[Short-term triple therapy with pantoprazole, clarithromycin and metronidazole in eradication of Helicobacter pylori]

In a prospective study, thirty consecutive patients presenting with either H.pylori positive (histology and/or culture) ulcer disease (n = 17; acute ulcer: n = 11) or functional dyspepsia (n = 13) were treated over one week with pantoprazole 40 mg bd, clarithromycin 250 mg bd and metronidazole 400 mg bd. Four weeks after discontinuation of the study medication H.pylori eradication was assessed by means of an urease test, culture and histology. One patient had to be withdrawn from the study after one day because of a concomitant infectious disease requiring long-term antibiotic treatment. Another patient refused the final follow-up endoscopy. 28 patients completed the study without contravening the protocol. H.pylori infection was eradicated in 24 out of 28 patients (eradication rate: 86%; 95%-confidence interval: 57%-96%). Cure of bacterial infection was more frequently obtained in ulcer patients as compared to patients suffering from functional dyspepsia (94% vs 75%; p = 0.28). In 2 patients, treatment failure was associated with pretherapeutic resistance of H. pylori to either clarithromycin or metronidazole. Without antiulcer treatment beyond eradication therapy, ulcer healing was endoscopically confirmed after 5 weeks in 9 out of 10 patients available for follow-up (healing rate: 90%; 95%-confidence interval: 56%-100%). Seven patients reported mild adverse events that did not lead to discontinuation of the study medication (rate: 23%; 95%-confidence interval: 10%-42%). After cure of the infection, histology demonstrated a statistically highly significant improvement (p < 0.001) of both grade and activity of antrum and body gastritis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Bleeding peptic ulcers--how can recurrent bleeding be prevented?]

Bleeding is the most frequent complication of peptic ulcer disease. Patients with a previous ulcer hemorrhage have a high risk for future bleeding episodes. Therefore, treatment aiming at ulcer prophylaxis is mandatory. Helicobacter pylori infection, acid/pepsin and intake of Aspirin or NSAIDs are the main causal factors involved in the pathogenesis of peptic ulcer disease. Ulcers induced by nonsteroidal anti-inflammatory drugs can be cured by gastric acid suppression (e.g. omeprazole) and prevented by withdrawal of the ulcerogenic substances or co-medication with omeprazole or misoprostol. Acid and Helicobacter pylori are necessary, albeit by themselves not sufficient factors in the causal web of the formerly idiopathic, gastritis-associated peptic ulcer disease of the stomach and the duodenum. Maintenance therapy with antisecretory drugs results in a marked decrease of ulcer recurrences and probably further ulcer complications after an index bleeding, but a definite cure of the ulcer disease is not feasible in the majority of patients. The proportion of patients remaining in remission is dependent on the degree of gastric acid suppression. Therefore, potent antisecretory drugs such as the proton pump inhibitor omeprazole should be used if a physician decides to initiate a long-term maintenance therapy. Several studies have demonstrated beyond doubt that cure of Helicobacter pylori eradication resulted in a stable remission of gastric and duodenal ulcer disease. In addition, a true reinfection after apparent eradication of the bacteria has been rarely observed in adults.(ABSTRACT TRUNCATED AT 250 WORDS)

One-week low-dose triple therapy for the eradication of Helicobacter pylori infection

OBJECTIVE

To evaluate the efficacy and safety of two 1-week low-dose triple therapy regimens for the treatment of Helicobacter pylori infection.

PATIENTS AND METHODS

Eighty patients with H. pylori infection and peptic ulcer disease (n = 64) or functional dyspepsia (n = 16), with similar demographic and clinical characteristics, were treated for 1 week with either omeprazole 20 mg once in the morning and clarithromycin 250 mg and metronidazole 400 mg twice daily (OCM; n = 40) or with omeprazole 20 mg once in the morning and clarithromycin 250 mg and tetracycline 500 mg twice daily (OCT; n = 40). H. pylori infection was assessed by urease test, culture and histology performed before and 4 (or more) weeks after cessation of the eradication therapy.

RESULTS

H. pylori infection was treated successfully in 38 out of 40 patients by OCM and in 26 out of 40 patients by OCT (95 versus 65%, respectively; P = 0.0015). The OCM regimen was well tolerated in all patients except for one who complained of epigastric pain. Three patients on the OCT regimen reported side effects (abdominal pain, diarrhoea, pruritus), two of whom discontinued the study medication after 1 day.

CONCLUSIONS

The 1-week low-dose triple therapy comprising omeprazole, clarithromycin and metronidazole was highly effective in eradicating H. pylori and was well tolerated. The replacement of metronidazole by tetracycline resulted in a significant decrease in the eradication rate.

High-dose omeprazole plus amoxicillin or clarithromycin cures Helicobacter pylori infection in duodenal ulcer disease

Treatment with omeprazole plus amoxicillin or clarithromycin resulted in encouraging Helicobacter pylori cure rates in pilot and controlled studies. The present prospective, randomized study was designed to compared the efficacy and safety of amoxicillin and clarithromycin as constituents of omeprazole-enhanced antibiotic therapy of H. pylori infection. Fifty patients with active duodenal ulcer disease and histologically and/or culturally confirmed H. pylori colonization of the gastric mucosa were treated with omeprazole (day 1-14: 40 mg twice daily, day 15-42: 20 mg once in the morning). The patients were randomly assigned to receive either amoxicillin (1 g twice daily; group I: n = 25) or clarithromycin (500 mg twice daily; group II: n = 25) during the first 2 weeks of treatment. The patients of group I and II had comparable demographic and clinical characteristics. One patient of group I was lost to follow-up. H. pylori infection was cured in 87.5% of group I and 84.0% of group II (p = 1.00). All ulcers had healed after 6 weeks of omeprazole treatment. Pain relief occurred within the first day of treatment in the majority of patients of both groups (p = 0.89). Minor side effects were recorded in 6 patients of group I and in 4 patients of group II (25 vs. 16%; p = 0.50). In 1 female patient amoxicillin had to be withdrawn after 3 days because of nausea and emesis. In conclusion, 2 weeks of treatment with omeprazole plus amoxicillin or clarithromycin are highly and equally effective regimens to cure H. pylori infection in patients with duodenal ulcer disease.

Omeprazole plus amoxicillin for cure of Helicobacter pylori infection. Factors influencing the treatment success

BACKGROUND

Omeprazole plus amoxicillin may cure Helicobacter pylori infection. However, the published results vary rather widely, and the factors influencing the treatment success remain unclear.

METHODS

Four hundred and twenty-three H. pylori-positive patients were treated with 1- or 2-week regimens comprising 40 mg or 80 mg omeprazole and amoxicillin in 11 prospective protocols. A complete set of data was available for 405 patients (ulcer disease, n = 383; dyspepsia, n = 22) and was submitted to uni- and multi-variate statistical analyses to elucidate the factors affecting the cure rates of the infection; 18 patients were lost to follow-up.

RESULTS

The overall proportion of H. pylori cure was 76%. Insufficient compliance (p < 0.001), a short duration of treatment (p < 0.001), smoking (p = 0.003), and omeprazole pretreatment (p = 0.041) were the significant independent factors predicting treatment failure, whereas advanced age (p = 0.002), high scores of grade and of activity of gastritis (p = 0.035 and p = 0.019, respectively), and gastric ulcer disease (p = 0.058) were independent factors predicting treatment success.

CONCLUSIONS

Several patient- and therapy-related factors diminish or increase the rate of H. pylori cure obtained by omeprazole/amoxicillin. These should be considered in future studies comparing different treatment regimens for curing H. pylori infection and also when designing treatment regimens applicable for routine clinical practice.

[The modified 13C-urea breath test in the diagnosis of Helicobacter pylori colonization of the gastric mucosa]

The value of a modified 13C-urea breath test for the detection of Helicobacter pylori was analysed in a prospective study of 50 consecutive patients (28 women, 22 men, aged 20-90 years) with unknown Helicobacter pylori status about to undergo upper intestinal endoscopy. Four biopsies each were obtained in each patient from the antrum and the body of the stomach and examined for Helicobacter pylori infection of the gastric mucosa histologically (haematoxylin-eosin and Giemsa stain), with the rapid urease test and by culture. The patients then underwent a modified 13C-urea breath test. Results were positive histologically and(or) by culture in 29 patients, while the breath test was positive in 28 (sensitivity 96.3%). The breath test was falsely positive in two (specificity 91.3%). The biopsy urease test had a sensitivity of 96.3% with a 100% specificity. These results demonstrate that the modified 13C-urea breath test is a simple and accurate way of demonstrating Helicobacter pylori infection, equal in diagnostic value to the biopsy urease test.

Highly significant change of the clinical course of relapsing and complicated peptic ulcer disease after cure of Helicobacter pylori infection

OBJECTIVES

The aim of the present study was to compare the rates of peptic ulcer recurrence and of complications in a cohort of 190 patients, before and up to 4 yr after eradication of Helicobacter pylori infection.

METHODS

190 patients with recurrent and/or complicated H. pylori-positive peptic ulcer disease (duodenal ulcer, n = 124; gastric ulcer, n = 59; gastroduodenal double ulcer, n = 2; anastomotic ulcer after partial gastric resection, n = 5) were prospectively followed up to 4 yr after eradication of H. pylori. Patients were investigated clinically and endoscopically, including the assessment of H. pylori infection before treatment, 4 wk after cessation of the eradication therapy, in 1-yr intervals and when symptoms of the ulcer disease recurred.

RESULTS

Cure of H. pylori infection was obtained by either omeprazole plus amoxicillin (n = 157) or oral triple therapy (n = 33). The overall ulcer relapse rate was 0.9% per patient year. Comparing the pre- and postherapeutical course of the disease, the 1-yr ulcer recurrence rate decreased from 67.9% to 1.1% (P < 0.0001), and the 2-yr relapse rate decreased from 91.1% to approximately 3.0% (calculation: 0.9% ulcer recurrences per patient year x 329 patient years) (P < 0.0001) without relevant differences between the two major groups of patients with either duodenal or gastric manifestation of their ulcer disease. Ulcer complications did not occur. The H. pylori recurrence rate was 2.6% in the 1st and 1.2% in the 2nd yr after eradication. In the 3rd and 4th yr, no H. pylori reinfections were detected.

CONCLUSION

Cure of H. pylori infection was associated with a highly significant change of the disease history in this large group of patients with formerly relapsing and/or complicated peptic ulcers. In addition, H. pylori eradication is a stable phenomenon at least during the first 4 yr after treatment. Thus, H. pylori eradication should be considered in those patients with peptic ulcer disease severe enough to require avoidance of ulcer recurrence or its complications.

[Helicobacter pylori therapy with omeprazole and clarithromycin: current status]

Clarithromycin and its 14-OH-metabolite are highly effective against Helicobacter pylori in vitro. This drug is acid stable and soluble and reaches considerable concentrations in the gastric mucosa and the mucus layer after oral administration. Several studies have meanwhile demonstrated that combined treatment with omeprazole and clarithromycin may eradicate. H. pylori infection in a remarkable proportion of treated patients. On the basis of the results of a recently published randomized doubleblind multicenter trial, at two-week therapy course comprising omeprazole 40 mg once in the morning and clarithromycin 500 mg thrice daily can be recommended for routine practice. One-week low dose triple therapy regimens combining omeprazole, clarithromycin and tinidazole or metronidazole might be a valuable alternative to omeprazole enhanced antibiotic monotherapy in the future, but the encouraging results of three pilot studies (H. pylori cure rates: 90%-100%) have to be confirmed in randomized and controlled trials.

[24-hour gastric pH profile with 2 x 20 mg and 2 x 40 mg omeprazole in patients with Helicobacter pylori-associated gastroduodenal ulcer disease]

Fifty patients suffering from Helicobacter pylori associated duodenal (n = 25) or gastric ulcer disease (n = 25) were randomly treated with either omeprazole 20 mg b.i.d. (n = 25) or 40 mg b.i.d. (n = 25). From day 8 to 9, a 24-hour gastric pH measurement was performed in all patients. Patients with duodenal ulcer disease treated with 40 mg or 80 mg omeprazole demonstrated similar gastric pH patterns without statistically significant differences with regard to the mean (5.10 versus 5.17, p = 0.6439) and median pH (5.35 versus 5.30, p = 0.8277) as well as to the percent of time spent below distinctive pH thresholds. Patients suffering from gastric ulcer disease respond somewhat better to the higher omeprazole dose as compared to the 40 mg omeprazole regimen reaching statistical significance (mean pH: 5.04 versus 5.74, p = 0.0124; median pH: 5.30 versus 5.95, p = 0.0114; %-time spent below pH 2, 3, 4, and 5, respectively). In conclusion, there was virtually no (duodenal ulcer) or only a slight (gastric ulcer), probably clinically irrelevant, benefit to doubling the omeprazole dose (20 mg b.i.d. vs. 40 mg b.i.d.) with regard to the 24-hour gastric pH patterns.

Medium- and high-dose omeprazole plus amoxicillin for eradication of Helicobacter pylori in duodenal ulcer disease

The purpose of the present study was to investigate the Helicobacter pylori eradication potency of combined amoxicillin-omeprazole treatment in patients with duodenal ulcer disease and to compare the efficacy of two omeprazole and amoxicillin doses concerning H. pylori eradication, ulcer healing, pain relief, and safety. Ninety patients with active H. pylori-positive (culture and/or histology) duodenal ulcer disease were randomly treated with either omeprazole 20 mg twice a day plus amoxicillin 1 g twice a day (group I, N = 30), omeprazole 40 mg twice a day plus amoxicillin 1 g twice a day (group II, N = 30), or omeprazole 40 mg twice a day plus amoxicillin 1 g three times a day (group III, N = 30) over two weeks, followed by ranitidine at bedtime for another four weeks. The overall proportion of H. pylori eradication was 83% and of ulcer healing 92% without statistically significant differences between the study groups. Complete pain relief occurred after a median of one day in all groups. Six patients complained of side effects during the therapy phase, which led to therapy discontinuation in one female patient. In conclusion, omeprazole plus amoxicillin is a highly effective and well-tolerated therapy regimen to eradicate H. pylori in duodenal ulcer disease. In addition, the results suggest that there is no clear dose-response relation between the dosages of omeprazole and amoxicillin used in this study on the one hand and the H. pylori eradication rates on the other.

Effective treatment after failure of omeprazole plus amoxycillin to eradicate Helicobacter pylori infection in peptic ulcer disease

METHODS

Fifty patients with relapsing or complicated Helicobacter pylori positive duodenal (n = 41) or gastric ulcer disease (n = 9) and failure of a combined treatment with omeprazole plus amoxycillin to eradicate H. pylori infection were re-treated with either oral triple therapy (bismuth subsalicylate, metronidazole, tetracycline) plus ranitidine [group I: n = 22] or high-dose omeprazole (40 mg b.d. to t.d.s.) plus amoxycillin (1 g t.d.s.) [group II: n = 28].

RESULTS

Patients of group I and II had similar demographic and clinical characteristics. The overall proportion of eradication of H. pylori infection was 81.8% in group I and 78.6% in group II (P = N.S.) as judged from negative bacterial findings by means of an urease test, specific culture and histology after modified Giemsa stain. Ulcer healing was observed in all patients after a maximum duration of 10 weeks. Ten patients on triple therapy and only one patient on omeprazole plus amoxycillin (45.5% vs. 3.6%; P < 0.001) complained of side effects without necessity of discontinuation of the study medication in either group. Twenty patients (group I: n = 10; group II: n = 10) with relapsing duodenal ulcer disease and successful cure were prospectively followed for one year without any evidence of ulcer relapse or H. pylori re-infection.

CONCLUSION

Oral triple therapy plus ranitidine or high-dose omeprazole plus amoxycillin remain highly effective in eradicating H. pylori infection in patients with peptic ulcer disease and treatment failure of omeprazole/amoxycillin, but the omeprazole enhanced antibiotic monotherapy seems to be superior with regard to side effects. Thus, high-dose omeprazole/amoxycillin is recommended as the treatment of first choice in these selected patients. Triple therapy should be reserved for patients intolerant of amoxycillin.

[Hepatocellular carcinoma following intravenous thorium X therapy]

Twelve years after receiving radiation therapy with thorium X (280 microCi) for long-standing Bechterew's disease (ankylosing spondylitis) a 52-year-old man was found, by ultrasonography and computed tomography, to have a round mass, 11 x 12 cm, in the left lobe of the liver. Laparoscopy discovered coarse, discoloured nodes on the surface of the right and left lobes of the liver which histologically showed hepatocellular carcinoma. There were no known risk factor for liver carcinoma (like cirrhosis, positive hepatitis B serology, alcohol abuse, haemochromatosis or alpha 1-antitrypsin deficiency). As exploratory laparotomy found the tumour to be inoperable, 15 chemotherapeutic embolizations were performed. An abdominal wall metastasis was resected after 17 months. At the time of this report, 20 months after the diagnosis was first made, the patient is in a poor general condition. Internal radiotherapy with thorium X was used, all else having failed, in the treatment of severe ankylosing spondylitis. Although it is not possible to prove a direct causal relationship between the thorium X radiation and development of a liver carcinoma, the coincidence is remarkable.

Medium- or high-dose omeprazole plus amoxicillin eradicates Helicobacter pylori in gastric ulcer disease

OBJECTIVE

To compare the efficacy of two omeprazole/amoxicillin regimens concerning Helicobacter pylori eradication, ulcer healing, pain relief, and safety in patients with gastric ulcer disease.

METHODS

In a prospective, single-blind, single-center study, 70 patients with active, H. pylori-positive (histology and/or culture) gastric ulcers were randomly treated with either omeprazole 20 mg b.i.d. plus amoxicillin 1 g b.i.d. (group I; n = 35) or with omeprazole 40 mg b.i.d. plus amoxicillin 1 g b.i.d. over 2 wk, followed by full dose ranitidine for another 4 wk. Patients were investigated clinically and endoscopically prior to treatment and after 6 wk, including the assessment of H. pylori status by means of urease test, specific culture, and histology.

RESULTS

Patients of group I and II had similar demographic and clinical characteristics. Three patients were lost to follow-up. The overall proportion of H. pylori eradication was 88.1% (group I, 91.2%; group II, 84.8%, p = NS). The ulcer healing rate was 79.1% after 6 wk, 92.5% after 10 wk, and 100% after 6 months, without a statistically significant difference between the study groups. Complete pain relief occurred after a median of 2 days (group I) and 1.5 days (group II, p = NS), respectively. Six patients (9.0%) complained of side effects that led to discontinuation of amoxicillin treatment in three patients (4.5%).

CONCLUSIONS

Omeprazole plus amoxicillin is a highly effective and well-tolerated therapy regimen to eradicate H. pylori from the gastric mucosa of patients with gastric ulcer disease. In addition, the results clearly suggest that medium- and high-dose omeprazole schedules are equally effective with regard to bacterial eradication, ulcer healing, pain relief, and safety in gastric ulcers. Thus, medium- and not high-dose omeprazole plus amoxicillin should be the treatment regimen of first choice to eradicate H. pylori in gastric ulcer disease.

[Omeprazole modified antibiotic therapy of Helicobacter pylori infection: can clarithromycin be replaced by roxithromycin?]

Thirty-five consecutive patients (median age: 50 years, 17 men and 18 women) suffering from Helicobacter pylori associated peptic ulcer disease (duodenal ulcer: n = 15, gastric ulcer: n = 13) or severe functional dyspepsia (n = 7) were enrolled in a two-center clinical trial and treated with omeprazole 20 mg bid preprandially and roxithromycin 300 mg bid postprandially over two weeks. After cessation of the study medication, ulcer patients received a full dose H2-blocker treatment up to the final examination four weeks later. All patients completed the trial without contravening the protocol. Side effects were not recorded. The overall proportion of cure of Helicobacter pylori-infection was 29% (10 out of 35 patients) without statistically significant difference between the two participating centers (center I: 7 out of 20 patients [35%], center II: 3 out of 15 patients [20%]; p = 0.33). We conclude from our results that omeprazole plus roxithromycin is an ineffective treatment schedule with regard to cure of H.pylori-infection in patients with peptic ulcer disease or dyspepsia.

Evidence for the essential role of Helicobacter pylori in gastric ulcer disease

Helicobacter pylori (H pylori) eradication heals chronic active type B gastritis and dramatically changes the natural history of duodenal ulcer disease. There are few data concerning the role of anti-H pylori treatment in gastric ulcer disease. A total of 83 patients presenting with H pylori positive active gastric ulcer disease were treated with omeprazole and antibiotics (amoxicillin, ciprofloxacin, roxithromycin) in seven different clinical protocols, each of which included the attempt to eradicate H pylori infection and to evaluate the post-therapeutic course of ulcer disease. The overall proportion of H pylori eradication was 67.9% (53 of 78 patients available for follow up). Best results were obtained with two week treatment regimens comprising omeprazole 20 mg twice daily and amoxicillin 500 mg four times a day or 1000 mg twice daily (eradication > 80%). Eradication of H pylori speeds up ulcer healing, with a six week healing rate of 84.9% compared with 60% in patients with persistent H pylori infection (p = 0.0148). In a subgroup of 11 patients with refractory ulcers, H pylori eradication (n = 10) was associated with ulcer healing on continued acid suppression in nine cases. One male patient with chronic antral ulcer did not respond to treatment within the next six months (H pylori and ulcer persistence), and in one female patient a resistant body ulcer was identified as gastric lymphoma. Fifty patients with healed ulcers were followed up for one year. Patients with (n = 32) and without (n = 18) bacterial eradication had similar demographic and clinical characteristics. H pylori eradication was associated with a statistically significant reduction of ulcer recurrences (3.1 v 55.6%, p<0.001). This study concludes that H pylori eradication considerably changes the natural history of H pylori associated gastric ulcer disease. In addition, H pylori eradication speeds up ulcers healing and is associated with healing of previously refractory ulcers. Thus, treatment aimed at bacterial eradication should be considered in all patients with gastric ulcers severe enough to contemplate further treatment options.

Medium-term results of oral and intravenous omeprazole/amoxicillin Helicobacter pylori eradication therapy

OBJECTIVES

The aim of the present study was to examine the effect of the application route of the antibiotic amoxicillin in Helicobacter pylori eradication, using omeprazole/amoxicillin.

METHODS

In a prospective medium-term study, 31 patients with H. pylori-positive gastroduodenal ulcer disease were treated with a 14-day course of 20 mg omeprazole bid orally, combined with either 1 g amoxicillin tid intravenously (n = 15) or 500 mg amoxicillin six times daily orally (n = 16).

RESULTS

H. pylori eradication, defined as negative bacterial findings in urease test, culture, and histology at least 4 wk after cessation of study medication, was achieved in 93% (14/15) of the patients in the first group and in 91% (11/12) of the patients in the second group. To obtain medium-term results, patients in whom H. pylori had been successfully eradicated were investigated with a 13C-urea breath test at least 6 months later. Medium-term eradication rates of 91% (10/11 patients) in the first and 100% (10/10 patients) in the second group were observed.

CONCLUSIONS

In view of the equally high eradication rates obtained by a 14-day course of intravenously administered amoxicillin and an oral therapy of the same length and dosage, during the necessary induction of luminal hypoacidity by the proton pump inhibitor omeprazole, we conclude that the route of administration of amoxicillin does not play a decisive role in bacterial eradication.

Role of Helicobacter pylori eradication in the prevention of peptic ulcer bleeding relapse

The objective of the present work was to determine the effect of treating Helicobacter pylori infection on the recurrence of peptic ulcer bleeding. We prospectively followed 66 out of 70 consecutive H. pylori-positive (histology and/or culture) patients with conservatively and endoscopically managed peptic ulcer bleeding (duodenal ulcer; n = 39, gastric ulcer: n = 25, gastroduodenal double ulcer: n = 2) for a median period of 17 months (range 6-33 months). Patients were treated in seven different clinical protocols, each of which included the attempt to eradicate H. pylori infection. Patients with (n = 42) and without (n = 24) bacterial eradication had similar demographic and clinical characteristics. Eradication of H. pylori was associated with a statistically significant reduction of ulcer recurrences (2.4 vs. 62.5%; p < 0.001) and bleeding relapses (0 vs. 37.5%; p = 0.01). We conclude that H. pylori eradication markedly changes the natural history in patients with complicated duodenal and gastric ulcer disease. Thus, treatment aimed at bacterial eradication should be considered in all patients with conservatively managed bleeding from H. pylori-positive ulcers.

Amoxicillin plus omeprazole versus triple therapy for eradication of Helicobacter pylori in duodenal ulcer disease: a prospective, randomized, and controlled study

Treatment with amoxicillin and omeprazole resulted in encouraging Helicobacter pylori eradication rates in pilot studies that included medium term follow up. These results were evaluated in a prospective, randomised and controlled study. Forty patients with active duodenal ulcer disease and H pylori colonisation of the gastric mucosa were randomly assigned to receive either omeprazole (20 mg twice daily) and amoxicillin suspension (500 mg four times daily) for two weeks (group I) or bismuth subsalicylate (600 mg three times daily), metronidazole (400 mg three times daily), tetracycline (500 mg three times daily), and ranitidine (300 mg in the evening) for two weeks (group II). Study medication was followed in both groups by a four week treatment course with 300 mg ranitidine up to the final examination. One patient from each group was lost to follow up. H pylori was eradicated in 78.9% of group I and 84.2% of group II (p = 1.00). All ulcers in patients on omeprazole plus amoxicillin healed but in the triple treatment group four patients had residual peptic lesions after six weeks (ulcer healing rate: 78.9%, p = 0.11). Complete pain relief occurred after a median duration of 1 day in group I and of 6 days in group II (p = 0.03). There were no major complications in either group but minor side effects were more frequently recorded in patients on triple therapy (63.2% v 15.8%, p < 0.01). In conclusion, two weeks of treatment with omeprazole plus amoxicillin is as good as triple therapy plus ranitidine in eradicating H pylori but seems better with regard to safety, pain relief, and ulcer healing. Thus, amoxicillin plus omeprazole should be recommended as the treatment of choice in eradicating H pylori in patients with duodenal ulcer disease.