Editing Peptic ulcer disease (section)

==Management==
[[File:Antisectetory drugs.jpg|thumb|Peptic ulcer treatment: pharmacology of drugs]]

===Eradication therapy===
Once the diagnosis of ''H. pylori'' is confirmed, the first-line treatment would be a triple regimen in which [[pantoprazole]] and [[clarithromycin]] are combined with either [[amoxicillin]] or [[metronidazole]]. This treatment regimen can be given for 7–14 days. However, its effectiveness in eradicating ''H. pylori'' has been reducing from 90% to 70%. However, the rate of eradication can be increased by doubling the dosage of pantoprazole or increasing the duration of treatment to 14 days. Quadruple therapy (pantoprazole, clarithromycin, amoxicillin, and metronidazole) can also be used. The quadruple therapy can achieve an eradication rate of 90%. If the clarithromycin resistance rate is higher than 15% in an area, the usage of clarithromycin should be abandoned. Instead, [[bismuth]]-containing quadruple therapy can be used (pantoprazole, bismuth citrate, [[tetracycline]], and metronidazole) for 14 days. The bismuth therapy can also achieve an eradication rate of 90% and can be used as second-line therapy when the first-line triple-regimen therapy has failed.

===NSAIDs-induced ulcers===
NSAID-associated ulcers heal in six to eight weeks provided the NSAIDs are withdrawn with the introduction of [[proton pump inhibitor]]s (PPI).<ref name="Angel 2017"/>

===Bleeding===
[[Image:GU with clip.jpg|right|thumb|Endoscopic clipping placed on a gastric ulcer at risk for bleeding]]
For those with bleeding peptic ulcers, [[fluid replacement]] with [[crystalloid solution|crystalloids]] is sometimes given to maintain volume in the blood vessels. Maintaining haemoglobin at greater than 7 g/dL (70 g/L) through restrictive blood transfusion has been associated with reduced rate of death. [[Glasgow-Blatchford score]] is used to determine whether a person should be treated inside a hospital or as an outpatient. [[Intravenous]] PPIs can suppress stomach bleeding more quickly than oral ones. A neutral stomach pH is required to keep platelets in place and prevent clot lysis. [[Tranexamic acid]] and [[antifibrinolytic]] agents are not useful in treating peptic ulcer disease.<ref name="Angel 2017"/>

Early endoscopic therapy can help to stop bleeding by using [[cautery]], [[endoclip]], or [[epinephrine]] injection. Treatment is indicated if there is active bleeding in the stomach, visible vessels, or an adherent clot. Endoscopy is also helpful in identifying people who are suitable for hospital discharge. [[Prokinetic agent]]s such as [[erythromycin]] and [[metoclopramide]] can be given before endoscopy to improve endoscopic view. Either high- or low-dose PPIs are equally effective in reducing bleeding after endoscopy. High-dose intravenous PPI is defined as a bolus dose of 80&nbsp;mg followed by an infusion of 8&nbsp;mg per hour for 72 hours—in other words, the continuous infusion of PPI of greater than 192&nbsp;mg per day. Intravenous PPI can be changed to oral once there is no high risk of rebleeding from peptic ulcer.<ref name="Angel 2017"/>

For those with [[hypovolemic shock]] and ulcer size of greater than 2&nbsp;cm, there is a high chance that the endoscopic treatment would fail. Therefore, surgery and angiographic embolism are reserved for these complicated cases. However, there is a higher rate of complication for those who underwent surgery to patch the stomach bleeding site when compared to repeated endoscopy. [[Angiographic embolisation]] has a higher rebleeding rate but a similar rate of death to surgery.<ref name="Angel 2017"/>

===Anticoagulants===
According to expert opinion, for those who are already on anticoagulants, the [[international normalized ratio]] (INR) should be kept at 1.5. For aspirin users who required endoscopic treatment for bleeding peptic ulcer, there is two times increased risk of rebleeding but with ten times reduced risk of death at eight weeks following the resumption of aspirin. For those who were on double antiplatelet agents for indwelling stent in blood vessels, both antiplatelet agents should not be stopped because there is a high risk of stent thrombosis. For those who were under [[warfarin]] treatment, [[fresh frozen plasma]] (FFP), vitamin K, prothrombin complex concentrates, or recombinant factor VIIa can be given to reverse the effect of warfarin. High doses of vitamin K should be avoided to reduce the time for rewarfarinisation once the stomach bleeding has stopped. Prothrombin complex concentrates are preferred for severe bleeding. Recombinant factor VIIa is reserved for life-threatening bleeding because of its high risk of thromboembolism.<ref name="Angel 2017"/> [[Anticoagulant#Directly acting oral anticoagulants|Direct oral anticoagulants]] (DOAC) are recommended instead of warfarin as they are more effective in preventing thromboembolism. In case of bleeding caused by DOAC, [[activated carbon|activated charcoal]] within four hours is the antidote of choice.