Peptic ulcer treatment

Because many ulcers stem from H. pylori bacteria, doctors use a two-pronged approach to peptic ulcer treatment:

• Kill the bacteria.
• Reduce the level of acid in your digestive system to relieve pain and encourage healing.

Accomplishing these two goals requires the use of at least two, and sometimes three or four, of the following medications:

• Antibiotic medications. Doctors use combinations of antibiotics to treat H. pylori because one antibiotic alone isn't sufficient to kill the organism. For the treatment to work, it's essential that you follow your doctor's instructions precisely. Antibiotics commonly prescribed for treatment of H. pylori include amoxicillin (Amoxil), clarithromycin (Biaxin) and metronidazole (Flagyl). Some companies package a combination of two antibiotics together, with an acid suppressor or cytoprotective agent specifically for treatment of H. pylori infection. These combination treatments are sold under the names Prevpac and Helidac. You'll likely need to take antibiotics for two weeks, depending on their type and number. Other medications prescribed in conjunction with antibiotics generally are taken for a longer period.
• Acid blockers. Acid blockers — also called histamine (H-2) blockers — reduce the amount of hydrochloric acid released into your digestive tract, which relieves ulcer pain and encourages healing. Acid blockers work by keeping histamine from reaching histamine receptors. Histamine is a substance normally present in your body. When it reacts with histamine receptors, the receptors signal acid-secreting cells in your stomach to release hydrochloric acid. Available by prescription or over-the-counter (OTC), acid blockers include the medications ranitidine (Zantac), famotidine (Pepcid), cimetidine (Tagamet) and nizatidine (Axid).
• Antacids. Your doctor may include an antacid in your drug regimen. An antacid may be taken in addition to an acid blocker or in place of one. Instead of reducing acid secretion, antacids neutralize existing stomach acid and can provide rapid pain relief.
• Proton pump inhibitors. Another way to reduce stomach acid is to shut down the "pumps" within acid-secreting cells. Proton pump inhibitors reduce acid by blocking the action of these tiny pumps. These drugs include the prescription medications omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex) and esomeprazole (Nexium). The drug pantoprozole (Protonix) can be taken orally or administered intravenously in the hospital. Proton pump inhibitors are frequently prescribed to promote the healing of peptic ulcers. If you are admitted to the hospital with a bleeding ulcer, taking intravenous proton pump inhibitors decreases the chance that bleeding will recur. Proton pump inhibitors also appear to inhibit H. pylori. However, long-term use of proton pump inhibitors, particularly at high doses, may increase your risk of hip fracture.
• Cytoprotective agents. In some cases, your doctor may prescribe these medications that help protect the tissues that line your stomach and small intestine. They include the prescription medications sucralfate (Carafate) and misoprostol (Cytotec). Another nonprescription cytoprotective agent is bismuth subsalicylate (Pepto-Bismol). In addition to protecting the lining of your stomach and intestines, bismuth preparations appear to inhibit H. pylori activity.

If H. pylori isn't identified in your system, then it's likely that your ulcer is due to NSAIDs — which you should quit using, if possible — or acid reflux, which can cause esophageal ulcers. In both cases, your doctor will try to reduce acid levels — through use of acid blockers, antacids or proton pump inhibitors — and may also have you use cytoprotective drugs.

Ulcers that fail to heal
Peptic ulcers that don't heal with treatment are called refractory ulcers. There are many reasons why an ulcer may fail to heal. Not taking medications according to directions is one reason. Another is that some types of H. pylori are resistant to antibiotics. Other factors that can interfere with the healing process include regular use of tobacco, alcohol or nonsteroidal anti-inflammatory drugs (NSAIDs). Sometimes the problem is accidental: People are unaware that a medication they're taking contains an NSAID.

In rare cases, refractory ulcers may be a result of:

• Extreme overproduction of stomach acid, such as occurs in Zollinger-Ellison syndrome
• An infection other than H. pylori
• Stomach cancer
• Other digestive diseases, including Crohn's disease or cancer

Treatment for refractory ulcers generally involves eliminating factors that may interfere with healing, along with stronger doses of ulcer medications. Sometimes, additional medications may be included. Surgery to help heal an ulcer is necessary only when the ulcer doesn't respond to aggressive drug treatment.