1. Diagnostic Evaluation Radiographic barium study –Less sensitive in small ulcers <0.5cm –Well-demarcated crater (bulb) Endoscopic Procedure –Biopsy sample can be obtained –Therapy can be administered Injection of epinephrine or sclerosant into and around vessels Coaptive coagulation of vessel using thermal probe or hemoclips Urea breath test Stool antigen

2. Acid neutralizing/ Inhibitory drugs –Antacids – AlOH, MgOH 100-140 meq/L 1-3 h after meals and hs –H 2 Receptor Antagonists Cimetidine (400 mg bid), Ranitidine (300 mg hs), Famotidine (40 mg hs), Nizatidine (300 mg hs) –Proton Pump Inhibitors Omeprazole (20 mg/d), Lansoprazole (30 mg/d), Rabeprazole (20 mg/d), Pantoprazole (40 mg/d) Esomeprazole (20 mg/d)

3. Mucosal Protective Agents –Sucralfate (1g qid) –Bismuth-Containing Preparations Bismuth subsalicylate (2 tablets qid) –Prostaglandin Analogues Misoprostol (200μg qid)

4. Eradication of H. pylori Combination Therapy (14 days) –2 antibiotics + either PPI, H 2 blocker, or bismuth compound Bismuth subsalicylate (2 tablets qid) Metronidazole (250 mg qid) Tetracycline (500 mg qid) Ranitidine bismuth citrate (400 mg bid) Tetracycline(500 mg bid) Clarithromycin or Metronidazole(500 mg bid) Omeprazole(20 mg bid) Clarithromycin(250 or 500 mg bid) Metronidazole or Amoxicillin(1 g bid)

5. Surgical Therapy Vagotomy and drainage –Ablating cholinergic input –Pyloroplasty/ gastroduodenostomy Compensate for vagotomy-induced gastric disorders Highly selective vagotomy –Only vagal fibers innervating portion of stomach with parietal cells are transected Vagotomy with antrectomy –Eliminate additional stimulant of gastric acid secretion, gastrin