Graham said that at his center in Houston about half of new ulcers are caused by H. pylori, with the rest caused by NSAIDs.
Peterson said that at a university hospital, like his in Denver, almost no ulcers are caused by H. pylori.
Ulcers caused by the bacteria are more frequent at centers caring for more socioeconomically disadvantaged populations.
Graham said that the prevalence of H. pylori was on the decline even before gastroenterologists started treating ulcers with antibiotics because of its fecal-oral transmission route.
It's a disease of poor hygiene and poor sanitation, he said, and doesn't transmit well between people. Quality sanitation had the bacteria retreating already in developed countries, although H. pylori remains a major problem in the developing world.
In the U.S., management of patients with ulcers involves testing for the bacteria. This can be done on biopsies taken during endoscopy, or with less-invasive blood, fecal antigen, and urea breath tests.
The "test-and-treat" approach says that if a patient shows signs of an ulcer and is positive for H. pylori they can be treated to eliminate the infection, without the need for endoscopic confirmation of an ulcer.
"The theory being that if they actually had an ulcer by treating H. pylori we would get rid of the ulcer, and if they didn't then that's okay. Getting rid of H. pylori was probably good in and of itself," Peterson said.
According to the most recent guidelines from the American College of Gastroenterology, published in 2007, first-line treatments for H. pylori ulcers include 10 to 14 days of therapy with a proton pump inhibitor, clarithromycin, and amoxicillin or metronidazole or a proton pump inhibitor, bismuth, tetracycline, and metronidazole.
Graham noted that there is increasing resistance to clarithromycin, which is not well known by clinicians. He said that H. pylori is sensitive to many other antibiotics.
In patients who show signs of an ulcer but who are H. pylori-negative, endoscopy is required to confirm an ulcer.
If it's determined that a patient has been taking an NSAID, stopping the drug and starting on antisecretory therapy will heal most ulcers, according to Graham. Healing time varies based on the severity of the ulcer, with some of the deepest ones taking six or seven months to heal completely.
But unlike in the past, "virtually every ulcer that we see is ultimately healed," Peterson said.
As perhaps a sign of the importance of Warren and Marshall's discovery, Graham said he was recently asked to condense five chapters on peptic ulcer disease in a major medical textbook into one.
"Peptic ulcer disease has become a minor event and eventually will become historical as far as a concept," Graham said.