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Peptic ulcer and Helicobacter pylori
The two main causes of peptic ulcer are H. pylori and NSAIDs; H. pylori is diagnosed with a breath test or stool antigen (after stopping the PPI), treated with 14 days of bismuth quadruple therapy, and eradication is always confirmed.
Why it matters in the exam
Dyspepsia questions first test when gastroscopy is needed: age 60 or more or alarm features — weight loss, bleeding, iron deficiency anaemia, difficulty swallowing, recurrent vomiting or a mass. Below that age and without alarm features, the approach is "test and treat" for H. pylori. The non-invasive tests — the urea breath test or stool antigen — require stopping the PPI for two weeks and antibiotics or bismuth for four weeks beforehand, or they may be falsely negative. Serology does not separate active from past infection.
In treatment: where clarithromycin resistance is above 15% (including Israel), the first choice is bismuth quadruple therapy — PPI, bismuth, tetracycline and metronidazole — for 14 days; clarithromycin triple therapy only when the organism is known to be susceptible. After treatment, eradication is confirmed with a breath or stool test at least 4 weeks after the antibiotics end. A gastric ulcer needs biopsies to exclude malignancy and sometimes a repeat gastroscopy, while a duodenal ulcer does not. In an NSAID ulcer the drug is stopped and a PPI given for 8 weeks. Multiple ulcers in unusual sites with diarrhoea — suspect Zollinger-Ellison syndrome.
Key points
- Gastroscopy at 60 or older or with alarm features; otherwise "test and treat".
- Breath test or stool antigen, after stopping the PPI for two weeks.
- Bismuth quadruple therapy for 14 days.
- Test for cure no sooner than 4 weeks after treatment.
- Gastric ulcer — biopsy; NSAID ulcer — stop the drug and PPI for 8 weeks.
Summary table
| Topic | Criterion | Action | Exam note |
|---|---|---|---|
| Gastroscopy | Age 60 or more or an alarm feature | Endoscopy | Otherwise "test and treat" |
| H. pylori testing | Breath test or stool antigen | Stop PPI for two weeks and antibiotics for 4 weeks before | Serology cannot separate active from past |
| First treatment | Clarithromycin resistance above 15% | PPI + bismuth + tetracycline + metronidazole for 14 days | Triple only with known susceptibility |
| Confirming eradication | Every treated patient | Breath or stool test at least 4 weeks after treatment | Not serology |
| Gastric ulcer | At gastroscopy | Biopsies to exclude malignancy | Duodenal ulcer — no routine biopsy |
| NSAID ulcer | NSAID or aspirin use | Stop and PPI for 8 weeks | If they must continue — regular PPI |
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Sources
- Maastricht VI/Florence Consensus Report: Management of Helicobacter pylori infection, 2022 — Testing, first-line regimens and eradication confirmation
- ACG Clinical Guideline: Treatment of Helicobacter pylori Infection, 2024 — Bismuth quadruple therapy and resistance
- ACG and CAG Clinical Guideline: Management of Dyspepsia, 2017 — Alarm features and endoscopy
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.