A 34-year-old man comes to the office due to epigastric pain. He has had the pain for several months and describes it as being worse at night and relieved by eating. The patient has no significant medical history and takes no medications. He does not use tobacco, alcohol, or recreational drugs. The patient immigrated to the United States from China 4 years ago. Vital signs are within normal limits. Physical examination shows mild epigastric tenderness to deep palpation. Laboratory testing demonstrates iron deficiency anemia and the presence of fecal occult blood. Upper gastrointestinal endoscopy reveals a 1-cm ulcer in the first portion of the duodenum. Additional test results are pending. In addition to proton pump inhibitor therapy, which of the following would be most appropriate to prevent ulcer recurrence based on this patient's most likely diagnosis?
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This patient's symptoms and endoscopic findings are consistent with duodenal peptic ulcer disease (PUD). Most patients with duodenal ulcers have concomitant Helicobacter pylori infection. The remaining cases are typically associated with nonsteroidal anti-inflammatory drug (NSAID) use, which is unlikely in this patient who takes no medications. More than 50% of the world population is colonized with H pylori, with a particularly high prevalence in Asia and South America.
Treatment of the patient's condition and prevention of ulcer recurrence require eradication of H pylori infection. Effective regimens typically involve a combination of antibiotics (eg, tetracycline, metronidazole) and proton pump inhibitors (eg, omeprazole), sometimes with bismuth subsalicylate. The antibiotic regimen can be tailored based on local resistance patterns (ie, triple vs quadruple therapy).
(Choice B) Gastric cytoprotectants (eg, sucralfate) bind to the base of mucosal ulcers and protect them against gastric acid. These agents help duodenal ulcers heal but would be less effective in preventing ulcer recurrence compared with eradication of H pylori.
(Choice C) Glucocorticoids should be avoided in patients with PUD because they can promote peptic ulcer formation, especially when combined with NSAIDs.
(Choice D) Proton pump inhibitors suppress gastric acid secretion to a greater extent than H2-receptor blockers (eg, famotidine), allowing for superior ulcer healing during PUD treatment. However, neither medication would prevent ulcer recurrence, which requires H pylori eradication.
(Choice E) Metoclopramide is a dopamine antagonist with prokinetic and antiemetic properties that can be used to treat gastrointestinal motility disorders (eg, gastroparesis); however, it does not significantly affect PUD.
(Choice F) Prostaglandin analogues such as misoprostol are used to prevent NSAID-induced peptic ulcers.
Educational objective:
Most duodenal peptic ulcers are caused by Helicobacter pylori infection. Treatment and prevention of disease recurrence focus on eradicating the infection with antibiotics (eg, tetracycline, metronidazole), typically in combination with proton pump inhibitors (eg, omeprazole) and, often, bismuth subsalicylate (quadruple therapy).