Gastroenterology
Peptic Ulcer Disease & H. pylori
Gastroenterology

Peptic Ulcer Disease & H. pylori

Testing pathway + quadruple therapy + confirmation.

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◆Presentation

  • •Duodenal ulcer: epigastric pain 2–3 hr after meals + at night, IMPROVES with eating; H. pylori most common cause
  • •Gastric ulcer: pain WORSENS with food; weight loss common
  • •Relief with antacids
  • •Melena = upper GI bleed

◆Workup by age and alarms

  • •Age <60 + no alarms → noninvasive H. pylori testing (urea breath or stool antigen)
  • •Age ≥60 or alarms (weight loss, bleeding, anemia, dysphagia, vomiting, FH upper GI ca) → EGD
  • •Serology positive lifelong; not useful for confirmation

◆H. pylori treatment

  • •Quadruple therapy: PPI + bismuth + tetracycline + metronidazole (or tinidazole)
  • •Old triple: PPI + clarithromycin + amoxicillin (now less preferred due to clarithromycin resistance)
  • •Penicillin allergy → substitute amoxicillin with metronidazole

◆Eradication confirmation

  • •Required for all treated patients
  • •Urea breath test OR stool antigen (active infection markers)
  • •Off PPI ≥2 weeks; off antibiotics/bismuth ≥4 weeks
  • •Serology does NOT distinguish past from active infection
  • •If positive after first-line: rescue therapy with different combination

◆Other PUD complications

  • •Perforation: sudden severe pain + rigid abdomen + free air under diaphragm on upright CXR → emergent surgery
  • •Gastric outlet obstruction (chronic duodenal scarring): succussion splash + vomiting undigested food
  • •Hemorrhage from gastroduodenal artery erosion

◆Other gastric inflammatory conditions

  • •Autoimmune (type A): antibodies vs parietal cells → loss of IF → B12 deficiency + ↑gastrin
  • •Iron pill gastritis: epigastric pain + black stools → switch to IV iron
  • •MALT lymphoma: H. pylori-associated; may resolve with antibiotic eradication

◆Gastroparesis

  • •Diabetic autonomic neuropathy most common
  • •Early satiety + nausea + bloating + vomiting undigested food hours later
  • •Gastric emptying study confirms
  • •Metoclopramide or erythromycin (prokinetics)
  • •Tight glycemic control; small frequent low-fat low-fiber meals
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