The precise diagnosis and duration of
peptic ulcer disease can now be made endoscopically. Numerous effective medical
therapies are available to treat these disorders. While the vast majority of patients respond to medical
therapy with complete healing of
ulcers within 4 to 6 weeks, a small percentage require longer and probably more intense treatment. A total assessment of the patient's lifestyle is important in order to achieve the best therapeutic response. Cigarette smoking is a potent negative factor for both healing and
ulcer recurrence. The question of who should continue on maintenance
therapy and for how long has not been answered. Certainly, the first-time
ulcer patient who smokes and becomes asymptomatic on treatment requires nothing more than standard 4- to 6-week
therapy and discontinuation of smoking. Patients with recurrent disease and those who have sustained complications such as
bleeding or perforation probably warrant 6 to 12 months of maintenance
therapy, with close follow-up thereafter. Some patients will require continuous maintenance
therapy in order to remain asymptomatic. In such patients it is important to determine that the problem is, in fact, "routine"
peptic ulcer disease.
Ulcers associated with
NSAIDs are unique in that their cause is known and, at present, their treatment is specific. Studies to date indicate that the only appropriate
therapy to prevent
NSAID ulcers is
misoprostol, and that this
drug is also effective in healing such
ulcers while
NSAID treatment is continued. Except for complications, few patients now need to be referred for surgical intervention. Those who are should receive the least destructive procedure possible. The efficacy of medical
therapy is generally enhanced following selective and
highly selective vagotomy. No patient should be referred electively to surgery without the
Zollinger-Ellison syndrome being ruled out.