What is the evidence of type III peptic ulcer and Helicobacter (H) pylori infection?

Type III Peptic Ulcer and H. pylori Infection

Direct Answer

H. pylori eradication treatment should be initiated immediately upon reintroduction of oral feeding in patients with bleeding peptic ulcers (Type III), as this is the most cost-effective strategy for preventing recurrent hemorrhage and reduces long-term mortality risk. 1

H. pylori Prevalence in Bleeding Peptic Ulcers

The prevalence of H. pylori infection in patients with bleeding peptic ulcers (Type III) is notably lower than in uncomplicated peptic ulcer disease, ranging from 43% to 56% in recent European studies, compared to nearly 90-100% in uncomplicated ulcers 1. This lower prevalence is primarily explained by concurrent NSAID use in these patients 1.

Despite this lower prevalence, H. pylori eradication effectively prevents bleeding recurrence in infected patients with documented peptic ulcer bleeding 1.

Timing of Eradication Treatment

Critical timing consideration: H. pylori eradication has no effect on early rebleeding rates after endoscopic hemostasis 1. However, delaying treatment until after hospital discharge leads to:

• Reduced patient compliance 1
• Loss to follow-up 1
• Missed opportunity for secondary prevention 1

The recommended approach is empirical treatment immediately after oral feeding is restarted (Evidence level: 1b, Grade A recommendation) 1. This strategy is most cost-effective when H. pylori prevalence in the bleeding ulcer population exceeds 40% 1.

Treatment Regimen for Type III Ulcers

First-Line Triple Therapy

• PPI (e.g., lansoprazole 30 mg) twice daily 2, 3
• Amoxicillin 1 gram twice daily 2, 3
• Clarithromycin 500 mg twice daily 2, 3
• Duration: 14 days for optimal eradication rates 2, 3

This regimen achieves eradication rates of 86-92% in evaluable analysis 2, 3.

Alternative Regimens in High Clarithromycin Resistance Areas

In regions with clarithromycin resistance >20%, bismuth quadruple therapy or concomitant therapy (nonbismuth quadruple therapy) is preferred as first-line treatment 4, 5.

Post-Treatment Management Specific to Bleeding Ulcers

PPI continuation is mandatory after eradication therapy in bleeding ulcers until:

• Complete ulcer healing is endoscopically confirmed 1
• H. pylori eradication is documented 1

This differs from uncomplicated duodenal ulcers where PPI can be discontinued after eradication therapy 1.

Confirmation of Eradication

Eradication must be confirmed in all gastric ulcer patients, including those with bleeding 1. Testing should be performed:

• No earlier than 4 weeks after completing therapy 4
• Using urea breath test or stool antigen test (non-invasive methods preferred) 1, 4

Long-Term Outcomes

After successful H. pylori eradication in bleeding ulcer patients:

• The residual risk of peptic ulcer bleeding is very low, even with continued aspirin use 1
• Ulcer recurrence rates drop dramatically from 38.9-66.7% in H. pylori-positive patients to 0-11.1% in eradicated patients 6
• Patients have an excellent long-term prognosis with sustained remission 4

Common Pitfalls to Avoid

Do not delay treatment until after discharge—this is the single most common error leading to treatment failure 1.

Do not assume all bleeding ulcers are H. pylori-related—remember that 44-57% may be NSAID-related without H. pylori infection 1. However, empirical treatment is still cost-effective given the high stakes of recurrent bleeding 1.

Do not stop PPI therapy immediately after eradication treatment in bleeding ulcers—continue until healing is confirmed 1.

Do not use serologic testing for post-treatment confirmation, as antibodies persist after eradication 1.