Persistent Helicobacter pylori Infection After a Course of Antimicrobial Therapy—What's Next?

A 35-year-old Hispanic woman with no significant past medical history presents to the emergency department at midnight with a 3-month history of intermittent epigastric pain culminating in 3 episodes of coffee-ground emesis on the day of presentation. Her blood pressure is 90/60 mm Hg and her pulse is 95 beats per minute with evidence of postural orthostasis. Nasogastric lavage reveals coffee-ground material, which clears with a liter of saline. Her hematocrit is 32% before hydration. She is stabilized and resuscitated with intravenous fluids. Upper endoscopy reveals a 1-cm, clean-based, duodenal bulb ulcer. Gastric biopsies reveal a negative rapid urease test but histology reveals active gastritis and Helicobacter pylori (H pylori) organisms. On discharge the following morning she is instructed to take a proton pump inhibitor (PPI), amoxicillin 1 g, and clarithromycin 500 mg twice daily for 7 days. The patient returns to her primary care physician 4 weeks later, reporting initial symptom improvement followed by a gradual recurrence of her epigastric pain. The primary care physician orders a serology test that is positive for H pylori. This is followed by a course of PPI, amoxicillin 1 g, and clarithromycin 500 mg given twice daily for 14 days. The patient returns to her primary care physician 3 months later reporting persistent dyspepsia. She is referred to a gastroenterologist for her persistent symptoms. An esophagogastroduodenoscopy is performed, revealing erosive gastropathy with mucosal biopsy specimens confirming persistent gastritis and H pylori organisms.