Treatment strategies for symptom resolution, healing, and Helicobacter pylori eradication in duodenal ulcer patients.

The introduction of anti-Helicobacter pylori therapy has increased the number of options available for the management of patients with duodenal ulcer disease. The aim of this paper is to summarize current knowledge and use it to form a strategy relevant to the management of patients with duodenal ulcer disease. Four key aspects are addressed. (i) Selection of duodenal ulcer patients for anti-H. pylori treatment. As the subgroup of patients who will develop minor disease activity in the future cannot be identified with sufficient precision, and the therapeutic gain achieved by curing H. pylori infection is significant, all patients with duodonal ulcer and H. pylori infection should receive eradication therapy. (ii) Confirmation of H. pylori infection before eradication. A diagnostic test confirm H. pylori infection is useful in identifying the small group of H. pylori-negative duodenal ulcer patients with nonsteroidal anti-inflammatory drug (NSAID)-induced ulcer or Zollinger-Ellison syndrome. (iii) Choice of treatment. This should be based on efficacy of eradication, rate of ulcer healing and symptom resolution, adverse effects profile, simplicity and cost. At present, there are four effective eradication therapies documented: omeprazole plus amoxycillin or clarithromycin; omeprazole, amoxycillin and metronidazole; 'classic' triple therapy (bismuth, amoxycillin (or tetracycline) and metronidazole); and ranitidine, amoxycillin and metronidazole. (iv) Confirmation of eradication after treatment. This is needed in cases in which the chosen therapy has an efficacy below 80-90%. The test is important to identify those patients who require repeated treatment, before they present with an ulcer relapse.