TABLE 731 Traditional Drugs for Peptic Ulcers

Although NSAIDs should be stopped in patients with peptic ulcer disease whenever possible, misoprostol may prevent ulcer formation in those on concurrant NSAID therapy. Misoprostol is a prostaglandin analogue that may act by increasing mucous and bicarbonate production and by increasing mucosal blood flow.

If H. pylori infection is diagnosed in the presence of peptic ulcer disease, eradication is clearly indicated. 1 15 Multiple regimens have been proposed and studied mainly using combinations of bismuth subsalicylate, amoxicillin, tetracycline, metronidazole, clarithromycin, an H 2RA (mainly ranitidine), and a PPI (mainly omeprazole). Usual treatment lasts 2 weeks, costs from $30 to $360 and is effective in from 60 to greater than 90 percent of cases. I8,1, 15

Patients generally do not present to the emergency department with a definitive diagnosis of peptic ulcer disease but, rather, with a symptom, such as epigastric pain. If appropriate history, physical examination, and laboratory evaluation result in a physician's impression of "possible peptic ulcer disease" or "dyspepsia," the physician is left with three main options: empiric treatment with conventional antiulcer medication, immediate referral for definite diagnosis (endoscopic or radiologic study), or noninvasive testing for H. pylori followed by antibiotic therapy for patients with positive test results. 119

Traditional emergency department treatment would entail initiating a trial of antacids and/or H 2RAs and early referral to a primary care provider to direct evaluation and subsequent treatment. This still is a reasonable option. Immediate referral for definite diagnosis is mandated if certain "alarm" features are present: advanced age, weight loss, long history, anemia, persistent anorexia, early satiety, persistent vomiting, or gastrointestinal bleeding. 11 16 Cost-effectiveness analysis supports treatment of H. pylori-positive dyspeptic patients with antimicrobial and antisecretory therapy followed by endoscopic study only in those with persistent symptoms.3,1 18 It would also be reasonable for the emergency department physician to begin symptomatic therapy, order serologic testing for H. Pylori, and refer for early follow-up with a primary care provider for initiation of antibacterial therapy if the test results are positive.

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