Current indications for acid suppressants in Helicobacter pylori-negative ulcer disease

Although Helicobacter pylori infection remains the single most common cause of peptic ulcer, an increasing proportion of patients have H. pylori-negative ulcers. The proportion is higher in the USA - and possibly Australia - than elsewhere. Although the precise aetiology of these ulcers is often unknown, some are caused by the use of aspirin or non-steroidal anti-inflammatory drugs. In areas with a high prevalence of H. pylori-negative ulcers, the empirical treatment of H. pylori infection for newly diagnosed peptic ulcer disease should be discouraged. All such patients should have documentation of their H. pylori status before treatment. Patients with H. pylori-negative ulcers may have the more serious ulcer diathesis and are likely to require long-term management with acid-suppressing drugs. Proton pump inhibitors are likely to be the drugs of choice; patients may be relatively refractory to H-2-receptor antagonists. The optimal duration of treatment is undefined but might be lifelong. There are no prospective studies of the efficacy of surgery or mucosal-protective agents in the treatment of H. pylori-negative ulcers.