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Gastroenterology206 papers

Peptic ulcer

Last edited: 4/13/2026

Overview

Peptic ulcer disease involves sores in the lining of the stomach or duodenum, often caused by Helicobacter pylori infection or nonsteroidal anti-inflammatory drug (NSAID) use 2.

Diagnosis

  • Clinical Presentation: Epigastric pain, often related to meals 2.
  • Endoscopy: Visual confirmation of ulcer presence 3.
  • Helicobacter pylori Testing: Serology, urea breath test, stool antigen test 521.
  • Upper GI Series: Radiographic imaging to identify ulcers 3.

    • Management

  • First-Line Treatment:
    • - Antibiotics: Triple therapy (proton pump inhibitor + two antibiotics) for H. pylori eradication 533. - Proton Pump Inhibitors (PPIs): For acid suppression 25.
  • Adjunctive Treatments:
    • - H2 Receptor Antagonists: For maintenance therapy or in combination with PPIs 22. - NSAID Management: Alternative analgesics or gastroprotective agents if NSAIDs are necessary 2.

    Special Populations

  • Elderly: Enhanced Recovery After Surgery (ERAS) protocols beneficial in emergency surgeries 1.
  • Pregnancy: Avoid NSAIDs; consider PPIs cautiously under close monitoring 21.
  • Comorbidities: Older age, comorbidity burden, and severe postoperative complications significantly impact long-term mortality 19.

    • Key Recommendations

  • Eradicate H. pylori in patients diagnosed with peptic ulcers to prevent recurrence and complications (Evidence: Strong 533).
  • Use laparoscopic repair for perforated peptic ulcers to improve outcomes compared to open surgery (Evidence: Strong 1314).
  • Implement ERAS protocols in elderly patients undergoing emergency surgery for perforated peptic ulcers to enhance recovery (Evidence: Moderate 1).
  • Monitor and manage NSAID use carefully to reduce peptic ulcer risk, especially in high-risk populations (Evidence: Moderate 221).
  • Perform early surgical intervention for perforated peptic ulcers to reduce mortality risk; each hour of delay increases mortality by 6% (Evidence: Strong 9).

    • References

    1 Wael M, Shehab AS, El-Sayes I, Seif-Eldeen MIA. Implementation of enhanced recovery after surgery (ERAS) protocols in elderly patients undergoing emergency surgery for perforated peptic ulcer: a comparative analysis. BMC gastroenterology 2025. link 2 Tuerk E, Doss S, Polsley K. Peptic Ulcer Disease. Primary care 2023. link 3 Williams BS, Huynh TA, Mahmoud A. Gastric, Duodenal, and Small Bowel Emergencies. The Surgical clinics of North America 2023. link 4 Toale C, Kelly A, Leahy F, Meagher H, Stapleton PJ, Moloney MA et al.. Effect of . Journal of wound care 2022. link 5 Kamada T, Satoh K, Itoh T, Ito M, Iwamoto J, Okimoto T et al.. Evidence-based clinical practice guidelines for peptic ulcer disease 2020. Journal of gastroenterology 2021. link 6 Ellis H. Advances in general surgery 50 years ago. British journal of hospital medicine (London, England : 2005) 2021. link 7 Fagundes FL, Pereira QC, Zarricueta ML, Dos Santos RC. Malvidin Protects against and Repairs Peptic Ulcers in Mice by Alleviating Oxidative Stress and Inflammation. Nutrients 2021. link 8 Shirazi M, Zaban MT, Gummadi S, Ghaemi M. Peptic ulcer perforation after cesarean section; case series and literature review. BMC surgery 2020. link 9 Boyd-Carson H, Doleman B, Cromwell D, Lockwood S, Williams JP, Tierney GM et al.. Delay in Source Control in Perforated Peptic Ulcer Leads to 6% Increased Risk of Death Per Hour: A Nationwide Cohort Study. World journal of surgery 2020. link 10 Bupicha JA, Gebresellassie HW, Alemayehu A. Pattern and outcome of perforated peptic ulcer disease patient in four teaching hospitals in Addis Ababa, Ethiopia: a prospective cohort multicenter study. BMC surgery 2020. link 11 Pan CW, Liou LR, Mong FY, Tsao MJ, Liao GS. Simple laparoscopic repair of perforated peptic ulcer without omental patch. Asian journal of surgery 2020. link 12 Manco G, Caramaschi S, Rolando G, Malagoli M, Zanelli G, Reggiani Bonetti L et al.. Primary laparoscopic approach to repair perforated peptic ulcer. A retrospective cohort study. Minerva chirurgica 2020. link 13 Quah GS, Eslick GD, Cox MR. Laparoscopic Repair for Perforated Peptic Ulcer Disease Has Better Outcomes Than Open Repair. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract 2019. link 14 Davenport DL, Ueland WR, Kumar S, Plymale M, Bernard AC, Roth JS. A comparison of short-term outcomes between laparoscopic and open emergent repair of perforated peptic ulcers. Surgical endoscopy 2019. link 15 Narayanan M, Reddy KM, Marsicano E. Peptic Ulcer Disease and . Missouri medicine 2018. link 16 Varcus F, Paun I, Duta C, Dobrescu A, Frandes M, Tarta C. Laparoscopic repair of perforated peptic ulcer. Minerva chirurgica 2018. link 17 Siow SL, Mahendran HA, Wong CM, Hardin M, Luk TL. Laparoscopic versus open repair of perforated peptic ulcer: Improving outcomes utilizing a standardized technique. Asian journal of surgery 2018. link 18 Park SJ, Park H, Lee YC, Choi CH, Jeon TJ, Park JC et al.. Effect of scheduled second-look endoscopy on peptic ulcer bleeding: a prospective randomized multicenter trial. Gastrointestinal endoscopy 2018. link 19 Thorsen K, Søreide JA, Søreide K. Long-Term Mortality in Patients Operated for Perforated Peptic Ulcer: Factors Limiting Longevity are Dominated by Older Age, Comorbidity Burden and Severe Postoperative Complications. World journal of surgery 2017. link 20 Sweeney EG, Guillemin K. H. pylori's BabA Embraces Change. Cell host & microbe 2016. link 21 Kyaw MH, Chan FK. Pharmacologic options in the management of upper gastrointestinal bleeding: focus on the elderly. Drugs & aging 2014. link 22 He Y, Chan EW, Man KK, Lau WC, Leung WK, Ho LM et al.. Dosage effects of histamine-2 receptor antagonist on the primary prophylaxis of non-steroidal anti-inflammatory drug (NSAID)-associated peptic ulcers: a retrospective cohort study. Drug safety 2014. link 23 Miyake K, Akimoto T, Kusakabe M, Sato W, Yamada A, Yamawaki H et al.. Water-soluble vitamin deficiencies in complicated peptic ulcer patients soon after ulcer onset in Japan. Journal of nutritional science and vitaminology 2013. link 24 Laine L, Jensen DM. Management of patients with ulcer bleeding. The American journal of gastroenterology 2012. link 25 Critchley AC, Phillips AW, Bawa SM, Gallagher PV. Management of perforated peptic ulcer in a district general hospital. Annals of the Royal College of Surgeons of England 2011. link 26 Cheung J, Sawisky G, Enns R, Byrne MF, Zhu Q, Wong CK. Practices in peptic ulcer bleeding controversies among university- versus nonuniversity-affiliated gastroenterologists. Canadian journal of gastroenterology = Journal canadien de gastroenterologie 2010. link 27 Shiotani A, Sakakibara T, Yamanaka Y, Imamura H, Tarumi K, Manabe N et al.. Upper gastrointestinal ulcer in Japanese patients taking low-dose aspirin. Journal of gastroenterology 2009. link 28 Zetterström R. The Nobel Prize in 2005 for the discovery of Helicobacter pylori: implications for child health. Acta paediatrica (Oslo, Norway : 1992) 2006. link 29 Ciacci C, Mazzacca G. The history of Helicobacter pylori: a reflection on the relationship between the medical community and industry. Digestive and liver disease : official journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver 2006. link 30 Lesur G, Bour B, Aegerter P. Management of bleeding peptic ulcer in France: a national inquiry. Gastroenterologie clinique et biologique 2005. link80717-1) 31 van Rensburg O. Helicobacter pylori in peptic ulcer disease. SADJ : journal of the South African Dental Association = tydskrif van die Suid-Afrikaanse Tandheelkundige Vereniging 2004. link 32 Lamarque D, M Peek R. Pathogenesis of Helicobacter pylori infection. Helicobacter 2003. link 33 Duggan A. Helicobacter pylori: when is treatment now indicated?. Internal medicine journal 2002. link 34 Chiorean MV, Locke GR, Zinsmeister AR, Schleck CD, Melton LJ. Changing rates of Helicobacter pylori testing and treatment in patients with peptic ulcer disease. The American journal of gastroenterology 2002. link 35 Tsugawa K, Koyanagi N, Hashizume M, Tomikawa M, Akahoshi K, Ayukawa K et al.. The therapeutic strategies in performing emergency surgery for gastroduodenal ulcer perforation in 130 patients over 70 years of age. Hepato-gastroenterology 2001. link 36 Bateson MC. Helicobacter pylori. Postgraduate medical journal 2000. link 37 Baron JH. Treatments of peptic ulcer. The Mount Sinai journal of medicine, New York 2000. link 38 Brown LF, Wilson DE. Gastroduodenal ulcers: causes, diagnosis, prevention and treatment. Comprehensive therapy 1999. link 39 Rapport RS. H. pylori and peptic ulcers still misunderstood. New Jersey medicine : the journal of the Medical Society of New Jersey 1999. link 40 Safatle-Ribeiro AV, Ribeiro Júnior U, Habr-Gama A, Gama-Rodrigues JJ. Double pylorus: case report and review of the literature. Revista do Hospital das Clinicas 1999. link 41 . New treatment for peptic ulcer disease. Postgraduate medicine 1999. link 42 Williams CL. Helicobacter pylori and endoscopy. The Journal of hospital infection 1999. link 43 Salcedo JA, Al-Kawas F. Treatment of Helicobacter pylori infection. Archives of internal medicine 1998. link 44 Patchett SE. Helicobacter pylori eradication cost-benefit: the case against. British medical bulletin 1998. link 45 Lang KA, Pickard JS. Peptic ulcer disease in the military aviator: a management approach. Aviation, space, and environmental medicine 1998. link 46 Tsai KC, Wang HP, Huang GT, Wang SM. Preoperative sonographic diagnosis of sealed-off perforated gastric ulcer. Journal of clinical ultrasound : JCU 1998. link1097-0096(199806)26:5<269::aid-jcu8>3.0.co;2-a) 47 Duggan A, Logan R. Diagnosis of Helicobacter pylori in Britain. Journal of gastroenterology 1998. link 48 Tytgat GN. Treatment of Helicobacter pylori infection: management of patients with ulcer disease by general practitioners and gastroenterologists. Gut 1998. link 49 Breuer T, Goodman KJ, Malaty HM, Sudhop T, Graham DY. How do clinicians practicing in the U.S. manage Helicobacter pylori-related gastrointestinal diseases? A comparison of primary care and specialist physicians. The American journal of gastroenterology 1998. link 50 Breuer T, Sudhop T, Goodman KJ, Graham DY, Malfertheiner P. How do practicing clinicians manage Helicobacter pylori-related gastrointestinal diseases in Germany? A survey of gastroenterologists and family practitioners. Helicobacter 1998. link 51 Rall CJ, Munshi AD, Stasior DS. Disease management strategies and the gastroenterologist. Gastroenterology clinics of North America 1997. link70339-3) 52 Peura DA. Ulcerogenesis: integrating the roles of Helicobacter pylori and acid secretion in duodenal ulcer. The American journal of gastroenterology 1997. link 53 Covacci A, Falkow S, Berg DE, Rappuoli R. Did the inheritance of a pathogenicity island modify the virulence of Helicobacter pylori?. Trends in microbiology 1997. link01035-4) 54 Goh KL. Helicobacter pylori and peptic ulcer disease--a causal link. The Medical journal of Malaysia 1997. link 55 Falk GW. H pylori 1997: testing and treatment options. Cleveland Clinic journal of medicine 1997. link 56 Hippisley-Cox J, Pringle M. A pilot study of a randomized controlled trial of pragmatic eradication of Helicobactor pylori in primary care. The British journal of general practice : the journal of the Royal College of General Practitioners 1997. link 57 Kang JY, Fock KM, Ng HS, Ho KT, Chee A. Working Party report of the Gastroenterological Society of Singapore. Part I--Helicobacter pylori and peptic ulcer disease in Singapore. Singapore medical journal 1996. link 58 Rune SJ. History of Helicobacter infection. Scandinavian journal of gastroenterology. Supplement 1996. link 59 Brun J. Managing patients in general practice. Scandinavian journal of gastroenterology. Supplement 1996. link 60 Fendrick AM, Hirth RA, Chernew ME. Differences between generalist and specialist physicians regarding Helicobacter pylori and peptic ulcer disease. The American journal of gastroenterology 1996. link 61 Cello JP. Helicobacter pylori and peptic ulcer disease. AJR. American journal of roentgenology 1995. link 62 Baron JH. Peptic ulcers can now be cured without operation. Annals of the Royal College of Surgeons of England 1995. link 63 Anderson ML. Helicobacter pylori infection. When and in whom is treatment important?. Postgraduate medicine 1994. link 64 Counselman FL. An unusual presentation of Fitz-Hugh-Curtis syndrome. The Journal of emergency medicine 1994. link90694-7) 65 Rautelin H, von Bonsdorff CH, Blomberg B, Danielsson D. Ultrastructural study of two patterns in the interaction of Helicobacter pylori with neutrophils. Journal of clinical pathology 1994. link 66 George DE, Glassman M. Peptic ulcer disease in children. Gastrointestinal endoscopy clinics of North America 1994. link 67 Stermer E, Hardoff D, Zuckerman E, Miselevich I. Helicobacter pylori-associated peptic ulcer in heterotopic gastric mucosa within ileal duplication. Journal of clinical gastroenterology 1994. link 68 Laine L, Freeman M, Cohen H. Lack of uniformity in evaluation of endoscopic prognostic features of bleeding ulcers. Gastrointestinal endoscopy 1994. link70202-0) 69 Fedotin MS. Helicobacter pylori and peptic ulcer disease. Reexamining the therapeutic approach. Postgraduate medicine 1993. link 70 Berardi RR, Dunn-Kucharski VA. Peptic ulcer disease: an update. American pharmacy 1993. link30757-1) 71 Byck R. Read my lips. Journal of clinical gastroenterology 1992. link 72 Fernando D. Helicobacter pylori and peptic ulcer disease in Sri Lanka. The Ceylon medical journal 1992. link 73 Bednarz W, Doliński J, Domosławski P, Wojczys R, Gościniak G. Helicobacter pylori in experimental acute and chronic gastric and duodenal ulcer in Buffalo [correction of Bufallo] rats. Materia medica Polona. Polish journal of medicine and pharmacy 1992. link 74 Boyd EJ, Penston JG, Wormsley KG. Maintenance therapy in duodenal and gastric ulcer disease: survey of practice amongst British gastroenterologists. Alimentary pharmacology & therapeutics 1992. link 75 Watanabe Y, Aoike A. Factors influencing peptic ulcer frequency in Asian and Australasian countries. Gastroenterologia Japonica 1991. link 76 Omardeen FL, Terry SI. Helicobacter pylori. The West Indian medical journal 1991. link 77 Kumar S, Small P, Nawroz I, Mohammed R. Helicobacter pylori and Meckel's diverticulum. Journal of the Royal College of Surgeons of Edinburgh 1991. link 78 Spiro HM. Some perspectives on peptic ulcer. The Medical clinics of North America 1991. link30422-9) 79 Ruzyłło E, Domosławski Z, Wojnar S, Swiatkowska K. Natural history of peptic ulcer disease in Poland. Part. IX. Peptic ulcer disease and cardiovascular and respiratory system diseases. Materia medica Polona. Polish journal of medicine and pharmacy 1990. link 80 Bayerdörffer E, Ottenjann R. The role of antibiotics in Campylobacter pylori associated peptic ulcer disease. Scandinavian journal of gastroenterology. Supplement 1988. link 81 Day SJ. Optimal placebo response rates for comparing two binomial proportions. Statistics in medicine 1988. link 82 Gustavsson S, Adami HO, Lööf L, Nyberg A, Nyrén O. Symptomatic cimetidine treatment of duodenal and prepyloric ulcers. Digestive diseases and sciences 1986. link 83 Mimura T, Kameda K, Terada T, Kohda I, Tanaka C, Aonuma S. Increase of anti-ulcerogenic activity by reduction and alkylation of disulfide bonds of a globulin fraction from bovine serum. Journal of pharmacobio-dynamics 1982. link 84 Levine JS, Nakane PK, Allen RH. Human intrinsic factor secretion: immunocytochemical demonstration of membrane-associated vesicular transport in parietal cells. The Journal of cell biology 1981. link 85 Rebhun J. Dudenal ulceration in allergic children. Annals of allergy 1975. link 86 Kolmodin-Hedman B, Swensson A. Problems related to shift work. A field study of Swedish railroad workers with irregular work hours. Scandinavian journal of work, environment & health 1975. link

    Original source

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      Implementation of enhanced recovery after surgery (ERAS) protocols in elderly patients undergoing emergency surgery for perforated peptic ulcer: a comparative analysis. — Wael M, Shehab AS, El-Sayes I, Seif-Eldeen MIA BMC gastroenterology (2025)
    2. [2]
      Peptic Ulcer Disease. — Tuerk E, Doss S, Polsley K Primary care (2023)
    3. [3]
      Gastric, Duodenal, and Small Bowel Emergencies. — Williams BS, Huynh TA, Mahmoud A The Surgical clinics of North America (2023)
    4. [4]
      Effect of — Toale C, Kelly A, Leahy F, Meagher H, Stapleton PJ, Moloney MA et al. Journal of wound care (2022)
    5. [5]
      Evidence-based clinical practice guidelines for peptic ulcer disease 2020. — Kamada T, Satoh K, Itoh T, Ito M, Iwamoto J, Okimoto T et al. Journal of gastroenterology (2021)
    6. [6]
      Advances in general surgery 50 years ago. — Ellis H British journal of hospital medicine (London, England : 2005) (2021)
    7. [7]
      Malvidin Protects against and Repairs Peptic Ulcers in Mice by Alleviating Oxidative Stress and Inflammation. — Fagundes FL, Pereira QC, Zarricueta ML, Dos Santos RC Nutrients (2021)
    8. [8]
      Peptic ulcer perforation after cesarean section; case series and literature review. — Shirazi M, Zaban MT, Gummadi S, Ghaemi M BMC surgery (2020)
    9. [9]
      Delay in Source Control in Perforated Peptic Ulcer Leads to 6% Increased Risk of Death Per Hour: A Nationwide Cohort Study. — Boyd-Carson H, Doleman B, Cromwell D, Lockwood S, Williams JP, Tierney GM et al. World journal of surgery (2020)
    10. [10]
      Pattern and outcome of perforated peptic ulcer disease patient in four teaching hospitals in Addis Ababa, Ethiopia: a prospective cohort multicenter study. — Bupicha JA, Gebresellassie HW, Alemayehu A BMC surgery (2020)
    11. [11]
      Simple laparoscopic repair of perforated peptic ulcer without omental patch. — Pan CW, Liou LR, Mong FY, Tsao MJ, Liao GS Asian journal of surgery (2020)
    12. [12]
      Primary laparoscopic approach to repair perforated peptic ulcer. A retrospective cohort study. — Manco G, Caramaschi S, Rolando G, Malagoli M, Zanelli G, Reggiani Bonetti L et al. Minerva chirurgica (2020)
    13. [13]
      Laparoscopic Repair for Perforated Peptic Ulcer Disease Has Better Outcomes Than Open Repair. — Quah GS, Eslick GD, Cox MR Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract (2019)
    14. [14]
      A comparison of short-term outcomes between laparoscopic and open emergent repair of perforated peptic ulcers. — Davenport DL, Ueland WR, Kumar S, Plymale M, Bernard AC, Roth JS Surgical endoscopy (2019)
    15. [15]
      Peptic Ulcer Disease and — Narayanan M, Reddy KM, Marsicano E Missouri medicine (2018)
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      Laparoscopic repair of perforated peptic ulcer. — Varcus F, Paun I, Duta C, Dobrescu A, Frandes M, Tarta C Minerva chirurgica (2018)
    17. [17]
      Laparoscopic versus open repair of perforated peptic ulcer: Improving outcomes utilizing a standardized technique. — Siow SL, Mahendran HA, Wong CM, Hardin M, Luk TL Asian journal of surgery (2018)
    18. [18]
      Effect of scheduled second-look endoscopy on peptic ulcer bleeding: a prospective randomized multicenter trial. — Park SJ, Park H, Lee YC, Choi CH, Jeon TJ, Park JC et al. Gastrointestinal endoscopy (2018)
    19. [19]
      Long-Term Mortality in Patients Operated for Perforated Peptic Ulcer: Factors Limiting Longevity are Dominated by Older Age, Comorbidity Burden and Severe Postoperative Complications. — Thorsen K, Søreide JA, Søreide K World journal of surgery (2017)
    20. [20]
      H. pylori's BabA Embraces Change. — Sweeney EG, Guillemin K Cell host & microbe (2016)
    21. [21]
      Pharmacologic options in the management of upper gastrointestinal bleeding: focus on the elderly. — Kyaw MH, Chan FK Drugs & aging (2014)
    22. [22]
      Dosage effects of histamine-2 receptor antagonist on the primary prophylaxis of non-steroidal anti-inflammatory drug (NSAID)-associated peptic ulcers: a retrospective cohort study. — He Y, Chan EW, Man KK, Lau WC, Leung WK, Ho LM et al. Drug safety (2014)
    23. [23]
      Water-soluble vitamin deficiencies in complicated peptic ulcer patients soon after ulcer onset in Japan. — Miyake K, Akimoto T, Kusakabe M, Sato W, Yamada A, Yamawaki H et al. Journal of nutritional science and vitaminology (2013)
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      Management of patients with ulcer bleeding. — Laine L, Jensen DM The American journal of gastroenterology (2012)
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      Management of perforated peptic ulcer in a district general hospital. — Critchley AC, Phillips AW, Bawa SM, Gallagher PV Annals of the Royal College of Surgeons of England (2011)
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      Practices in peptic ulcer bleeding controversies among university- versus nonuniversity-affiliated gastroenterologists. — Cheung J, Sawisky G, Enns R, Byrne MF, Zhu Q, Wong CK Canadian journal of gastroenterology = Journal canadien de gastroenterologie (2010)
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      Upper gastrointestinal ulcer in Japanese patients taking low-dose aspirin. — Shiotani A, Sakakibara T, Yamanaka Y, Imamura H, Tarumi K, Manabe N et al. Journal of gastroenterology (2009)
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      The Nobel Prize in 2005 for the discovery of Helicobacter pylori: implications for child health. — Zetterström R Acta paediatrica (Oslo, Norway : 1992) (2006)
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      The history of Helicobacter pylori: a reflection on the relationship between the medical community and industry. — Ciacci C, Mazzacca G Digestive and liver disease : official journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver (2006)
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      Management of bleeding peptic ulcer in France: a national inquiry. — Lesur G, Bour B, Aegerter P Gastroenterologie clinique et biologique (2005)
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      Helicobacter pylori in peptic ulcer disease. — van Rensburg O SADJ : journal of the South African Dental Association = tydskrif van die Suid-Afrikaanse Tandheelkundige Vereniging (2004)
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      Pathogenesis of Helicobacter pylori infection. — Lamarque D, M Peek R Helicobacter (2003)
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      Helicobacter pylori: when is treatment now indicated? — Duggan A Internal medicine journal (2002)
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      The therapeutic strategies in performing emergency surgery for gastroduodenal ulcer perforation in 130 patients over 70 years of age. — Tsugawa K, Koyanagi N, Hashizume M, Tomikawa M, Akahoshi K, Ayukawa K et al. Hepato-gastroenterology (2001)
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      Helicobacter pylori eradication cost-benefit: the case against. — Patchett SE British medical bulletin (1998)
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      Preoperative sonographic diagnosis of sealed-off perforated gastric ulcer. — Tsai KC, Wang HP, Huang GT, Wang SM Journal of clinical ultrasound : JCU (1998)
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      Diagnosis of Helicobacter pylori in Britain. — Duggan A, Logan R Journal of gastroenterology (1998)
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