Helicobacter Pylori: When should you diagnose and treat

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Helicobacter Pylori When should you diagnose
and treat?

• Christopher M. Mathews, M.D.
• Wake Forest University
• Department of Internal Medicine

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Patient 1

• 38 y.o. male No pmhx transported to the CCU after
  presenting to Elkin with CP and found to have a
  troponin .02. The patient rules out for a mi
  overnight. The next a.m. after further
  questioning you discover that the patient has had
  epigastic pain with excessive belching for the
  last three days. Patient denies every
  experiencing the pain before. What should you do?

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Helicobacter pylori
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Epidemiology

• Over ½ the worlds population infected
• Less than 20 with associated conditions
• High density of living
• Low socioeconomic
• In U.S., more common in Blacks/Hispanics

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Its all about Urease

• Urea -gt
• Ammonia CO2
• Neutralizes acid
• Forms protective cloud around Hp

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pH dependent urea channel

• Opened with acidic environment
• Increase the pH with PPI or H2 blocker affects
  urease activity
• Decrease the urease activity -gt decrease the
  sensitivity of urease base test
• Off meds for 2 4 weeks
• Can affect UBT, Bx, histology

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Diagnostic Tests

• Noninvasive
• Invasive

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Noninvasive Tests

• Serology IgG antibodies to H. pylori, only
  indicates infection, does not confirm if active
• Urea Breath test on urea 12C replaced by 13C or
  14C
• Stool antigen

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Invasive Tests

• Biopsy urease test affected by antisecretory
  meds.
• Histology -
• Culture sensitivities, reserved for individuals
  that have failed 2 or more attempts at
  eradication

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Tests available at the Baptist

• Serology
• Histology

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Key Point

• Order the test only if you plan to treat a
  positive result

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Guidelines for testing

• Active peptic disease
• Documented h/o peptic ulcer disease
• Mucosal-associated-lymphoid-type lymphoma (MALT)
• ?

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Lassen et alTest and Treat Compared to Prompt EGD

• Randomized trial
• Patients referred by GP in Denmark to university
  hospital
• gt two weeks of dyspepsia

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Exclusion

• lt 18 years of age
• Previous GI surgery
• Tx with ulcer healing meds in the last month
• Pregnant
• Alarm type symptoms

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Alarm symptoms

• Anorexia
• Anemia
• Weight loss
• Gross/occult GI bleed
• Dysphagia
• Severe/recurrent emesis

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Methods

• Randomized to test and treat or prompt EGD
  biopsy

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Test and Treat

• Hp () -gt two weeks of erad. Tx
• Hp (-) , NSAID use one month prior to study -gt
  EGD
• Hp (-) with predominat GERD -gt PPI
• Hp (-), NSAID (-), GERD (-) -gt reassure

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Prompt EGD

• EGD biopsy -gt treatment based on findings

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EGD Findings

• 129 (52) Normal
• 70 (28) Reflux esophagitis
• 25 (10) Gastric ulcer
• 22 (9) Duodenal ulcer
• 2 (1) Gastric cancer

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Gastric Cancer

• 76 y.o. male with Hp (), adenocarcinoma
• 22 y.o. male with Hp (-) malignant lymphoma

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Survey

• G.I. symptom scale
• Influence of dyspeptic symptoms
• Satisfaction with treatment
• Utilization of medical services ( presciptions,
  GP visits, sick days, procedure, etc.)

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Results

• No statistically significant differences except
  for satisfaction with treatment and total numbers
  of EGD

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Results after one year
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Numbers of EGD in Test and Treat

• 59 of the patients underwent EGD for continued
  symptoms

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Problems

• No age limit
• Referred to university hospital

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Chiba ColleaguesEradication of Hp vs acid
suppression

• Double blind placebo controlled trial
• Recruitment/intervention in primary care setting
  in Canada
• Patient had to be gt 18 y.o. and have
  uninvestigated dyspepsia for gt 3 months

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Exclusion Criteria

• Previous gastric surgery
• Upper GI investigation in last 6 mon. or gt 2
  times over the last 10 years
• Ulcer or esophageal disease
• GERD
• Eradication of Hp in the last 6 months
• IBS

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Methods

• Qualified patients underwent Helisal rapid blood
  test
• 446 () test confirmed with 13C breath test
• 152 (33) had a negative breath test
• 294 patients randomized to receive one week of
  triple therapy or one week of PPI , placebo
  metronidazole, and placebo clarithromyocin

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ResultsTreatment outcomes
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ResultEradication vs. Placebo Cost
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Adverse Outcomes

• 2 deaths
• Metastatic brain cancer with unknown primary
• 69 y.o. male with esophageal cancer, admitted
  three months into study

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Problems

• No age limit
• Exclusion criteria did not include alarm symptoms
• Inconsistent management (patients were d/c to GP
  following one week of eradication or placebo

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ConclusionsTest and Treat

• lt 45 years of age
• No alarm symptoms
• Dyspepsia symptoms gt 3 4 weeks
• If symptoms persist refer for EGD

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Patient 1

• H2 blocker, lifestyle changes, and follow up

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Patient 1 with 4 weeks of dyspepsia

• Test for H. pylori
• () then eradicate
• (-) then PPI trial

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Patient 2 49 yo male with 4 weeks of dyspepsia

• Refer for EGD