H. pylori and peptic ulcer disease

H. pylori is the most common cause of peptic ulcer disease. For information about other causes of peptic ulcer disease, see Causes of peptic ulcer disease. The use of nonsteroidal anti-inflammatory drugs (NSAIDs) in patients with H. pylori infection increases the risk of ulcer disease (see NSAID-induced ulcers).

Successful eradication of H. pylori infection cures H. pylori-associated ulcer disease by promoting ulcer healing and preventing relapse. H. pylori eradication is mandatory initial treatment for uncomplicated H. pylori-associated ulcers. Successful eradication speeds ulcer healing and greatly reduces the chance of relapse, almost to zero in the absence of other risk factors, effectively curing the disease.

For uncomplicated duodenal ulcer disease, eradication therapy is usually all that is required.

For all complicated ulcers (ie ulcers associated with bleeding and perforation), gastric ulcers, ulcers occurring in high-risk patients or NSAID-induced ulcers, ongoing proton pump inhibitor (PPI) therapy for about 8 weeks is appropriate. This maximises the likelihood of ulcer healing, particularly in patients who remain infected after eradication therapy. PPIs are superior to H₂-receptor antagonists for ulcer healing. Some patients (especially those who had an ulcer associated with H. pylori infection and NSAID use) may need long-term secondary prophylaxis with PPIs to prevent relapse (see Maintenance therapy after H. pylori eradication in adults).

If untreated, H. pylori-associated ulcer disease has a chronic relapsing course, characterised by periodic episodes of pain. It carries a risk of complications, including bleeding and perforation. Therefore, any patient with a documented history of an H. pylori-associated ulcer who has not received eradication therapy still has chronic peptic ulcer disease and is at risk of ulcer relapse. Actively seeking to identify (using noninvasive tests or endoscopy) and eradicate H. pylori in these patients is a valuable way to prevent this. This ‘search-and-treat’ strategy (whether or not the patient has symptoms of ulcer disease) is especially useful for reducing ulcer morbidity and mortality in higher-risk patients, particularly elderly people and people taking NSAIDs (including aspirin) (see NSAID-induced ulcers).