Peptic Ulcer Disease
Peptic Ulcer Disease & H. Pylori
Modern, evidence-based diagnosis and treatment of peptic ulcer disease, H. pylori infection, and ulcer-related complications across the Dallas–Fort Worth area.
Peptic ulcer disease (PUD) remains common despite the dramatic decline in H. pylori prevalence and broader use of acid suppression. The two dominant causes — H. pylori infection and NSAID use — account for the vast majority of cases. Identifying the cause and treating it definitively is what separates good ulcer care from a cycle of recurrence.
What Is Peptic Ulcer Disease?
A peptic ulcer is a break in the gastric or duodenal mucosa that extends through the muscularis mucosae. Symptoms include:
- Epigastric pain — classically burning or gnawing
- Pain that improves with food (duodenal) or worsens with food (gastric)
- Nausea, early satiety, bloating
- GI bleeding — sometimes the first presentation (melena, hematemesis, occult bleeding causing iron-deficiency anemia)
- Perforation — sudden severe abdominal pain (surgical emergency)
Causes
H. pylori infection
The most common cause of duodenal ulcers and a major cause of gastric ulcers. H. pylori is a gram-negative bacterium that causes chronic gastritis and predisposes to peptic ulceration and gastric cancer. Treatment eradicates the bacterium and eliminates the underlying cause of recurrent disease.
NSAIDs and aspirin
NSAIDs (ibuprofen, naproxen, diclofenac) and aspirin cause direct mucosal injury and inhibit prostaglandin-mediated mucosal protection. Risk increases with higher dose, older age, prior ulcer, concurrent steroids or anticoagulants, and H. pylori coinfection.
Less common causes
- Zollinger-Ellison syndrome (gastrinoma)
- Stress-related mucosal injury (in critical illness)
- Crohn's disease (gastroduodenal involvement)
- Idiopathic peptic ulcer (no identifiable cause)
Diagnosis
- Upper endoscopy (EGD) is the standard for diagnosing PUD — visualizes the ulcer, assesses bleeding risk (Forrest classification), allows biopsies, and tests for H. pylori
- H. pylori testing: urea breath test, stool antigen, or biopsy-based testing during EGD. PPI must be held for 1–2 weeks and antibiotics for 4 weeks before non-invasive testing to avoid false negatives
- Biopsy of all gastric ulcers to rule out malignancy
- Repeat endoscopy in 8–12 weeks for gastric ulcers to confirm healing — especially when malignancy cannot be excluded
- Fasting gastrin and secretin stimulation when Zollinger-Ellison is suspected (multiple ulcers, ulcers in unusual locations, refractory disease)
Treatment
H. pylori eradication
Per the 2024 ACG H. pylori guideline, first-line therapy depends on local resistance patterns:
- Bismuth quadruple therapy (PPI + bismuth + metronidazole + tetracycline × 14 days) — preferred first-line in most U.S. settings given rising clarithromycin resistance
- Rifabutin triple therapy (PPI + amoxicillin + rifabutin × 14 days, e.g., Talicia) — increasingly used as a first-line or salvage option
- Levofloxacin- or vonoprazan-based regimens — second- or third-line
- Always confirm eradication at least 4 weeks after completing antibiotics with urea breath test or stool antigen
Acid suppression
- PPI — typically 4–8 weeks for duodenal ulcer, 8–12 weeks for gastric ulcer
- For NSAID-induced ulcers: stop the NSAID if possible; if NSAID is essential, continue with co-prescribed PPI long-term and consider COX-2 selective agent
Bleeding ulcer management
- Endoscopic hemostasis for high-risk lesions (active bleeding, visible vessel)
- IV PPI bolus + infusion (or high-dose oral PPI) post-procedure
- Repeat endoscopy in 24 hours selectively; angiographic embolization or surgery for refractory cases
Peptic Ulcer Disease & H. Pylori: Common Questions
What causes peptic ulcers?
Two main causes: H. pylori infection and NSAID/aspirin use. Less common: Zollinger-Ellison, Crohn's, stress-related injury. Smoking, alcohol, and stress can worsen ulcers but don't typically cause them alone.
Should I be tested for H. pylori?
Test for H. pylori if you have: peptic ulcer (active or prior), unexplained iron-deficiency anemia, ITP, MALT lymphoma, family history of gastric cancer, or before long-term NSAIDs. Routine screening of asymptomatic adults is not recommended in the U.S.
How is H. pylori treated in 2024?
Per the 2024 ACG guideline: first-line is typically bismuth quadruple therapy × 14 days (PPI + bismuth + metronidazole + tetracycline). Rifabutin triple therapy is also first-line. Always confirm eradication 4+ weeks after completing antibiotics.
Can I take ibuprofen if I have a history of ulcers?
Generally no — or only with a co-prescribed PPI. If an NSAID is essential, use lowest dose, shortest duration, consider COX-2 selective, and always with PPI. Eradicate H. pylori first before resuming long-term NSAIDs.
Why does my gastric ulcer need a follow-up endoscopy?
Gastric ulcers can occasionally represent malignancy that looks benign initially. Standard: biopsy all gastric ulcers and repeat endoscopy in 8–12 weeks to confirm healing. Duodenal ulcers don't require routine repeat endoscopy.
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