In recent years, researchers have shown that the natural history of peptic ulcer disease -- normally a chronic relapsing condition -- is markedly changed when H. pylori is cleared from the gastric mucosa by antibiotic therapy. Ulcers are healed, and recurrences are practically eliminated. In their two-year follow-up of 109 patients with healed duodenal or gastric ulcers, Graham et al showed that ulcer recurrence was significantly reduced in patients who had received triple-antibiotic therapy plus ranitidine, compared with patients who had received ranitidine alone (12% recurrence versus 95%, respectively, for patients with duodenal ulcer, and 13% versus 74% for patients with gastric ulcer). 
Of those patients who received ranitidine alone, 50% relapsed within 12 weeks of healing, and by the end of the study period, only three patients in the ranitidine-alone group were free of ulcer. In seven patients who received triple therapy, H. pylori was not eradicated; four of these had ulcer recurrence, the other three were lost to follow-up. Three patients with duodenal ulcer and two with recurrent gastric ulcer had relapses despite eradication of H. pylori; all were taking NSAIDs. Indeed, the only two risk factors for ulcer recurrence were chronic NSAID therapy and H. pylori infection; smoking and alcohol consumption, long thought to be associated with peptic ulcer disease, did not emerge as risk factors. Ten patients in the ranitidine-alone group who relapsed after ulcer healing were crossed over to triple therapy (plus ranitidine). The antibiotic regimen cleared H. pylori infection, and follow-up (ranging from 23 to 116 weeks) showed no relapses. Four patients with ranitidine-resistant ulcers were also crossed over to triple therapy and showed prompt healing with no relapse (follow-up: median, 40 weeks). The investigators recommended that "patients with resistant ulcers (defined as failure to heal in 12 weeks), those with ulcer-associated complications, and those with symptoms severe enough to be candidates for surgery receive triple therapy for H. pylori infection."
Graham DY. Ann Intern Med
Of those patients who received ranitidine alone, 50% relapsed within 12 weeks of healing, and by the end of the study period, only three patients in the ranitidine-alone group were free of ulcer. In seven patients who received triple therapy, H. pylori was not eradicated; four of these had ulcer recurrence, the other three were lost to follow-up. Three patients with duodenal ulcer and two with recurrent gastric ulcer had relapses despite eradication of H. pylori; all were taking NSAIDs. Indeed, the only two risk factors for ulcer recurrence were chronic NSAID therapy and H. pylori infection; smoking and alcohol consumption, long thought to be associated with peptic ulcer disease, did not emerge as risk factors. Ten patients in the ranitidine-alone group who relapsed after ulcer healing were crossed over to triple therapy (plus ranitidine). The antibiotic regimen cleared H. pylori infection, and follow-up (ranging from 23 to 116 weeks) showed no relapses. Four patients with ranitidine-resistant ulcers were also crossed over to triple therapy and showed prompt healing with no relapse (follow-up: median, 40 weeks). The investigators recommended that "patients with resistant ulcers (defined as failure to heal in 12 weeks), those with ulcer-associated complications, and those with symptoms severe enough to be candidates for surgery receive triple therapy for H. pylori infection."Graham DY. Ann Intern Med
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