In a patient with epigastric pain that worsens after meals and an endoscopically confirmed duodenal ulcer, what is the next step in management?

Management of Endoscopically Confirmed Duodenal Ulcer

The next step is to test for H. pylori infection and initiate eradication therapy if positive, combined with proton pump inhibitor (PPI) therapy—making option B (H. pylori eradication therapy) the correct answer, though it must be paired with PPI treatment. 1, 2

Immediate Management Strategy

H. pylori Testing and Eradication

• Test all patients with confirmed duodenal ulcer for H. pylori infection immediately, as this bacterium is present in 90-100% of duodenal ulcer cases and eradication essentially cures the disease by preventing recurrences. 2, 3
• Start eradication therapy as soon as H. pylori is confirmed positive, rather than delaying treatment, as postponing therapy leads to reduced compliance and loss to follow-up. 2
• The preferred first-line regimen is bismuth quadruple therapy (BQT) for 14 days: high-dose PPI twice daily + bismuth subsalicylate + metronidazole + tetracycline, which achieves 80-90% eradication rates. 2, 4
• Alternative first-line option is triple therapy for 14 days: PPI + clarithromycin 500 mg twice daily + amoxicillin 1 g twice daily, though this should only be used in areas with known low clarithromycin resistance. 5, 6, 4

Concurrent PPI Therapy

• Initiate full-dose PPI therapy (omeprazole 20 mg once daily or equivalent) immediately for patients with epigastric pain, as this is the first-choice therapy for ulcer-like dyspepsia and ensures healing of the ulcer. 1
• Continue PPI therapy for 4-6 weeks total to allow complete ulcer healing, even while H. pylori eradication is ongoing. 1, 7
• For H. pylori-negative duodenal ulcers specifically, full-dose PPI therapy is mandatory to ensure healing, as these ulcers still require acid suppression. 1

Why Other Options Are Incorrect

Option A: Elective Surgical Repair

• Surgery is NOT indicated for uncomplicated duodenal ulcer in the modern era, as H. pylori eradication achieves healing rates exceeding 90% and prevents recurrences without surgical intervention. 2
• Surgery is reserved only for complications (perforation, uncontrolled bleeding despite endoscopic therapy, or gastric outlet obstruction). 2

Option C: PPI Alone

• PPI monotherapy without addressing H. pylori is inadequate, as it treats symptoms but does not cure the underlying disease—ulcer recurrence rates remain 26% without eradication versus near-zero with successful eradication. 2
• While PPI is necessary, it must be combined with H. pylori testing and eradication therapy. 1, 2

Option D: Diet Change

• Diet modification has no proven role in duodenal ulcer healing or prevention and should not be recommended as primary therapy. 1
• The focus must be on eliminating H. pylori infection and acid suppression. 1, 2

Critical Follow-Up Steps

Confirmation of Eradication

• Test-of-cure is mandatory in all duodenal ulcer patients using urea breath test or monoclonal stool antigen test at least 4 weeks after completing therapy and at least 2 weeks off PPI therapy. 2, 8
• False-negative rates of 25-55% occur during acute bleeding episodes, so if initial testing was done during active bleeding, repeat testing is essential. 2

Post-Eradication Management

• Discontinue PPI therapy after documented successful H. pylori eradication in uncomplicated duodenal ulcer, as prolonged acid suppression is unnecessary once the infection is cured. 2, 3
• Endoscopic confirmation of healing is generally not necessary for duodenal ulcers after successful eradication, unlike gastric ulcers which require repeat endoscopy to exclude malignancy. 2

Common Pitfalls to Avoid

• Do not delay H. pylori eradication therapy—start immediately upon diagnosis rather than waiting for symptom resolution or discharge. 2
• Do not use 7-10 day treatment courses—all eradication regimens must be 14 days to optimize success rates. 6, 4
• Do not skip test-of-cure—reinfection or treatment failure occurs in 10-20% of cases and requires different salvage therapy. 2, 8
• Do not continue long-term PPI after successful eradication in uncomplicated duodenal ulcer—this represents overtreatment and unnecessary medication exposure. 2