A 48-year-old woman from Mumbai presents with a 6-week history of postprandial epigastric pain and early satiety. She has a past medical history of rheumatoid arthritis treated with indomethacin for 2 years. On examination, she is afebrile with mild epigastric tenderness. Hemoglobin is 8.5 g/dL. Upper endoscopy shows a 2 cm ulcer in the gastric antrum with a clean base and no active bleeding. H. pylori rapid urease test is positive. What is the most appropriate next step in management?

Explanation

## Management of H. pylori-Associated Peptic Ulcer with NSAID Co-exposure ### Clinical Scenario Analysis - **Dual pathogenic factors:** H. pylori infection (positive urease test) + chronic NSAID use (indomethacin for 2 years) - **Gastric antrum ulcer:** Classic location for H. pylori-induced ulcers - **Anemia (Hb 8.5 g/dL):** Indicates chronic blood loss - **Clean base:** No active bleeding, but risk of recurrence without eradication therapy ### Rationale for Triple Therapy **Key Point:** When both H. pylori and NSAIDs are present, the management strategy must address BOTH: 1. **Eradicate H. pylori** with triple therapy (PPI + two antibiotics) 2. **Discontinue the offending NSAID** to remove the second ulcerogenic stimulus 3. **Correct anemia** with iron supplementation ### Standard Triple Therapy Regimen | Component | Dose | Duration | Notes | |-----------|------|----------|-------| | **PPI** (e.g., omeprazole) | 20 mg BD | 14 days | Reduces acid, improves antibiotic penetration | | **Amoxicillin** | 1 g BD | 14 days | β-lactam; good gastric mucosa penetration | | **Clarithromycin** | 500 mg BD | 14 days | Macrolide; synergistic with amoxicillin | | **H. pylori eradication rate** | — | — | ~85–90% with standard triple therapy | **High-Yield:** The 14-day duration of triple therapy is superior to 7-day regimens (eradication rate ~90% vs. ~80%). In India, amoxicillin resistance is low, making this regimen reliable. **Mnemonic: PAC** — **P**roton pump inhibitor, **A**moxicillin, **C**larithromycin (standard triple therapy). ### Why NSAID Discontinuation Is Mandatory - Continuing indomethacin while treating H. pylori will result in ulcer recurrence in ~50% of cases - The ulcer is now driven by two mechanisms; removing one (NSAID) is essential - Alternative analgesics (acetaminophen, selective COX-2 inhibitors with PPI) should be offered ### Post-Treatment Verification - **Test of cure:** H. pylori serology or stool antigen at 4 weeks post-therapy (not earlier, to avoid false negatives) - **Repeat endoscopy:** NOT routine unless symptoms persist or complications suspected (bleeding, perforation) - **Iron supplementation:** For anemia correction (ferrous sulfate 325 mg daily) **Clinical Pearl:** In patients on long-term NSAIDs with H. pylori, the combination is synergistic for ulcer formation. Eradicating H. pylori alone without stopping the NSAID leaves the patient at high risk of recurrence. [cite:Harrison 21e Ch 289; KD Tripathi 8e Ch 46]