## Management of H. pylori–Positive Peptic Ulcer Disease **Key Point:** This patient has a bleeding peptic ulcer (evidenced by melena and anemia) with confirmed H. pylori infection. The standard of care is eradication therapy plus acid suppression. ### Rationale for Triple Therapy **High-Yield:** The current gold standard for H. pylori eradication in India is triple therapy consisting of: 1. A proton pump inhibitor (omeprazole 20 mg BD) 2. Amoxicillin 1 g BD (or metronidazole if penicillin-allergic) 3. Clarithromycin 500 mg BD Duration: **14 days** [cite:Harrison 21e Ch 297] Followed by PPI monotherapy for an additional 4 weeks to allow ulcer healing and mucosal regeneration. ### Why This Approach Works **Clinical Pearl:** H. pylori eradication eliminates the primary pathogenic factor in ~90% of duodenal ulcers and ~70% of gastric ulcers, preventing recurrence. Monotherapy with PPI alone does not eradicate the organism and leads to high relapse rates. ### Post-Eradication Follow-up - Confirm eradication with urea breath test or stool antigen test at least 4 weeks after completing therapy - Continue PPI for a total of 4–6 weeks from initiation - Patient should avoid NSAIDs and alcohol - Lifestyle modification: smoking cessation, dietary modification **Mnemonic:** **CAO** = Clarithromycin, Amoxicillin, Omeprazole (triple therapy backbone) ### Bleeding Management The patient has evidence of bleeding (melena, Hb drop to 8.2 g/dL). Endoscopy showed a clean base with no active bleeding, so: - No endoscopic intervention required at present - Transfuse if Hb <7 g/dL or symptomatic - Continue IV PPI (omeprazole 80 mg bolus then 8 mg/hr infusion) during acute phase - Transition to oral PPI once stable
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