Seek urgent care now if any of these are present

• Vomiting blood or coffee-ground material
• Black, tarry stools, rectal bleeding
• Fainting, marked weakness, shortness of breath, chest pain
• Sudden severe or persistent abdominal pain, rigid abdomen, fever
• Repeated vomiting, weight loss, anemia, or trouble swallowing

Usual treatment approach

1. Confirm the cause
   • Test for Helicobacter pylori with a urea-breath test, stool-antigen test, or biopsy at endoscopy.
   • Review use of NSAIDs such as ibuprofen, naproxen, diclofenac, ketorolac, and aspirin.
   • At age 65, upper endoscopy is commonly appropriate, particularly for new symptoms, anemia, weight loss, vomiting, bleeding, or suspected gastric ulcer. Gastric ulcers are often biopsied and followed to document healing.
2. Heal the ulcer with acid suppression
   • A proton-pump inhibitor (PPI), such as omeprazole, pantoprazole, or esomeprazole, is usually used once or twice daily.
   • Typical healing duration is about 4 weeks for uncomplicated duodenal ulcers and 6-8 weeks for gastric ulcers, depending on the cause and endoscopic findings.
   • If the ulcer is NSAID-related and the NSAID can be stopped, 4-8 weeks of PPI treatment is generally used. Swanson's Family Medicine Review notes that stopping the NSAID and treating with a PPI is effective for many such ulcers (Swanson's Family Medicine Review, 4. Treatment).
3. If H. pylori is positive, eradicate it
   • Current North American guidance generally favors 14 days of optimized bismuth quadruple therapy: a PPI plus bismuth, tetracycline, and metronidazole.
   • Clarithromycin or levofloxacin regimens should generally not be used unless antibiotic susceptibility is known, because resistance is common. The 2024 ACG treatment guidance recommends optimized bismuth quadruple therapy as first-line treatment in treatment-naive patients.
   • Confirm eradication at least 4 weeks after antibiotics with a breath or stool test. To avoid a false-negative result, hold PPIs for 2 weeks and bismuth/antibiotics for 4 weeks before testing, as stated in the ACG guideline highlights.
4. If NSAIDs or aspirin are involved
   • Stop nonessential NSAIDs. Do not substitute with another NSAID.
   • If she takes aspirin, clopidogrel, warfarin, apixaban, rivaroxaban, or similar drugs, do not stop these without speaking to the prescribing clinician, especially if used for a prior heart attack, stroke, stent, or atrial fibrillation.
   • If an NSAID is unavoidable, the prescriber may use ongoing PPI protection and reassess whether another pain strategy is safer.
5. Avoid factors that delay healing
   • Avoid smoking and alcohol.
   • Avoid non-prescribed NSAIDs.
   • Acetaminophen/paracetamol is often safer for pain than NSAIDs, but the dose must account for liver disease and alcohol intake.

Age-specific medication checks