Long-term Follow-up and Serological Study after Triple Therapy of Helicobacter pylori-associated Duodenal Ulcer

Objective: The purpose of this study was to monitor the change of IgG antibodies to Helicobacter pylori during the course of a long-term follow-up after the eradication of H. pylori , as well as to evaluate the efficacy of triple therapy in preventing the recurrence of duodenal ulcer (DU). Methods: Twenty-three DU patients with positive II. pylori were studied; among those patients, 20 ulcers healed after initial treatment of triple therapy. Each patient received a follow-up endoscopy and biopsy examination every 3 months for 1 yr, or whenever the ulcer symptoms recurred. Serological tests for IgG antibodies were performed with a commercial ELISA. Results: Of the 20 patients with healed ulcers, one dropped out of this study; the recurrence rate of DU at 1 yr was 5% (1/19). There was no recurrence of ulcer in 17 H. pylori -negative patients and only one recurrence out of two H. pylori - positive patients. After the eradication of H. pylori , the seroconversion rates of IgG were 5%, 21 %, 42%, 76%, and 94% at 0, 3, 6, 9, and 12 months, respectively. After 6 months, 95% (18/19) of the patients in which H. pylori was eradicated had at least a one-grade fall in IgG titers ( P < 0.001). One patient had a relapse of H. pylori which was accompanied with re-elevating IgG titers. Conclusions: We conclude that seroconversion, which usually occurs after 1 yr, indicates complete eradication of H. pylori . Furthermore, we suggest that the success of the eradication of H. pylori can be judged without endoscopic examination, 8 months after treatment by triple therapy, according to the fall of IgG titers or seroconversion. Re-elevating IgG titers may be a warning of the possibility of relapse or reinfection of H. pylori .     

Five-Day Bismuth-Free Triple Therapy for the Eradication of Helicobacter pylori and Reduction of Duodenal Ulcer Relapse

Previous studies have demonstrated that the eradication of Helicobacter pylori ( H. pytori ) is associated with a significant reduction of the rate of duodenal ulcer (DU) relapse. The aim of this study was to assess the long-term effect of a bismuth-free triple therapy on the eradication of H. pylori and reduction of DU relapse. After informed consent, 61 patients with endoscopically proven DU and H. pylori infection detected on ¹⁴C-urea breath test (BT) were included in the study. All patients received a combination of furazolidone, amoxicillin, and metronidazole, three times a day, for 5 days, in addition to eventual classical antiulcer agents prescribed by their attending physicians. BT was repeated after an interval of at least 60 days to evaluate H. pylori eradication. Endoscopy and another BT were performed again at 6.5 months after therapy to detect possible recurrences. Forty-eight patients completed the trial: 26 (54%) patients were negative for H. pylori at 6.5 months after the end of treatment, and 22 (46%) persisted H. pylori positive. Ninety-two percent of the patients in whom the bacteria were eradicated showed endoscopically healed ulcers and were asymptomatic, and two that were sympatomatic presented only occasional pain not requiring therapy. Among the 22 patients who persisted H. pylori positive, six (27%) showed endoscopically active ulcers ( p = 0.012) and eight (36%) patients continued to be symptomatic ( p < 0.01), and were still using antiulcer drugs ( p < 0.002) 6.5 months after treatment. It is concluded that combined treatment with furazolidone, amoxicillin, and metronidazole for 5 days represents a well-tolerated, inexpensive, and effective therapeutic regime for the eradication of H. pylori and abolition of DU relapse in more than 50% of the patients during a follow-up period of 6.5 months.     

Long-Term Helicobacter pylori Recurrence after Successful Eradication with Triple Therapy

To establish the rate of Helicobacter pylori recurrence after a standard triple-therapy regimen (bismuth subsalicylate, tetracyeline, metronidazole) and determine which clinical factors affect reinfection, we prospectively followed 118 patients after successful H. pylori eradication. Elimination of H. pylori was confirmed by repeat endoscopy and urea breath test 4 wk after completion of therapy. Serial [¹³]urea breath tests were performed at 3-month intervals; antral biopsies were used to verify reinfection. Recurrence of H. pylori infection occurred in 4/118 (3.4%) patients. Three of the four relapses occurred in the 1st yr after treatment. Gender, age, ethnic group, alcohol consumption, cigarette use, and gastrointestinal diagnosis do not predict H. pylori recurrence. We conclude that the rate of recurrence after successful H. pylori eradication is low, and that when reinfection takes place, if occurs most commonly within the 1st yr after treatment.     

Low Dose, Short-Term Triple Therapy for Cure of Helicobacter pylori Infection and Healing of Peptic Ulcers

Objectives: The aim of this study was to confirm the efficacy and tolerability of a new, low dose, short-term triple therapy for cure of Helicobacter pylori infection, as suggested by Bazzoli, in a larger population. Methods: On an "intention-to-treat" basis, 116 patients with active (n = 41) or healed (n = 47) peptic ulcer disease or ulcer-like dyspepsia (n = 28) and H. pylori infection received a 1-wk course of omeprazole 20 mg b.i.d. , clarythromycin 250 mg b.i.d. , and tinidazole 500 mg b.i.d. , Four weeks after treatment withdrawal, cure of H. pylori infection was evaluated by rapid urease test and histology. Results: One hundred and sixteen patients returned for follow-up. In 108 patients, H. pylori could not be identified 4 wk after cessation of therapy. The eradication rate was calculated to 93%. In addition, all patients with active peptic ulcers showed complete healing at follow-up despite no further treatment. Drug acceptance and compliance was excellent. Conclusion: Triple therapy as suggested by Bazzoli with omeprazole (in this study given b.i.d. for better compliance), clarythromycin, and tinidazole is indeed highly effective for both cure of H. pylori infection and for healing of peptic ulcers, is easy to perform, is cheap, and is without clinically significant side effects, even in a larger population.     

Apparent Reversal of Early Gastric Mucosal Atrophy after Triple Therapy for Helicobacter pylori

Helicobacter pylori may be difficult to detect in individuals with intestinal metaplasia or atrophic gastritis, even though bacteria may persist in the mucosa in low numbers, maintaining elevated serum H. pylori antibody levels. We report a patient with marked, endoscopically visible gastric mucosal changes and focal changes of histological atrophic gastritis, who was negative for H. pylori on urease test, culture, and histology, but had positive H. pylori serology. When treated with triple therapy and reassessed at 6 months, his H. pylori antibody titer fell to low/negative levels, abnormal mucosa was replaced by a velvety, normal lining, and the previous evidence of histological atrophic gastritis was no longer detectable.     

克拉霉素为基础的三联方案根除幽门螺杆菌的疗效研究

克拉霉素是根除幽门螺杆菌（Hpylori）感染的有效药物,以克拉霉素为基础的三联方案根除Hpylori在临床上广泛应用。目的：评估克拉霉素为基础的三联方案根除日．pylori的疗效。方法：133例Hpylori感染患者随机分为3组,A组：埃索美拉唑20mgbid＋克拉霉素0．5gbid＋阿莫西林1gbid,疗程7d;B组：埃索美拉唑20mgbid＋克拉霉素0．5gbid＋左氧氟沙星0．5gqd,疗程7d;C组：埃索美拉唑20mgbid＋克拉霉素0．5gbid＋呋喃唑酮0．1gtid,疗程7d。治疗结束后4～8周复查”C-尿素呼气试验和快速尿素酶试验以评估根除疗效。结果：128例患者按方案完成治疗。A、B、C组按意向治疗（11-r）分析日．pylori根除率分别为84．4％、77．3％、75．0％,按方案（PP）分析分别为88．4％、79,1％、78．6％。A组的11Tr和PP根除率高于B组和C组,但差异无统计学意义（P〉0．05）。结论：克拉霉素联合质子泵抑制剂（PPI）和阿莫西林7d疗法仍为有效的Hpylori感染根除方案。     

Duodenal erosions after eradication of Helicobacter pylori infection

BACKGROUND: There is interest in the development of GERD after Helicobacter pylori eradication. In contrast, the development of duodenal erosions after therapy has received scant attention. Patients were examined after eradication of H pylori infection to determine the frequency of post-therapy duodenal erosions (primary outcome) and whether there was a relation between development of duodenal and esophageal erosions. Additionally, factors were searched for that would identify patients at increased risk for duodenal erosions. METHODS: A single-center, endoscopist-blinded, observational study was conducted of 196 patients in whom H pylori was eradicated. The presence of esophageal or duodenal erosions was evaluated 4 weeks and 6 months after eradication. Serum gastrin and pepsinogen I (PG I) and II (PG II) levels were also determined for 83 patients entering the study during its final year. RESULTS: Multiple small duodenal erosions developed in 8.6% of patients after H pylori eradication and were more common in patients with pre-eradication duodenal ulcer (27.8%) compared with those with gastric ulcer (6.7%) or atrophic gastritis (1.4%) (p < 0.05). Duodenal erosions were associated with high levels of PG I before and after eradication. The frequency of duodenal erosions decreased over time (3.1% by 6 months). CONCLUSION: Duodenal erosions occur after H pylori eradication and appear to be related to duodenal ulcer and increased PG I levels, both of which are associated with increased acid secretion. Measurement of PG I may help to identify patients who have duodenal erosions develop after H pylori therapy for studies of the pathogenesis of these lesions.     

Patient Factors Affecting Helicobacter pylori Eradication with Triple Therapy

Duodenal ulcer recurrence and gastritis are reduced with successful Helicobacter pylori treatment. To identify the patient factors influencing H. pylori eradication, we prospectively evaluated 96 consecutive patients undergoing a single 2-wk course of bismuth, tetracycline, and metronidazole therapy. At the time of initial esophagogastroduodenoscopy with biopsies, each patient had a profile obtained which included demographic information, gastrointestinal pathology, and H. pylori status of the spouse. Elimination of H. pylori was confirmed by repeat esophagogastroduodenoscopy with biopsies 4 wk after the completion of therapy and serial urea breath tests. Eradication at 4 wk was successful in 80 of 96 (83%) patients. On multivariate analysis, H. pylori elimination was associated with advanced age ( p = 0.002) and a greater amount of chronic inflammation on baseline antral biopsy ( p = 0.024). Eradication was inversely associated with the presence of a gastric ulcer ( p = 0.008) and lack of medication compliance ( p = 0.030). Successful eradication reduced the severity of both acute and chronic antral mucosal inflammation. Household income, gender, ethnic group, smoking, alcohol intake, and H. pylori status of the spouse did not differ between the eradicated and noneradicated groups. We conclude that it will be important to control for influential patient factors in future studies of H. pylori treatment regimens.     

The Efficacy of Moxifloxacin-Containing Triple Therapy after Standard Triple,Sequential, or Concomitant Therapy Failure for Helicobacter pylori Eradication in Korea

Background/Aims

Retreatment after initial treatment failure for Helicobacter pylori is very challenging. The purpose of this study was to evaluate the efficacies of moxifloxacin-containing triple and bismuth-containing quadruple therapy.

Methods

A total of 151 patients, who failed initial H. pylori treatment, were included in this retrospective cohort study. The initial regimens were standard triple, sequential, or concomitant therapy, and the efficacies of the two following second-line treatments were evaluated: 7-day moxifloxacin-containing triple therapy (rabeprazole 20 mg twice a day, amoxicillin 1,000 mg twice a day, and moxifloxacin 400 mg once daily) and 7-day bismuth-containing quadruple therapy (rabeprazole 20 mg twice a day, tetracycline 500 mg 4 times a day, metronidazole 500 mg 3 times a day, and tripotassium dicitrate bismuthate 300 mg 4 times a day).

Results

The overall eradication rates after moxifloxacin-containing triple therapy and bismuth-containing quadruple therapy were 69/110 (62.7%) and 32/41 (78%), respectively. Comparison of the two regimens was performed in the patients who failed standard triple therapy, and the results revealed eradication rates of 14/28 (50%) and 32/41 (78%), respectively (p=0.015). The frequency of noncompliance was not different between the two groups, and there were fewer adverse effects in the moxifloxacin-containing triple therapy group (2.8% vs 7.3%, p=0.204 and 25.7% vs 43.9%, p=0.031, respectively).

Conclusions

Moxifloxacin-containing triple therapy, a recommended second-line treatment for initial concomitant or sequential therapy failure, had insufficient efficacy.     

Triple Therapy of Helicobacter pylori Infection in Peptic Ulcer: A 12-Month Follow-up Study of 93 Patients

This study was undertaken to evaluate the success of triple therapy in peptic ulcer patients and ulcer relapses. One hundred and one Consecutive Helicobacter pylori-positive peptic ulcer patients were assigned to an open trial with 2 weeks of treatment with colloidal bismuth subcitrate, amoxicillin, and metronidazole. At the 6-week follow-up only 1 duodenal ulcer was unhealed of 57 active ulcers, and H. pylori was found to be eradicated in 84% of the 100 subjects. The sensitivity to metronidazole was determined from 71 pretreatment strains of H. pylori. Eradication of H. pylori succeeded in 89% of the patients with metronidazole-susceptible strains and in 615% of patients with metronidazole-resistant strains (p > 0.03). All 16 patients in whom the treatment failed to eradicate the organism had metronidazole-resistant strains after treatment. The ulcer relapse rate was low. At the 12-month follow-up of 03 patients only 1 of the 84 H. pylori-negative patients (including 4 patients after new successful therapy) had relapsing ulcers (2 asymptomatic episodes), and 1 had H. pylori reinfection. whereas 3 of the 9 bacteria-positive patients relapsed (p = 0.002); at the 2-year control 2 more patients had ulcer relapses. The eradication of H. pylori infection clearly prevents relapses of peptic ulcer, but the success of triple therapy depends on the frequency of pretreatment metronidazole-resistant strains.     

Clinical Utility and Cost Effectiveness of Helicobacter pylori Testing for Patients with Duodenal and Gastric Ulcers

Objective: Current consensus guidelines recommend that all patients demonstrating either a gastric or duodenal ulcer he tested for Helicobacter pylori , the most common cause of ulcers. We determined the clinical utility and cost effectiveness of H. pylori testing in patients with duodenal and gastric ulcers. Methods: A retrospective evaluation and cost-effectiveness analysis of 565 consecutive patients with endoscopically demonstrated gastric or duodenal ulcers over a 4-yr period in a large, urban general hospital. The main outcome variables are the percentage of patients who had a gastric biopsy, the prevalence of H. pylori , and the cost effectiveness of testing (antral biopsy, CLO test, serum antibody, and urea breath test) for H. pylori. Results: Significantly more patients with endoscopically documented duodenal ulcers had an antral biopsy performed in 1993 and 1994 when compared with patients from 1991 and 1992 (p < 0.00001). For patients with gastric ulcers, biopsies were performed at a similar rate throughout this study. Overall, patients with duodenal and gastric ulcers demonstrated H. pylori 75% and 69% of the time, respectively. The total charges for biopsy documentation and treatment of H. pylori in all duodenal ulcer patients in this cohort was estimated at $25,135. If a biopsy for H. pylori had been performed in all patients the actual charges would have been $77,443. Conversely, charges would have been only $8085 had all patients been empirically treated for H. pylori based on the high pretest probability of infection. Conclusions: Routine testing for H. pylori is very expensive, regardless of the diagnostic method used. Biopsy results do not provide clinically useful information in most patients with duodenal ulcers and may be misleading if falsely negative.     

雷贝拉唑三联疗法治疗幽门螺杆菌阳性十二指肠溃疡

目的观察雷贝拉唑三联短程疗法治疗幽门螺杆菌(H.pylori)阳性十二指肠溃疡的疗效.方法100例经胃镜检查确诊为十二指肠溃疡并经快速尿素酶实验和病理学检查确定为H.pylori阳性的患者随机分为两组雷贝拉唑组和奥美拉唑组.两组先予以三联疗法雷贝拉唑10mg或奥美拉唑20mg、阿莫西林1g及克拉霉素500mg,每日2次,连续7天,然后给予雷贝拉唑10mg或奥美拉唑20mg,每天1次,连续7天,疗程结束后4周复查胃镜并检测H.pylori,并记录用药后患者症状的改变程度.结果93例完成治疗方案.其中雷贝拉唑组2周溃疡愈合率为93.6%,奥美拉唑组为73.9%,雷贝拉唑组明显高于奥美拉唑组,两组有显著性差异(P＜0.05),雷贝拉唑组第1、3天症状缓解率分别为68.1%、91.4%,奥美拉唑组为39.1%、65.2%,两组比较差异有显著性(P＜0.05);雷贝拉唑H.pylori根除率为91.5%,奥美拉唑组为86.9%,两组间无显著性差异(P＞0.05).结论雷贝拉唑、克拉霉素和阿莫西林三联短程疗法能有效根除H.pylori及提高溃疡愈合率,并能迅速缓解症状,与奥美拉唑三联疗法相比较,在H.pylori根除率上无显著性差异,而在2周溃疡愈合率及症状缓解率方面,雷贝拉唑却明显优于奥美拉唑.     

Long-term Follow-up of Endoscopic Treatment for Bleeding Gastric and Duodenal Ulcers

Objective: To examine the long-term consequences of endoscopic therapy for bleeding peptic ulcers. Methods: Eighty-seven consecutive patients who underwent endoscopic treatment for bleeding gastric ulcer (GU) and/or duodenal ulcer (DU) over a 42-month period were identified. Long-term follow-up was available for 76 (mean, 495 days; SEM, 45 days). Therapy consisted of epinephrine injection, heater probe use, or both. Recurrent hemorrhage only at the primary treatment site was considered. Results: The sites of hemorrhage were GU (40 patients), DU (34 patients), and both (2 patients). Emergent surgery was required in two GU patients for whom endoscopic treatment was ineffective. Recurrent hemorrhage ultimately occurred in 33% of patients—40% of GU and 25% of DU patients. Surgical therapy was eventually required in 26% of patients after endoscopic he-mostasis and was more frequent in patients with recurrent hemorrhage from DU than GU (78% vs 56%). For those patients who re-bled within 8 days of the index endoscopy, 82% required surgery, compared with 33% of patients who re-bled more than 8 days after the index endoscopy ( p = 0.03). Conclusions: The rate of recurrent hemorrhage after endoscopic hemostasis for bleeding GU and DU was 33% in our long-term follow-up. After endoscopic hemostasis, surgery was eventually required in 24% of all patients and in 64% of patients who had recurrent hemorrhage. Patients who had recurrent hemorrhage more than 1 wk after initial endoscopic hemostasis were effectively treated by repeated endoscopic therapy and were significantly less likely to require surgery than patients who re-bled within 1 wk.     

Long-Term Follow-up of Helicobacter pylori Serology after Successful Eradication

Objective : To determine the Helicobacter pylori IgG serology pattern 12–21 months after successful organism eradication and to assess the usefulness of IgG serology in the long-term follow-up of patients. Methods : We recruited patients from our 1990-91 study on IgG serology after H. pylori treatment. Forty-three of 45 patients (93%) agreed to participate. They had all been cured of H. pylori infection after triple antibiotic therapy and remained H. pylori negative at 1 yr posttreatment. H. pylori IgG antibody concentrations were measured in serum samples taken at 3-month intervals between 12 and 21 months posttreatment. [¹³C]-urea breath test was done at each blood draw to ensure continued eradication. Serology was determined by ELISA (Pylori Stat, BioWhittaker, Inc) and expressed as absorbance. Results: All 43 patients (100%) continued to be free of H. pylori and demonstrated a decline in their H. pylori IgG concentration compared with baseline. The overall decline in serology among all 43 patients was approximately 50%. Forty of 43 patients (93%) had a decline of more than 20% in H. pylori IgG concentration compared with baseline. However, 28 of 43 patients (65%) remained seropositive for more than 1 yr after successful H. pylori eradication. Conclusion : We conclude that a 20% decline in IgG concentration has an overall sensitivity of 93% for determining H. pylori eradication 12-21 months after H. pylori treatment. Serology is an attractive alternative to endoscopy or urea breath tests in monitoring patients after H. pylori treatment, but serum IgG levels should not be expected to reach seronegative range after successful H. pylori eradication.     

十二指肠溃疡患者根除幽门螺杆菌后抑酸维持治疗的疗效研究

背景：对感染幽门螺杆菌（H.pylori）的消化性溃疡患者成功根除且H.ylori后,是否应继续行抑酸治疗,目前尚存在争议。目的：探讨合并H.pylori感染的十二指肠溃疡（DU）患者根除H.pylori后抑酸维持治疗的疗效。方法：112例合并H.pylori感染的DU患者随机分为A组和B组,A组给予10d四联疗法：兰索拉唑30mg＋阿莫西林1g＋克拉霉素0．5gbid＋枸橼酸铋钾110mg qid,疗程10d。B组：在A组方案的基础上,疗程结束后再予兰索拉唑30mg,1次／d,维持4周。治疗结束4周后复查胃镜,评估H.pylori根除疗效、溃疡愈合率和腹痛缓解率。结果：109例患者完成方案。A、B两组按意向治疗（ITT）和按方案（PP）分析的H.pylori根除率（ITT：85．7％对87．5％;PP：88．9％对89．1％）和溃疡愈合率（ITT：87．5％对94．6％;PP：90．7％对96．4％）以及腹痛缓解率（95．6％对95．7％）相比差异均无统计学意义（P〉0．05）。结论：以10d四联疗法根除H.pylori后,可使多数DU患者的溃疡愈合,无需进一步行维持抑酸治疗。     

A Randomized Controlled Study Comparing Reverse Hybrid Therapy and Standard Triple Therapy for Helicobacter pylori Infection

Reverse hybrid therapy is an 1-step 2-phase treatment for Helicobacter pylori (H. pylori) infection with less cost than standard triple therapy. We conducted a randomized, controlled study to compare the efficacies of standard triple therapy and reverse hybrid therapy in the treatment of H. pylori infection.From October 2012 to March 2015, consecutive H. pylori-infected subjects were randomly allocated to receive either a reverse hybrid therapy (pantoprazole plus amoxicillin for 12 days and clarithromycin plus metronidazole for the initial 7 days) or a standard triple therapy (pantoprazole plus amoxicillin and clarithromycin for 12 days). H. pylori status was assessed 6 weeks after treatment. Additionally, antibiotic resistances and host CYP2C19 genotypes were examined and analyzed.A total of 440 H. pylori-infected patients were randomly assigned to receive either a reverse hybrid (n = 220) or a standard triple therapy (n = 220). The reverse hybrid group had a higher eradication rate than standard triple group either by intention-to-treat (93.6% vs. 86.8%; P = 0.016) or per-protocol analysis (95.7% vs. 88.3%; P = 0.005). The 2 patient groups exhibited similar frequencies of overall adverse events (14.1% vs. 9.5%) and drug compliance (96.8% vs. 98.6%). Clarithromycin resistance was an independent risk factor predicting eradication failure in standard triple group (P < 0.001), but not in reverse hybrid group. CYP2C19 genotypes did not affect the eradication rates in both groups.Reverse hybrid therapy can be considered for first-line treatment of H. pylori infection since the new therapy achieves a higher eradication rate than standard triple therapy with similar tolerability and less pharmaceutical cost.     

Ranitidine Bismuth Citrate With Clarithromycin Given Twice Daily Effectively Eradicates Helicobacter pylori and Heals Duodenal Ulcers

Objective : Ranitidine bismuth citrate (RBC) b.i.d. with Clarithromycin q.i.d. eradicates Helicobacter pylori (H. pylori ) in 82–94% of patients, and heals duodenal ulcers in 88–90% of patients. This double blind, placebo-controlled study examines the efficacy of a simpler b.i.d. treatment regimen, and examines the potential benefit of including a second antibiotic, metronidazole, to the b.i.d. treatment regimen. Methods : A total of 648 patients with active duodenal ulcer received RBC 400 mg b.i.d. for 4 wk, coprescribed with Clarithromycin 250 mg q.i.d. , Clarithromycin 500 mg b.i.d. , or Clarithromycin 500 mg b.i.d. with metronidazole 400 mg b.i.d. for the first 2 wk of treatment. Endoscopies were performed prestudy, after 4 wk of treatment, and at least 4 wk posttreatment. H. pylori status was assessed by CLOtest, ¹³C-urea breath test (UBT), and histology prestudy, and by UBT and histology at least 4 wk posttreatment. Adverse events were recorded at each visit. Results : All three regimens were highly effective and well tolerated. H. pylori eradication rates were 84–94% and duodenal ulcer healing rates were 92–96% (observed data). Highest H. pylori eradication and ulcer healing rates were achieved with RBC 400 mg b.i.d. with Clarithromycin 500 mg b.i.d. Conclusion : Ranitidine bismuth citrate with Clarithromycin 500 mg b.i.d. provides an effective, simple and well tolerated regimen for the eradication of H. pylori and healing of duodenal ulcers.     

Helicobacter pylori and Duodenal Ulcer Recurrence

Preliminary evidence suggests that eradication of Helicobacter pylori (H. pylori) may lead to prolonged remission of duodenal ulcer (DU). The aim of this study was to assess the long-term effect of eradication of H. pylori on the natural history of DU. Fifty-one patients with endoscopically proven duodenal ulcers, who were found to have H. pylori infection on histology and culture, and who were successfully eradicated of H. pylori with combination treatment of colloidal bismuth subcitrate and antibiotics, were studied. All patients were endoscoped at entry, 4 wk after cessation of treatment and again at 1 yr or sooner, if symptoms recurred. At each endoscopy, two antral biopsies were taken and assessed histologically and microbiologically for evidence of H. pylori infection. Recurrence of H. pylori infection occurred in 18/51 patients (35.3%) and, of these, 12 patients had evidence of recurrent peptic disease (five DU, seven duodenitis). In contrast, of the 33 who remained negative for H. pylori at 1 yr, none developed evidence of recurrent DU. Overall, DU recurrence occurred in 5/51 patients (11.7%), and occurred only in patients reinfected with H. pylori. This relapse rate compares favorably with patients on maintenance H2-receptor antagonist treatment. These results lend further support to the hypothesis that antral reinfection with H. pylori is associated with relapse of DU.