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Upon completion of the chapter, the reader will be able to:

  1. Recognize differences between ulcers induced by Helicobacter pylori, nonsteroidal anti-inflammatory drugs (NSAIDs), and stress-related mucosal damage (SRMD) in terms of risk factors, pathogenesis, signs and symptoms, clinical course, and prognosis.

  2. Identify desired therapeutic outcomes for patients with H. pylori–associated ulcers and NSAID-induced ulcers.

  3. Identify factors that guide selection of an H. pylori eradication regimen and improve adherence with these regimens.

  4. Determine the appropriate management for a patient taking a nonselective NSAID who is at high risk for ulcer-related gastrointestinal (GI) complications (eg, GI bleed) or who develops an ulcer.

  5. Employ an algorithm for evaluation and treatment of a patient with signs and symptoms suggestive of an H. pylori–associated or NSAID-induced ulcer.

  6. Given patient-specific information and the prescribed treatment regimen, formulate a monitoring plan for drug therapy either to eradicate H. pylori or to treat an active NSAID-induced ulcer or gastrointestinal (GI) complication.


Peptic ulcer disease (PUD) refers to a defect in the gastric or duodenal mucosal wall that extends through the muscularis mucosa into the deeper layers of the submucosa.1 PUD is a significant cause of morbidity and is associated with substantial health care costs.2,3 Although there are many etiologies of PUD, the three most common are (a) H. pylori infection, (b) use of nonsteroidal anti-inflammatory drugs (NSAIDs), and (c) stress-related mucosal damage (SRMD).

Complications of PUD include GI bleeding, perforation, and obstruction. Complications of untreated or undiagnosed H. pylori infection include gastric cancer and PUD. This chapter focuses mainly on pharmacotherapy of PUD related to H. pylori infection or NSAID use. Prophylaxis of stress-related mucosal damage in hospitalized patients is also discussed briefly.


In the United States, PUD affects approximately 4.5 million people annually.4 The mean direct medical cost (including pharmacy, inpatient, and outpatient costs) was $23,819 per patient per year in one study evaluating workplace absences, short-term medical disability, worker’s compensation, and medical and pharmacy claims for six large US employers.5

The prevalence of H. pylori infection in the United States and Canada is about 30%, whereas the global prevalence is greater than 50%. Factors that influence the incidence and prevalence of H. pylori infection include age, ethnicity, sex, geography, and socioeconomic status.

Helicobacter Pylori

H. pylori is usually contracted in the first few years of life and tends to persist indefinitely unless treated. The infection normally resides in the stomach and is transmitted through ingestion of fecal-contaminated water or food. The organism causes gastritis in all infected individuals, but fewer than 10% actually develop symptomatic PUD.

Nonsteroidal Anti-Inflammatory Drugs

Chronic NSAID ...

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