A 45-year-old woman with chronic NSAID use for rheumatoid arthritis develops acute epigastric pain and vomiting. Endoscopy shows a 1.5 cm duodenal ulcer with no active bleeding or visible vessel. H. pylori serology is negative. What is the most appropriate next step in management?

Explanation

## Management of NSAID-Induced Peptic Ulcer Disease **Key Point:** NSAID-induced ulcers require immediate cessation of the offending agent, high-dose PPI therapy, and consideration of gastroprotective agents (misoprostol or PPI continuation) if NSAIDs must be restarted. ### Rationale for Correct Answer This patient has an NSAID-induced duodenal ulcer (H. pylori negative, chronic NSAID use). The management strategy is: 1. **Discontinue NSAIDs immediately** — the primary pathogenic factor. Continuation prevents healing and increases rebleeding risk. 2. **High-dose IV PPI** — accelerates ulcer healing and prevents complications. Omeprazole 40 mg IV BD or pantoprazole 80 mg IV BD is standard. 3. **Admission** — necessary to monitor for complications (perforation, bleeding) and ensure compliance with NSAID cessation. 4. **Gastroprotection** — if NSAIDs are essential (e.g., severe RA), restart with concurrent PPI or misoprostol to prevent recurrence. **High-Yield:** NSAID-induced ulcers heal in 4–8 weeks with PPI; H. pylori-induced ulcers require eradication therapy. The distinction is critical for management. ### Comparison: NSAID vs H. pylori Ulcers | Feature | NSAID-Induced | H. pylori-Induced | |---------|---------------|------------------| | **Location** | Duodenum (60%), Stomach (40%) | Duodenum (70%), Stomach (30%) | | **Management** | Stop NSAID + PPI | H. pylori eradication + PPI | | **Recurrence without intervention** | 70–80% if NSAID restarted | 80–90% if H. pylori not eradicated | | **Gastroprotection** | PPI or misoprostol if NSAID essential | Not needed after eradication | | **Serology** | Negative | Positive | **Clinical Pearl:** Misoprostol is a prostaglandin analogue that restores the protective mucus layer and bicarbonate secretion — it is particularly useful in patients with severe RA who cannot discontinue NSAIDs. **Mnemonic: STOP NSAID** — Stop the drug, Treat with PPI, Omeprazole (or pantoprazole) high-dose, Protect with misoprostol if restart needed; Admit for monitoring, Surveillance for complications, Assess for H. pylori (negative here), Investigate perforation if acute pain, Discharge only when stable.