Peptic Ulcer Disease and H. pylori

• Audio chapter
  Single-voice audio, listen on the commute.
• ABIM-format MCQs
  5-option vignettes with full wrong-answer teaching.
• Study guide
  Tables, decision trees, primary sources.
• AI tutor
  Chapter-grounded, answers the question you're stuck on.

What this chapter covers

• Section 6.1: H. pylori biology, diagnosis, and test of cure

  Helicobacter pylori is a spiral, gram-negative, microaerophilic bacterium that lives in a niche no other organism reliably occupies, the layer of mucus that coats the gastric epithelium, and everything about diagnosis and treatment flows from how the organism survives there.

• Section 6.2: First-line eradication regimens

  First-line therapy has changed because clarithromycin resistance has risen above the threshold at which clarithromycin-based regimens can be given empirically with confidence.

• Section 6.3: Salvage therapy after failed eradication

  After first-line failure the patient is treatment-experienced, and the 2024 ACG guideline gives separate recommendations for this group because the data and the choices differ.

• Section 6.4: NSAID and aspirin ulcers

  NSAIDs and aspirin damage the gastroduodenal mucosa by a dual mechanism, and the systemic mechanism explains why parenteral, rectal, and topical NSAIDs all cause ulcer disease while the topical mechanism explains why a tablet swallowed without water injures the mucosa it touches.

• Section 6.5: Refractory and idiopathic ulcers

  A non-healing ulcer at follow-up endoscopy is a differential expansion problem, because the standard explanations (H. pylori and NSAIDs) have either been excluded or addressed, so look systematically for what was missed.

• Section 6.6: Perforation and penetration

  Perforation is the surgical emergency of peptic ulcer disease, and management depends on whether the perforation is free into the peritoneum or contained against an adjacent structure, and on whether the patient is hemodynamically stable.

Podcast episodes

1. 01

   Peptic Ulcer Disease and H. pylori: Test to Cure

   H. pylori care rests on two ideas: the organism's biology explains every test and its false negatives, and resistance patterns explain which drugs can be reused and which cannot. The episode follows a woman with a duodenal ulcer through who gets tested, how PPIs and antibiotics spoil testing, and why antral infection causes duodenal ulcer. It then covers why clarithromycin triple therapy fell, optimized bismuth quadruple therapy and the vonoprazan alternatives, how penicillin and macrolide history pick the regimen, and test of cure. A man whose infection survives two courses then shows how to confirm failure, which drugs to reuse, when to test for resistance, and when rifabutin triple therapy is the last step.

   Read the transcript →
2. 02

   Peptic Ulcer Disease and H. pylori: Ulcer Itself

   The organizing idea is that every ulcer has a cause to find and a complication to anticipate. The episode starts with how NSAIDs injure the stomach however they are given, then tallies risk factors into tiers that decide PPI protection, followed by celecoxib after a bleed, H. pylori testing, and what aspirin and clopidogrel change. It then asks why an ulcer fails to heal, with proper H. pylori retesting, hidden NSAIDs, adherence, and repeat biopsy for cancer, before the rarer causes and the gastrinoma pattern. Last come free perforation, with CT, resuscitation, and a Graham patch, then penetration that mimics pancreatitis, and endoscopic closure.

   Read the transcript →

Key topics

• ·Who should be tested for H. pylori
• ·Urease biology and active tests
• ·Test timing and false negatives
• ·Serology limits
• ·Antral versus whole-stomach infection
• ·Clarithromycin resistance
• ·Optimized bismuth quadruple therapy
• ·Vonoprazan regimens
• ·Penicillin allergy and macrolide history
• ·Test of cure
• ·Confirming treatment failure
• ·Resistance testing and rifabutin salvage
• ·How NSAIDs injure the stomach
• ·Risk factors and risk tiers
• ·PPI, misoprostol, and celecoxib protection
• ·H. pylori testing in NSAID and aspirin users
• ·Aspirin and clopidogrel after a myocardial infarction
• ·Non-healing ulcer and missed causes
• ·Repeat biopsy for gastric cancer and lymphoma
• ·Rarer causes of refractory ulcer
• ·Zollinger-Ellison syndrome testing
• ·Free perforation, Graham patch, penetration, and endoscopic closure