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A 62-year-old man complaining of upper abdominal pain is found by endoscopy to have a gastric ulcer.
(a) Would you carry out any other tests on this patient?
Yes, it is important to determine whether or not the patient is infected with Helicobacter pylori because infection of the gastric mucosa by this organism is an important aetiological factor in peptic ulcer disease. This is determined by a breath test. Samples of breath are taken before and after the patient drinks a solution of 13C-urea. Production of 13C-carbon dioxide indicates infection with H. pylori.
(b) What treatment would you give to heal the ulcer?
In the absence of H. pylori infection the usual treatment is to reduce gastric acid secretion with either a proton-pump inhibitor (e.g. omeprazole) or an H2-histamine antagonist (e.g. ranitidine). If a breath test reveals infection with H. pylori the organism must be eradicated or the ulcer is likely to recur within a year. Eradication of H. pylori involves treatment with a proton-pump inhibitor in combination with antibiotics (‘triple therapy’). One regimen is omeprazole in combination with clarithromycin and metronidazole. Triple therapy is usually effective in eradicating H. pylori but resistance to clarithromycin and metronidazole may occur. Successful triple therapy shortens the ulcer healing time and reduces the occurrence of gastric and duodenal ulcers.
(c) Which drugs are contraindicated in patients with peptic ulcer disease?
NSAIDs may cause gastrointestinal bleeding and ulceration. The incidence is lower with selective COX-2 inhibitors, but these drugs are associated with a higher incidence of cardiovascular adverse effects (Chapter 32). Patients with peptic ulcers or a history of peptic ulcer disease should stop taking NSAIDs if possible. If NSAIDs must be continued, the patient should be treated with a proton-pump inhibitor for as long as the NSAID is taken. Misoprostol is an alternative, but colic and diarrhoea may limit the dose.