A 62-year-old man presents with epigastric pain for the past several months. The pain is worse after eating and especially after drinking coffee. He also complains of excessive belching. He recently tried taking omeprazole for 2 weeks, but it did not help his pain. He has no significant past medical history. On physical examination, there is epigastric tenderness on deep palpation. An upper gastrointestinal endoscopy is performed, and the gastric mucosa shows mild inflammation and a small hemorrhagic ulcer in the antrum. A gastric biopsy shows active inflammation and gram-negative helical rods. What is the next step in the management of this patient’s condition?
Correct Answer: Give amoxicillin, clarithromycin, and omeprazole
General Feedback
This patient’s clinical symptoms suggest peptic ulcer disease (PUD), typically epigastric pain after eating, early satiety, and nausea. The diagnosis is confirmed in this patient with endoscopic evaluation. Patients with H. pylori infection on biopsy should receive eradication therapy with a proton pump inhibitor (PPI) and two antibiotics. The treatment regimen should consider local antibiotic resistance patterns, patient allergies to antibiotics, cost, and side effects. If there are no risk factors for macrolide resistance (prior treatment or local resistance >15%), then the recommended treatment is triple therapy with a proton pump inhibitor (PPI), amoxicillin, and clarithromycin for 14 days. In penicillin-allergic individuals, metronidazole can be substituted for amoxicillin.
If there are risk factors for macrolide resistance, then quadruple therapy with bismuth subsalicylate, a PPI, and two antibiotics (metronidazole and tetracycline) are given four times daily for 14 days. Bismuth has direct antimicrobial activity against bacterial and viral gastrointestinal pathogens, and the salicylate component has an antisecretory effect. Eradication should be confirmed 4 weeks after completion of therapy by a urea breath test, a fecal antigen test, or an upper endoscopy. Since PPIs inhibit growth and alter the distribution and morphology of H. pylori, they should be withheld for two weeks before testing.
Peptic ulcers are classified as gastric or duodenal, depending on their location. Ulcers measure at least 0.5 cm and penetrate the mucosa. The most common manifestations of PUD are dyspepsia, heartburn, epigastric pain, early satiety, and nausea. The pain associated with duodenal ulcers is often worse with an empty stomach, while the pain associated with gastric ulcers is often worse after eating and in the evening. Symptomatic patients over age 55 and those with alarm symptoms (weight loss, gastrointestinal bleeding, iron deficiency anemia, dysphagia, odynophagia, vomiting, palpable mass, or jaundice) require an upper gastrointestinal endoscopy.
There are 2 significant etiologies of PUD: H. pylori infection and NSAIDs. Patients should also be asked about NSAID use and counseled to avoid them during treatment for PUD. It is important to note that many people are colonized with H. pylori but do not have symptoms of infection (see image below). This patient has been diagnosed with an antral ulcer with H. pylori infection. Thus, he should undergo treatment to reduce the pain and discomfort and prevent future complications. The most common complications in patients with PUD include bleeding, perforation, gastric outlet obstruction, and gastric cancer. H. pylori infection is also associated with gastric cancer and mucosa-associated lymphoid tissue (MALT) lymphoma.
Urea breath tests and stool antigen tests are the most accurate non-invasive diagnostic tools for identifying H. pylori. These tests can also confirm bacterial eradication if they are performed several weeks after treatment. This patient is above 55 years old, with persistent symptoms not responsive to PPI treatment, so an esophagogastroduodenoscopy (EGD) is indicated.
The next step in the management of this patient’s condition is to give him eradication therapy for H. pylori infection. The recommended treatment regimen in this case is to give amoxicillin, clarithromycin, and omeprazole. This triple therapy should be administered for 14 days to effectively eradicate the H. pylori infection and promote ulcer healing.
It’s important to address the H. pylori infection because it is a common cause of peptic ulcer disease (PUD). H. pylori infection can lead to gastric inflammation and ulcers, as seen in this patient’s biopsy results. By eradicating the infection, you can help relieve the patient’s symptoms, promote healing of the ulcer, and reduce the risk of complications associated with PUD.
Additionally, it’s important to counsel the patient about lifestyle modifications, including avoiding irritants like coffee and NSAIDs, which can exacerbate PUD symptoms. Follow-up with the patient after completing the eradication therapy to confirm successful H. pylori eradication and monitor for symptom resolution and ulcer healing.
In some cases, if there are risk factors for macrolide resistance or patient allergies to specific antibiotics, the treatment regimen may need to be adjusted. Quadruple therapy with bismuth subsalicylate, a proton pump inhibitor, and two alternative antibiotics (such as metronidazole and tetracycline) may be considered.
The ultimate goal is to treat the underlying cause (H. pylori infection), promote ulcer healing, and provide relief from the patient’s symptom