A 52-year-old man from Delhi presents with a 3-month history of epigastric pain relieved by food and antacids. Upper endoscopy reveals a 1.5 cm antral ulcer with clean base. Rapid urease test is positive. He is not on NSAIDs. What is the most appropriate next step in management?

Question

Accepted Answer

C. Start triple therapy (omeprazole, amoxicillin, clarithromycin) for 14 days followed by omeprazole monotherapy. ## Clinical Scenario Analysis

This patient has **H. pylori-positive peptic ulcer disease** (PUD) confirmed by positive rapid urease test on endoscopy. The management of H. pylori-associated PUD follows a well-established eradication protocol.

## Management Algorithm for H. pylori-Positive PUD

```mermaid
flowchart TD
  A[H. pylori-positive PUD confirmed]:::outcome --> B{Eradication therapy indicated?}:::decision
  B -->|Yes| C[Triple or Quadruple therapy for 14 days]:::action
  C --> D[Omeprazole 20 mg BD + Amoxicillin 1 g BD + Clarithromycin 500 mg BD]:::action
  D --> E[Continue PPI monotherapy for 4-8 weeks total]:::action
  E --> F[Test of cure after 4 weeks if symptoms persist]:::action
  B -->|No| G[PPI monotherapy]
```

## Key Point:
**Triple therapy is the gold standard first-line eradication regimen** for H. pylori-positive PUD in India [cite:Harrison 21e Ch 297]. The standard regimen is:
- Omeprazole 20 mg BD (or pantoprazole 40 mg BD)
- Amoxicillin 1 g BD
- Clarithromycin 500 mg BD
- Duration: 14 days

## High-Yield:
**After eradication therapy completion**, continue PPI monotherapy for a total of 4–8 weeks to allow ulcer healing. Test of cure (urea breath test or stool antigen) is performed 4 weeks after completing eradication therapy if symptoms persist.

## Clinical Pearl:
The clean base of the ulcer on endoscopy is reassuring and does **not** suggest malignancy in this context. Biopsy for malignancy is indicated only if the ulcer has an irregular margin, raised edges, or nodular base—features of a malignant ulcer.

## Why This Approach?

1. **Eradication cures the disease**: H. pylori eradication heals >90% of ulcers and prevents recurrence, eliminating the need for long-term PPI therapy.
2. **Guideline-mandated**: All major guidelines (ASGE, BSG, ASGE) recommend triple therapy as first-line for H. pylori eradication.
3. **Cost-effective**: A 2-week course of triple therapy is more economical than indefinite PPI monotherapy.

![Peptic Ulcer Disease diagram](https://mmcphlazjonnzmdysowq.supabase.co/storage/v1/object/public/blog-images/explanation/2977.webp)

Answer

A. Start omeprazole 20 mg BD and repeat endoscopy in 4 weeks

Answer

B. Refer for surgical consultation for antrectomy

Answer

D. Perform CT abdomen to rule out malignancy

A 52-year-old man from Delhi presents with a 3-month history of epigastric pain relieved by food and antacids. Upper endoscopy reveals a 1.5 cm antral ulcer with clean base. Rapid urease test is positive. He is not on NSAIDs. What is the most appropriate next step in management?

Explanation

Clinical Scenario Analysis

Management Algorithm for H. pylori-Positive PUD

Key Point:

High-Yield:

Clinical Pearl:

Why This Approach?

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