Epigastric pain; duodenal better with food, gastric worse
Endoscopy if alarm (blood/anemia, PPI failure) → test H. pylori (urea breath / stool antigen / biopsy urease)
If positive → First-line: bismuth quadruple (PPI + bismuth + tetracycline 500 mg QID + metronidazole 500 mg TID–QID) ×14 d (ACG 2024). Clarithromycin triple ×14 d only if proven low local resistance and no prior macrolide use; penicillin allergy → bismuth quadruple
Confirm eradication: urea breath test or fecal antigen ≥4 wk after antibiotics and ≥2 wk off PPI
Order set
- H. pylori testing
- FBC
- Endoscopy if alarm
- Stop NSAIDs
Criteria
AdmitBleeding, perforation, or obstruction
ICUHaemodynamic instability / perforation
TransfuseHb <70 g/L
DischargeEradication + PPI, bleeding resolved, gastric ulcer follow-up scope
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
- Bleeding
- Perforation (peritonism)
- Gastric outlet obstruction
Differentials
- GORD
- Gastric cancer
- Pancreatitis
- Biliary
Common mistakes
- Not confirming eradication
- Missing gastric malignancy on gastric ulcer
Disposition & follow-up
Eradication + PPI; repeat scope for gastric ulcers.
Discharge package
MedicationsPPI; H. pylori eradication; avoid NSAIDs
Follow-upConfirm eradication; repeat scope for gastric ulcer
Warning symptomsBleeding, severe pain, vomiting
💊 Treatment detail — doses & preparation
OmeprazolePPI
Dose20–40 mg OD 30 min before breakfast ×4–8 wk
Preparation20/40 mg capsules (MUPS dispersible for NG)
MonitorLong-term: Mg²⁺, B12, C. diff risk
Amoxicillintriple therapy
Dose1 g PO BD ×14 d (within clarithromycin triple where used); rifabutin-based triple and vonoprazan-based regimens are newer options (ACG 2024)
Preparation500 mg capsules
MonitorComplete the course; allergy → bismuth quadruple
Clarithromycintriple therapy
Dose500 mg PO BD ×14 d — only where clarithromycin resistance <15% and no prior macrolide exposure (no longer co-first-line; ACG 2024)
Preparation250/500 mg tablets
MonitorMetallic taste; CYP interactions (statins, warfarin)
📖 ACG 2024 H. pylori (Maastricht VI 2022 parallel)Reviewed July 2026