In a patient presenting 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 immediately and initiate concurrent PPI therapy; if H. pylori is positive, start eradication therapy with 14-day triple therapy (PPI + amoxicillin + clarithromycin), and if negative, continue PPI alone for 4–6 weeks. 1

Immediate Dual-Track Approach

H. pylori Testing (Priority #1)

• Test all patients with confirmed duodenal ulcer for H. pylori infection promptly, as the bacterium is present in 90–100% of cases and eradication essentially cures the disease by preventing recurrences 1
• Use urea breath test (88–95% sensitivity, 95–100% specificity) or stool antigen test (94% sensitivity, 92% specificity) 2
• Do not delay testing or treatment—postponing H. pylori eradication reduces compliance and increases loss to follow-up 1

Concurrent PPI Therapy (Start Immediately)

• Initiate full-dose PPI therapy (omeprazole 20 mg once daily or equivalent) immediately for symptom control and ulcer healing, regardless of H. pylori status 1
• PPI is the first-choice treatment for ulcer-type dyspepsia and promotes ulcer healing 1
• Continue PPI for 4–6 weeks total to ensure complete ulcer healing 1

If H. pylori Positive: Eradication Therapy

First-Line Regimen

• Initiate 14-day triple therapy as soon as positive H. pylori result is obtained: PPI twice daily + amoxicillin 1000 mg twice daily + clarithromycin 500 mg twice daily 2, 3
• The 14-day bismuth quadruple regimen (high-dose PPI twice daily + bismuth subsalicylate + metronidazole + tetracycline) achieves 80–90% eradication rates and is an alternative first-line option 1
• Do not use 7–10-day courses—all regimens should be 14 days to optimize success 1

Evidence for Eradication

• Successful H. pylori eradication achieves ulcer healing rates exceeding 90% and prevents recurrence without surgery 1, 4, 5
• Ulcer recurrence occurs in approximately 26–50% of patients without eradication versus near-zero recurrence with successful eradication 1, 6, 5
• Eradication alone can heal duodenal ulcers even without concurrent acid suppression, though PPI accelerates symptom relief 4

If H. pylori Negative

• Continue full-dose PPI therapy for 4–6 weeks to achieve healing 1
• In H. pylori-negative duodenal ulcers, PPI therapy remains mandatory 1
• Reassess for NSAID use, aspirin, anticoagulants, or other ulcerogenic factors 2

Why Surgery and Diet Changes Are NOT the Answer

Surgery (Option A) Is Incorrect

• Elective surgical repair is not indicated for uncomplicated duodenal ulcer—modern H. pylori eradication yields healing rates >90% and prevents recurrence without surgery 1
• Surgery is reserved only for complications: perforation, uncontrolled bleeding despite endoscopic therapy, or gastric outlet obstruction 7, 1
• For bleeding duodenal ulcers requiring surgery, mortality correlates with preoperative physiologic status, making medical management preferable when feasible 7

Diet Change (Option D) Is Incorrect

• Dietary modification has no proven benefit for duodenal ulcer healing or prevention—management must focus on H. pylori eradication and acid suppression 1, 2
• Restricting diet too much could lead to malnutrition or abnormal eating habits 7

Critical Follow-Up Steps

Confirmation of Eradication (Test-of-Cure)

• Perform test-of-cure using urea breath test or monoclonal stool antigen at least 4 weeks after completing therapy and after a minimum 2-week PPI washout 1, 8
• During acute bleeding episodes, false-negative rates can reach 25–55%; repeat testing after hemostasis is essential 1, 8
• Do not skip the test-of-cure—reinfection or treatment failure occurs in 10–20% of cases and requires alternative salvage therapy 1

Post-Eradication Management

• Discontinue PPI therapy after documented successful H. pylori eradication in uncomplicated duodenal ulcer—prolonged acid suppression is unnecessary 1, 8
• Routine endoscopic confirmation of healing is generally not required for duodenal ulcers after successful eradication (unlike gastric ulcers, which require repeat endoscopy to exclude malignancy) 2, 8

Common Pitfalls to Avoid

• Do not use PPI monotherapy without addressing H. pylori—this is inadequate and leads to high recurrence rates 1
• Do not use H2-receptor antagonists as first-line therapy—they are significantly less effective than PPIs for duodenal ulcer healing 2
• Do not continue long-term PPI after successful eradication in uncomplicated duodenal ulcer—this represents overtreatment 1
• Do not postpone H. pylori eradication—start therapy immediately upon diagnosis 1

Algorithmic Summary

1. Endoscopy confirms duodenal ulcer → Test for H. pylori + Start PPI 20 mg daily
2. H. pylori positive → Add 14-day triple therapy (PPI bid + amoxicillin 1 g bid + clarithromycin 500 mg bid)
3. Continue PPI for 4–6 weeks total (during and after eradication therapy)
4. Test-of-cure at ≥4 weeks post-therapy (off PPI for ≥2 weeks)
5. If eradication confirmed → Stop PPI; no routine endoscopy needed
6. If eradication fails → Second-line salvage therapy (e.g., levofloxacin-based regimen)

The correct answer is B (H. pylori eradication therapy) combined with C (PPI), as both are required for optimal management. 1, 2, 3