A 55-year-old executive who is seen because of severe epigastric pain is found by Gastrodu-odenal endos¬copy to have a large ulcer in the duodenal bulb. He is placed on a diet and Hz blocker, but his symptoms persist. At this time it would be most appropriate to suggest a
|A||course of metronidazole, tetracycline, and bismuth¬|
|B||highly selective vagotomy|
|C||subtotal gastric resection and gastro¬ jejunostomy|
|D||truncal vagotomy and antrectomy|
a. Patients with peptic ulcer disease should stop smoking and avoid alcohol and NSAIDs (including aspirin).
b. Infectious disease consultation may be helpful in the compliant, symptomatic patient with persistent H. pylori infection following treatment; or another regimen could be tried (e.g., quadruple therapy).
c. If initial H. pylori testing is negative, the ulcer patient may be treated with H2-receptor blockers or proton pump inhibitors. Sucralfate or misoprostol may also be effective.
d. If ulcer symptoms persist, an empiric trial of anti-H. pylori therapy is reasonable (false-negative H. pylori tests are common).
e. Generally, antisecretory therapy can be stopped after 3 months if the ulcerogenic stimulus (usually H. pylori, NSAIDs, or aspirin) has been removed.
f. Long-term maintenance therapy for peptic ulcer should be considered in all patients admitted to hospital with an ulcer complication, all high-risk patients on NSAIDs or aspirin (the elderly or debilitated), and all patients with a history of recurrent ulcer or bleeding.
g. Misoprostol, sulcralfate, and acid suppression may be quite comparable in many of these groups, but misoprostol may cause diarrhea and cramps, and cannot be used in women of childbearing age because of its abortifacient properties.
h. The indications for surgery in peptic ulcer disease are bleeding, perforation, obstruction, and intractability or nonhealing.
i. Gastric cancer must always be considered in gastric ulcer, whereas malignancy is almost never an issue in duodenal ulcer.