Peptic Ulcer Disease and H. pylori: Testing and Treatment

Peptic ulcer disease means ulcers in the stomach (gastric ulcers) or the first part of the small intestine (duodenal ulcers). The two main causes are infection with Helicobacter pylori and the use of NSAIDs, including aspirin. Untreated ulcers can bleed or perforate.

Causes and risk factors

• Helicobacter pylori infection — very common in South Asia.
• NSAIDs and aspirin, especially in older people and with steroids, anticoagulants or SSRIs.
• Smoking and heavy alcohol use.
• Severe physiological stress (critical illness, burns).
• Rarely, Zollinger–Ellison syndrome (a gastrin-secreting tumour causing multiple or unusual ulcers).

Clinical features

Burning or gnawing epigastric pain, bloating, nausea and early fullness. Classically, duodenal ulcer pain improves with food and occurs at night, while gastric ulcer pain may worsen with eating. Symptoms are a poor guide to the ulcer's site, and many ulcers cause no symptoms until a complication occurs.

Alarm features needing urgent endoscopy

• Gastrointestinal bleeding (haematemesis or melaena).
• Iron deficiency anaemia.
• Unintentional weight loss.
• Difficulty swallowing.
• Persistent vomiting.
• An abdominal mass.
• New symptoms in an older patient (age thresholds vary by guideline).

Testing for H. pylori

• Non-invasive tests: the urea breath test or stool antigen test. Stop proton pump inhibitors (PPIs) for 2 weeks and antibiotics for 4 weeks before testing, to avoid false negatives.
• At endoscopy: rapid urease test and histology from biopsies.
• Serology cannot distinguish current from past infection, so it is not used to confirm eradication.

Treatment

• H. pylori eradication: a PPI with two or more antibiotics, usually for 14 days. The choice of regimen depends on local antibiotic resistance. Where clarithromycin resistance is high, which includes much of South Asia, international consensus (Maastricht VI) favours bismuth quadruple therapy (PPI, bismuth, tetracycline and metronidazole) or other locally effective regimens over standard clarithromycin triple therapy.
• Confirm eradication with a breath or stool test at least 4 weeks after treatment.
• PPI therapy to heal the ulcer, typically 4–8 weeks.
• Stop NSAIDs where possible. If they are essential, give PPI protection.
• Gastric ulcers usually need a repeat endoscopy to confirm healing and exclude cancer.

Complications

• Bleeding — the most common complication; presents with haematemesis or melaena. See our article on Upper GI Bleeding.
• Perforation — sudden severe abdominal pain, a rigid abdomen and free air under the diaphragm on an erect chest X-ray. A surgical emergency.
• Gastric outlet obstruction — vomiting of undigested food.
• H. pylori is also linked to gastric cancer and MALT lymphoma.

Exam pearls

• A posterior duodenal ulcer can erode the gastroduodenal artery and cause major bleeding.
• Free gas under the diaphragm on an erect chest X-ray means perforation.
• Always stop PPIs 2 weeks before H. pylori breath or stool testing.

For more, see Exam Night Notes 1.0: Gastro Surgery and the gastroenterology part of the Medicine Companion.

Test yourself

5 exam-style single-best-answer questions. Choose your answer, then tap “Show answer”.

1. How long should PPIs be stopped before an H. pylori urea breath test?

   1. No need to stop
   2. 3 months
   3. 2 weeks
   4. 6 months
   5. 24 hours
   Show answer

   Answer: C. 2 weeks
   PPIs suppress H. pylori and cause false negatives; stop them 2 weeks before (antibiotics 4 weeks).

2. Which test should NOT be used to confirm eradication of H. pylori?

   1. Urea breath test
   2. Biopsy urease test
   3. Histology
   4. Stool antigen test
   5. Serology
   Show answer

   Answer: E. Serology
   Antibodies persist after eradication, so serology cannot show cure.

3. Sudden severe epigastric pain, rigid abdomen and free gas under the diaphragm. Diagnosis?

   1. Acute pancreatitis
   2. Perforated peptic ulcer
   3. Gastritis
   4. Myocardial infarction
   5. Biliary colic
   Show answer

   Answer: B. Perforated peptic ulcer
   Free air under the diaphragm on erect chest X-ray indicates perforation of a hollow viscus.

4. Where clarithromycin resistance is high, which eradication regimen is favoured?

   1. Amoxicillin alone
   2. No treatment
   3. PPI + clarithromycin + amoxicillin
   4. Bismuth quadruple therapy
   5. PPI alone
   Show answer

   Answer: D. Bismuth quadruple therapy
   Maastricht VI favours bismuth quadruple therapy where clarithromycin resistance is high.

5. A posterior duodenal ulcer can erode which artery?

   1. Gastroduodenal artery
   2. Left gastric artery
   3. Splenic artery
   4. Hepatic vein
   5. Superior mesenteric artery
   Show answer

   Answer: A. Gastroduodenal artery
   The gastroduodenal artery lies behind the first part of the duodenum and can cause major bleeding.

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Disclaimer

For education and exam preparation only. This is not medical advice and must not be used to diagnose or treat patients. Always follow current clinical guidelines and the advice of qualified senior colleagues.