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Antral Ulcers: H. pylori, NSAIDs, Diagnosis & Treatment

Antral ulcers are peptic ulcers localized to the gastric antrum (distal stomach). They share etiology and management with duodenal ulcers.

Etiology

  • H. pylori (80–90%): Disrupts mucosal defense, increases acid, impairs bicarbonate.
  • NSAIDs/ASA: COX-1 inhibition → ↓ prostaglandins → ↓ mucus/bicarbonate, ↓ mucosal blood flow.
  • Synergy: H. pylori + NSAID → multiplicative risk.
  • Other: Smoking (impairs healing), stress (physiological), alcohol, Zollinger-Ellison (rare).

Symptoms

  • Epigastric pain (burning, gnawing) — often relieved by food/antacids (vs. gastric ulcer worsened by food).
  • Nausea, early satiety, bloating.
  • Bleeding: melena, hematemesis, iron deficiency anemia.
  • Perforation: acute abdomen (surgical emergency).

Diagnosis

  1. EGD (Esophagogastroduodenoscopy): Gold standard; visualizes ulcer, allows biopsy (H. pylori, histology, rule out malignancy).
  2. H. pylori testing: Biopsy (rapid urease, histology, culture), Urea breath test (UBT), Stool antigen — non-invasive preferred post-treatment.
  3. Serology: Not for active infection (persists post-eradication).

Treatment

  • H. pylori positive: Bismuth quadruple (PPI + bismuth + tetracycline + metronidazole 14 days) OR Concomitant (PPI + clarithro + amox + metronidazole 10–14 days) OR Sequential. Clarithromycin triple only if local resistance <15%. Confirm eradication (UBT/stool Ag ≥4 wks post-Rx).
  • NSAID-induced, H. pylori negative: PPI ×8 weeks; discontinue/change NSAID; consider COX-2 inhibitor + PPI if NSAID essential.
  • Bleeding ulcer: Endoscopic hemostasis (clips, injection, thermal) + high-dose IV PPI (bolus + infusion 72 hrs).

Prevention

  • H. pylori test-and-treat before chronic NSAID.
  • Lowest effective NSAID dose; avoid concurrent anticoagulants/antiplatelets if possible.
  • PPI prophylaxis for high-risk NSAID users (age>65, prior ulcer, anticoagulant, steroid).
  • Smoking cessation.

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