By subscribing you agree to the Terms of Use and Privacy Policy. Health Topics. Health Tools. Digestive Health. By Madeline R. Reviewed: August 12, He or she may prescribe you other medicines. Doctors use medicines, surgery, and chemotherapy to treat Zollinger-Ellison syndrome. Learn more about Zollinger-Ellison syndrome treatment. Most often, medicines heal a peptic ulcer. If an H. The infection and peptic ulcer will heal only if you take all medicines as your doctor prescribes.
When you have finished your medicines, your doctor may do another breath or stool test in 4 weeks or more to be sure the H. Sometimes, H. If the infection is still present, your peptic ulcer could return or, rarely, stomach cancer could develop. Your doctor will prescribe different antibiotics to get rid of the infection and cure your peptic ulcer.
Yes, a peptic ulcer can come back. If you need to take an NSAID, your doctor may switch you to a different medicine or add medicines to help prevent a peptic ulcer. Peptic ulcer disease can return, even if you have been careful to reduce your risk. To help prevent a peptic ulcer caused by H.
The NIDDK translates and disseminates research findings to increase knowledge and understanding about health and disease among patients, health professionals, and the public. How do doctors treat an H. Certain medications — which include aspirin or clopidogrel, taken regularly to help prevent heart attack or stroke, and drugs for arthritis.
Cancer — stomach cancer can present as an ulcer, particularly in older people. Helicobacter pylori The Helicobacter pylori bacterium H. Ulcer bleeding This is a serious complication of ulcer disease and is particularly deadly in the elderly or those with multiple medical problems. Perforated ulcer A severe, untreated ulcer can sometimes burn through the wall of the stomach, allowing digestive juices and food to leak into the abdominal cavity.
Diagnosis of a stomach ulcer Diagnosing a stomach ulcer is done using a range of methods, including: Endoscopy — a thin flexible tube is threaded down the oesophagus into the stomach under light anaesthesia. The endoscope is fitted with a small camera so the physician can see if there is an ulcer. Barium meal — a chalky liquid is drunk and an x-ray is performed, showing the stomach lining.
These tests are less common nowadays, but may be useful where endoscopy is unavailable. Biopsy — a small tissue sample is taken during an endoscopy and tested in a laboratory.
This biopsy should always be done if a gastric ulcer is found. C14 breath test — this checks for the presence of H. The bacteria convert urea into carbon dioxide. The test involves swallowing an amount of radioactive carbon C14 and testing the air exhaled from the lungs. A non-radioactive test can be used for children and pregnant women. Treatment for a stomach ulcer Special diets are now known to have very little impact on the prevention or treatment of stomach ulcers.
Treatment options can include: medication — including antibiotics, to destroy the H. Different drugs need to be used in combination; some of the side effects can include diarrhoea and rashes. Resistance to some of these antibiotics is becoming more common subsequent breath tests — used to make sure the H.
Most stomach ulcers are caused by infection with the Helicobacter pylori bacterium or anti-inflammatory medication, not stress or poor diet as once thought. Therefore, despite an acceptable rate of eradication, the higher doses of tetracycline and metronidazole in this regimen make it difficult to tolerate.
Because of metronidazole-resistant strains of H pylori , investigators have substituted either clarithromycin or azithromycin for metronidazole in the standard bismuth-based triple therapies in an effort to overcome this problem. Al-Assi et al 53 studied the combination of clarithromycin mg 3 times a day , tetracycline mg 4 times a day , and BSS 2 tablets [ mg per tablet] 4 times a day in 30 infected patients.
The combination was administered for 14 days. This combination is very effective against H pylori and may be an alternative treatment in those patients who are infected with metronidazole-resistant isolates.
As mentioned, azithromycin is a new macrolide antibiotic that is very active against H pylori and achieves excellent tissue penetration with a long half-life. In one study, 54 30 patients with H pylori infection were treated with 1 of 2 regimens: 2 tablets of BSS each tablet contained mg of bismuth 4 times a day, tetracycline hydrochloride mg 4 times a day , and either azithromycin mg twice a day in one group [18 patients] or mg 3 times a day in the other [12 patients] for 2 weeks.
Despite a comparable eradication rate to other effective bismuth-based triple therapies, this triple therapy is limited because its efficacy relies on high doses of azithromycin, which produce much too high a rate of adverse effects to make this regimen practical. Another trial 55 studied the combination of azithromycin, metronidazole, and bismuth. Fifty-six patients infected with H pylori received bismuth subcitrate mg 4 times a day for 14 days along with azithromycin mg daily for the first 3 days and metronidazole mg 4 times a day for the first 7 days.
The eradication rate for this regimen was Only 3 patients in this group experienced an adverse event; however, all were able to complete treatment. Although the adverse-effect profile improved by decreasing the dose and frequency of azithromycin administration, the eradication rate was significantly lowered, making this regimen impractical.
Most studies regarding bismuth-based triple therapy have been conducted using CBS, but more recent trials suggest that BSS can achieve similar eradication rates in the same combinations. To date, the bismuth-based triple therapies are the most effective and least costly treatments for the eradication of H pylori , because they have high cure rates even in those patients infected with metronidazole-resistant strains. Unfortunately, compliance is poor with these regimens because of the large number of tablets and frequent adverse effects.
Still, the search for therapies that are more effective than bismuth-based regimens is ongoing. In an attempt to find more tolerable triple drug regimens, proton pump inhibitors have been studied in combination with 2 other antibiotics.
The most studied has been omeprazole in combination with either metronidazole and amoxicillin or metronidazole and clarithromycin. More recently, in a randomized trial, 60 31 patients were treated with a 1-week course of this omeprazole-antibiotic combination. This implies that perhaps it is necessary to treat patients with this regimen longer to achieve a higher eradication rate. A smaller study 61 evaluated the efficacy of triple therapy using metronidazole, omeprazole, and clarithromycin.
Thirty-three patients with documented H pylori infection received omeprazole 20 mg twice a day , clarithromycin mg twice a day , and metronidazole mg twice a day for 2 weeks. A similar eradication rate This regimen has also been shown to retain its efficacy when given for only a week. Additionally, the efficacy of this therapy is also dependent on the length of time that it is given. In a small randomized trial, 63 patients received omeprazole 20 mg twice daily , clarithromycin mg twice daily , and amoxicillin 1 g twice daily for 7, 10, or 14 days.
Lansoprazole, another proton pump inhibitor, has been shown to be just as effective as omeprazole in triple antibiotic therapy. In a multicenter trial 64 conducted in the United Kingdom and Ireland, patients with either duodenal ulcer or gastritis and H pylori infection were randomized to 1 of 4 1-week regimens: lansoprazole 30 mg twice a day plus clarithromycin mg twice a day with either amoxicillin 1 g or metronidazole mg twice daily or amoxicillin 1 g plus metronidazole mg twice a day with either lansoprazole 30 mg or omeprazole 20 mg twice a day.
The combination of lansoprazole, amoxicillin, and clarithromycin and lansoprazole, clarithromycin, and metronidazole had eradication rates of The eradication rates of the lansoprazole, amoxicillin, and metronidazole and omeprazole, amoxicillin, and metronidazole therapies were Histamine 2 -receptor antagonists H 2 RAs have been used in combination with 2 antibiotics for the eradication of H pylori with good success.
The addition of ranitidine enhances the eradication rate of dual antibiotic therapy. In a randomized, double-blind, multicenter trial, 67 patients were randomized to either metronidazole mg 3 times a day and tetracycline mg 4 times a day with either ranitidine mg 4 times a day or placebo.
Eradication in the group receiving ranitidine was significantly enhanced with an eradication rate of A recent meta-analysis by Holtmann et al 69 suggests that eradication of H pylori with H 2 RAs in combination with antibiotics is similar to proton pump inhibitor combinations. Thus, omeprazole has an advantage over ranitidine with respect to antibiotic resistance.
This may be omeprazole's intrinsic antibacterial activity against H pylori , which ranitidine and other H 2 RAs do not possess. Quadruple antibiotic therapies have consisted of traditional bismuth-based triple therapy with the addition of an antisecretory agent, either an H 2 RA or a proton pump inhibitor, to achieve close to complete eradication. These regimens have consistently achieved high eradication rates. In a randomized placebo-controlled trial, 71 consecutive patients with peptic ulcer disease and biopsy-proven H pylori infection were randomized to 7 days of triple therapy with or without omeprazole 20 mg twice a day or placebo.
Triple antibiotic therapy consisted of CBS mg 4 times a day , tetracycline hydrochloride mg 4 times a day , and metronidazole mg 3 times a day.
Addition of omeprazole to this traditional triple therapy enhanced its efficacy. In another trial, 72 addition of either omeprazole or famotidine to triple antibiotic therapy was studied to see if the efficacy of triple antibiotic therapy could be improved. This prospective, randomized study enrolled patients with symptoms of dyspepsia and confirmed H pylori infection. Patients received a day course of CBS chewable tablets mg 4 times a day, tetracycline mg 4 times a day , and metronidazole mg 4 times a day in addition to either omeprazole 20 mg twice daily or famotidine 40 mg at bedtime.
One-hundred twenty two of the Again, addition of a proton pump inhibitor resulted in enhanced eradication efficacy despite a greater prevalence of metronidazole-resistant isolates.
Antibiotic resistance with regard to H pylori eradication has become a growing problem both here in the United States and in developing countries. Recent studies have demonstrated that triple drug regimens that contain both metronidazole and clarithromycin are able to maintain their efficacy against H pylori despite metronidazole resistance.
In a randomized multicenter trial 77 of patients with H pylori infection, 1 of the 3 following day regimens was administered: 1 omeprazole 20 mg , metronidazole mg , and clarithromycin mg twice daily; 2 omeprazole 20 mg , amoxicillin mg , and metronidazole mg twice daily; or 3 bismuth subcitrate mg , clarithromycin mg , and metronidazole mg twice a day.
None of the isolates were resistant to clarithromycin. Similar results were obtained in a randomized controlled trial 78 using omeprazole 20 mg , metronidazole mg , and clarithromycin mg twice daily for 1 week. Of the 64 patients enrolled, only 59 had successful culture and antibiotic sensitivity testing of their H pylori infection.
The 3 patients who failed therapy all had isolates that were resistant to metronidazole, including the patient who had the isolate that was clarithromycin resistant. Again, these 2 studies 77 , 78 demonstrate that, in those patients with only metronidazole-resistant isolates, triple therapy with metronidazole, clarithromycin, and omeprazole is still effective eradication therapy.
Although clarithromycin is one of the newer agents used in the eradication of H pylori , resistant strains are emerging. Therefore, with greater use of clarithromycin in regimens to eradicate H pylori , there is a high likelihood that the prevalence of resistant strains will continue to increase. This supports the view that clarithromycin-containing regimens should be avoided in those patients with prior exposure to the drug.
For patients who have failed treatment with clarithromycin-containing regimens, effective alternative antibiotic combinations should be given.
Choosing a single regimen from the myriad of regimens offered in the literature can be a bewildering experience; however, after careful analysis of the data, these can be narrowed to a select few.
Figure 1 outlines the algorithm we use for patients identified with a peptic ulcer and concurrent infection with H pylori. Table 1 lists the most effective regimens found in the literature. Based on the data reviewed, our first choice of treatment for eradication would be the metronidazole-omeprazole-clarithromycin regimen omeprazole [20 mg], clarithromycin [ mg], and metronidazole [ mg] twice a day for at least 7 to 10 days.
In addition, preliminary data seem to indicate that metronidazole resistance does not appear to reduce the efficacy of this regimen, suggesting that it can still be used in areas where metronidazole resistance is frequent; however, studies to directly address this issue still need to be conducted.
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