Helicobacter pylori-negative peptic ulcers: frequency and implications for management

Most patients with peptic ulcers are infected with Helicobacter pylori, but the infection may not be responsible for the ulcer. It is increasingly recognized that different causes of ulcers coexist in a given patient, confounding determination of the exact cause of the ulcer. For example, in infected patients with ulcers who also are using nonsteroidal anti-inflammatory drugs (NSAIDs), it is not possible to establish the ulcer's cause. Moreover, recent studies in the United States in infected patients with duodenal ulcers who were treated with various regimens to prove their efficacy in eradicating H. pylori and preventing ulcer recurrence found that approximately 20% of patients suffered an ulcer recurrence despite successful H. pylori eradication. The infection clearly did not cause their ulcers but was originally thought to have done so. Thus, as many as one-fifth of patients with ulcers may have the cause falsely attributed to H. pylori infection. When this number is added to that of ulcer patients who are H. pylori-negative upon original presentation--at least 20% in other recent U.S. studies--it is evident that the proportion of non-H. pylori ulcer patients is larger than originally believed. This proportion is likely to increase with the declining incidence of H. pylori infection. Other causes of ulcers include the use of aspirin and NSAIDs (which may be surreptitious), hypersecretory states, Crohn's disease, and patients with "idiopathic" ulcers. Patients with "idiopathic" ulcers are characterized by postprandial hypersecretion of acid and hypergastrinemia with accelerated gastric emptying. H. pylori ulcers may be difficult to manage because antisecretory drugs are less effective in inhibiting gastric acidity in the absence of H. pylori infection.