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Stomach· Chapter 06

Peptic Ulcer Disease and H. pylori

ACG bismuth quadruple as first-line, vonoprazan dual and triple after failed eradication, salvage therapy after culture and susceptibility, NSAID ulcer prevention strategy, and the refractory-ulcer workup that uncovers Zollinger-Ellison. With the H. pylori test-of-cure window every fellow gets wrong on rounds.

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43 MCQs2 podcast episodes
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What this chapter covers

  • Section 6.1: H. pylori biology, diagnosis, and test of cure

    Helicobacter pylori is a spiral, gram-negative, microaerophilic bacterium that lives in a niche no other organism reliably occupies, the layer of mucus that coats the gastric epithelium, and everything about diagnosis and treatment flows from how the organism survives there.

  • Section 6.2: First-line eradication regimens

    The first-line landscape has shifted because clarithromycin resistance has risen above the threshold at which clarithromycin-based regimens can be given empirically with confidence.

  • Section 6.3: Salvage therapy after failed eradication

    Failure of first-line eradication shifts management onto a second axis, treatment-experienced rather than treatment-naive, and the 2024 ACG guideline made this distinction explicit because the data and the choices are different.

  • Section 6.4: NSAID and aspirin ulcers

    NSAIDs and aspirin damage the gastroduodenal mucosa by a dual mechanism, and the systemic mechanism explains why parenteral, rectal, and topical NSAIDs all cause ulcer disease while the topical mechanism explains why a tablet swallowed without water injures the mucosa it touches.

  • Section 6.5: Refractory and idiopathic ulcers

    A non-healing ulcer at follow-up endoscopy is a differential expansion problem, because the standard explanations (H. pylori and NSAIDs) have either been excluded or addressed, and the candidate's job is to systematically exclude what was missed.

  • Section 6.6: Perforation and penetration

    Perforation is the surgical emergency of peptic ulcer disease, and management depends on whether the perforation is free into the peritoneum or contained against an adjacent structure, and on whether the patient is hemodynamically stable.

Podcast episodes

  1. 01

    H. pylori: Biology, Eradication, and Salvage

    H. pylori from biology through eradication and salvage. Bismuth quadruple and vonoprazan-based regimens have replaced clarithromycin triple as first-line where resistance is high. This episode covers the urease-driven diagnostics, when to test off PPI, first-line and salvage regimens, and confirming eradication. Board Pearls GI board review.

  2. 02

    NSAID Ulcers, Refractory Disease, and Perforation

    The non-H.-pylori side of ulcer disease: NSAID and aspirin ulcers with their multiplicative risk and the PPI co-prescription that prevents most of them, the refractory and idiopathic ulcers where Zollinger-Ellison and gastric cancer must be excluded, and the complications of bleeding and perforation. Board Pearls GI board review.