A 38-year-old woman comes to the office for follow-up after recent hospitalization. The patient went to the emergency department 2 weeks ago after several episodes of coffee-ground emesis. She had intermittent, burning, epigastric pain over the past several months prior to hospitalization. At that time, upper gastrointestinal endoscopy revealed a duodenal ulcer, and the patient was discharged on pantoprazole therapy. The patient reports improvement in abdominal pain and has had no further hematemesis, hematochezia, or melena. She has no other medical problems and in the past has taken only ibuprofen for occasional aches and pains. The patient does not use tobacco, alcohol, or illicit drugs and has no allergies. Family history is notable for gastric cancer in her father. Temperature is 36.5 C (97.7 F), blood pressure is 124/78 mm Hg, and pulse is 82/min. Cardiopulmonary examination is normal. The abdomen is nondistended, soft, and nontender. Gastric and duodenal biopsies performed during the endoscopy show chronic antral gastritis with presence of Helicobacter pylori but no evidence of malignancy.
Which of the following is the most appropriate next step in management of this patient?

Question

A 38-year-old woman comes to the office for follow-up after recent hospitalization.  The patient went to the emergency department 2 weeks ago after several episodes of coffee-ground emesis.  She had intermittent, burning, epigastric pain over the past several months prior to hospitalization.  At that time, upper gastrointestinal endoscopy revealed a duodenal ulcer, and the patient was discharged on pantoprazole therapy.  The patient reports improvement in abdominal pain and has had no further hematemesis, hematochezia, or melena.  She has no other medical problems and in the past has taken only ibuprofen for occasional aches and pains.  The patient does not use tobacco, alcohol, or illicit drugs and has no allergies.  Family history is notable for gastric cancer in her father.  Temperature is 36.5 C (97.7 F), blood pressure is 124/78 mm Hg, and pulse is 82/min.  Cardiopulmonary examination is normal.  The abdomen is nondistended, soft, and nontender.  Gastric and duodenal biopsies performed during the endoscopy show chronic antral gastritis with presence of Helicobacter pylori but no evidence of malignancy. 
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf47_d921_8f63_f5d886cb07c4_MD0005_00 Helicobacter pylori infection is an important risk factor for the development of peptic ulcer disease (PUD), gastric cancer, and mucosa-associated lymphoid tissue lymphoma. H pylori may also have a role in the pathogenesis of nonulcer dyspepsia and gastroesophageal reflux disease. It accounts for 70%-80% of duodenal ulcers and approximately 50% of gastric ulcers, and its eradication significantly reduces the risk of recurrence of PUD. Multiple regimens have been proposed for the eradication of H pylori infection, and the preferred initial regimen depends on local antibiotic susceptibility. In regions with limited clarithromycin resistance, an acceptable initial regimen is triple therapy with a proton pump inhibitor (PPI), clarithromycin, and amoxicillin for 14 days. Metronidazole can be substituted for amoxicillin in patients allergic to penicillin. In areas with clarithromycin resistance >15%, initial therapy should consist of 14 days of quadruple therapy with a PPI, bismuth, and 2 antibiotics (or a PPI and 3 antibiotics). (Choice B) The addition of bismuth without antibiotics would not result in the resolution of H pylori infection, and although sucralfate appears to suppress H pylori, it does not have a specific role in its eradication. (Choices C and D) Patients with H pylori infection are at increased risk for ulcer formation in the setting of nonsteroidal anti-inflammatory drugs, and patients should be encouraged to avoid their use until the completion of treatment. However, in the absence of antibiotic therapy the infection will likely persist, placing the patient at continued risk for complications associated with H pylori. In addition, indefinite continuation of PPI therapy is not appropriate for the management of PUD as therapy is often needed for only 2 weeks and is rarely indicated for >12 weeks. (Choice E) Misoprostol is a prostaglandin that inhibits gastric acid secretion and improves mucosal defenses. It has been used to prevent ulcers associated with the use of nonsteroidal anti-inflammatory drugs, but is not routinely used for PUD associated with H pylori. Educational objective: Patients with Helicobacter pylori-associated peptic ulcer disease should receive treatment based on local antibiotic susceptibility. Acceptable first-line regimens include triple drug therapy with a proton pump inhibitor, clarithromycin, and amoxicillin, or quadruple therapy with a proton pump inhibitor, bismuth, and 2 antibiotics (or a PPI and 3 antibiotics). References: Treatment of Helicobacter pylori infection: current status and future concepts. (http://www.ncbi.nlm.nih.gov/pubmed/24833858) Eradication of Helicobacter pylori infection: which regimen first? (http://www.ncbi.nlm.nih.gov/pubmed/24574740)

A 38-Year-Old Woman Comes to the Office for Follow-Up After