptoms, promote stepwise withdrawal of therapy when appropriate and provide lifestyle advice.

For full details then refer to the full guideline (1).

Reference:

1. NICE (September 2014).Dyspepsia and gastro-oesophageal reflux disease - Investigation and management of dyspepsia, symptoms suggestive of gastro-oesophageal reflux disease, or both