Patient’s Problem

A 35-year-old male, Mr. Rohan (name changed to protect identity), working as a sales representative, came with a six-week history of burning stomach pain, bloating, and frequent burping. His pain increased when his stomach was empty and eased briefly after eating.

He reported high work stress, smoked 5–7 cigarettes a day, relied on outside food, and often used ibuprofen for headaches.

Diagnosis

Based on his symptoms, testing, and endoscopy findings, the doctor diagnosed H. pylori gastritis with early peptic ulcer formation.

Findings included:
Physical Exam: Mild tenderness in the upper abdomen but no guarding, normal bowel sounds, and normal vital signs.
Lab Tests: CBC and CRP were normal, showing no anemia or systemic inflammation.
H. pylori Tests:

• Urea Breath Test: Positive
• Stool Antigen Test: Positive
  Endoscopy: Mild gastritis and a small superficial gastric ulcer. Biopsy confirmed H. pylori infection.

Treatment

Mr. Rohan was started on standard H. pylori eradication care.

Eradication Therapy: A guideline-based combination of antibiotics and acid-suppressing medication was prescribed to eliminate the infection.
Gastric Protection: Acid-reducing medicines were given to help the ulcer heal, and he was advised to avoid NSAIDs.
Lifestyle Measures: He was counselled to reduce smoking, limit alcohol, avoid spicy/fatty foods temporarily, eat regular meals, and manage stress.
Follow-Up: A repeat stool antigen or breath test was planned after four weeks to confirm eradication.

Result

At the 6–8 week follow-up, his symptoms had improved significantly. The burning pain resolved, the ulcer healed on follow-up imaging, and the repeat stool antigen test was negative. He also reduced smoking and limited his NSAID use.
If left untreated, H. pylori can progress to serious issues like bleeding ulcers or long-term gastric complications.

Note: This case study is for illustrative purposes only and should not replace professional medical advice. If you have concerns about your health, please consult with a qualified healthcare provider.