A prospective study suggests that peptic ulcer rebleeding is very unusual after H. pylori eradication and that maintenance antiulcer therapy may not be needed.

Helicobacter pylori infection is associated with peptic ulcer disease, and eradication of the infection reduces ulcer recurrence. The need for maintenance acid-reduction therapy in this setting is controversial.

To explore this issue, investigators at 10 university hospitals in Spain prospectively studied 1000 patients with endoscopically documented bleeding peptic ulcers and H. pylori infection. Participants were treated until eradication of the infection was confirmed by breath test. Thereafter, they received no acid-reduction therapy and were told not to take aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs). They returned at 1-year intervals for a clinical examination and a breath test for H. pylori. If signs or symptoms of upper gastrointestinal bleeding occurred, urgent endoscopy was performed.

All participants were followed for at least 12 months (total, 3253 patient-years of follow-up). Recurrence of peptic ulcer bleeding was rare, occurring in three participants during year 1 and two during year 2. All five cases of rebleeding involved either H. pylori reinfection or NSAID use. The cumulative incidence of rebleeding was 0.5% (95% confidence interval, 0.16%–1.16%) overall and 0.15% (95% CI, 0.05%–0.36%) per patient-year of follow-up.

Comment: These findings provide excellent evidence that H. pylori eradication is sufficient therapy for peptic ulcer patients — even if they had bleeding — in the absence of other causes for ulcers. Forty-one percent of the patients in this study had previously used NSAIDs or aspirin. Without a control group in which NSAIDs are continued, we cannot assess the effect of H. pylori eradication alone, but if such agents are avoided, H. pylori eradication appears to be definitive ulcer therapy. The real clinical challenge is to keep these patients from taking NSAIDs and identify those at high risk for H. pylori reinfection to determine who should be considered for continued antiulcer therapy.

Source: Journal Watch Gastroenterology