Revised in August 2007 and published in American Journal of Gastroenterology
Diagnostic testing for H. pylori should only be performed if tx is intended
Established indications for eradication of H pylori include
Established indications for eradication of H pylori include
peptic ulcer disease: active PUD, a h/o documented peptic ulcer
gastric MALT lymphoma, gastric cancer
uninvestigated dyspepsia: “test and treat strategy”
Uninvestigated dyspepsia (ie, unknown if pt has PUD)
Uninvestigated dyspepsia (ie, unknown if pt has PUD)
<55 years age
No “alarm features”
Bleeding
Anemia
Early satiety
Unexplained weight loss
Progressive dysphagia
Odynophagia
Recurrent vomiting
FMH GI CA
Previous esophagogastric CA
Still controversy regarding whether to test for H pylori in
Still controversy regarding whether to test for H pylori in
functional dyspepsia—a subset of patients with functional dyspepsia benefit from H pylori eradication
nonsteroidal anti-inflammatory drug (NSAID) use
iron-deficiency anemia—recent evidence suggests a link between H pylori infection and unexplained iron-deficiency anemia.
risk factors for developing gastric cancer
family members of patients with ulcer disease or gastric cancer
Prevalence of H. pylori is lower among patients with GERD and those with esophageal adenocarcinoma
Prevalence of H. pylori is lower among patients with GERD and those with esophageal adenocarcinoma
H. pylori-associated atrophic gastritis reduces acid secretion and may provide protection against these diseases.
Randomized trials of H. pylori eradication in nonulcer dyspesia (aka functional dyspepsia) have shown no benefit
Randomized trials of H. pylori eradication in nonulcer dyspesia (aka functional dyspepsia) have shown no benefit
There is little evidence that chronic H. pylori infection in the absence of gastric or duodenal ulceration causes UGI symptoms.
Non-invasive Diagnostic Tests
Non-invasive Diagnostic Tests
Serologic tests
Urea breath tests
Stool antigen
Endoscopic Tests
Urease
Histology
Culture
PCR
According to 2007 ACG Guidelines “there is no single test that can be considered the gold standard for the diagnosis of H. pylori”
According to 2007 ACG Guidelines “there is no single test that can be considered the gold standard for the diagnosis of H. pylori”
Most appropriate test depends on clinical situation
ELISA to detect IgG or IgA antibodies
ELISA to detect IgG or IgA antibodies
IgG Ab appear 2-3 weeks following infxn and slowly decrease after eradication
Inexpensive and widely available
Sensitivity and specificity
Sensitivity 85% and specificity ~80% (from meta-analysis)
Lower than in previous reports
If pretest probability is low, a negative test excludes dz. If test is positive it may be a false + so recheck with a confirmatory test
False + are more common in elderly and pt w/ cirrhosis
False + are more common in elderly and pt w/ cirrhosis
Also, may underestimate infxn in elderly b/c lack of Ab response (false -)
Not reliable in young children
Poor PPV in low prevalence populations
Limited use for F/U of therapy
Takes a long time for serology to become negative
In pt cured of infection, titers are at ~50% at 3 mths
For populations with a low pretest probability of H pylori infection, the nonendoscopic urea breath and fecal antigen tests have a better positive predictive value than do antibody tests.
For populations with a low pretest probability of H pylori infection, the nonendoscopic urea breath and fecal antigen tests have a better positive predictive value than do antibody tests.
Antibody testing identifies an immunologic reaction to the infection, whereas the urease tests and fecal antigen test identify the presence of active H pylori infection.
A. H. pylori IgG serology
A. H. pylori IgG serology
B. Fecal antigen test
C. Urea breath test
D. EGD
Serology would be appropriate in this scenario for patients on PPI therapy who cannot stop therapy for two weeks prior to the tests of active infection, i.e. stool antigen or breath test.
Serology would be appropriate in this scenario for patients on PPI therapy who cannot stop therapy for two weeks prior to the tests of active infection, i.e. stool antigen or breath test.
Hydrolysis of urea CO2 and NH3. Measures labeled carbon.
Hydrolysis of urea CO2 and NH3. Measures labeled carbon.
Sensitivity and specificity typically >95% in most studies
False positive (decreased specificity) in pt with acute UGI bleed
False negative tests (decreased sensitivity) if patient is on PPI in prior 2 weeks or has taken antibiotics in prior 4 weeks. (24 hours for H2 blocker)
Useful for documenting if eradication has been successful
Wait 4-8 weeks before repeat
Reliable in kids >6 yrs
Reliable in kids >6 yrs
Best test in elderly population
Most reliable non-endoscopic test to document eradication after treatment
Stop PPI and other meds that may interfere 4 wks prior to endoscopy
In pt who have not been on PPI within 1-2 wk OR Abx or bismuth within 4 wk of EGD, the rapid urease test provides an accurate, inexpensive means of identifying H. pylori
In pt who have not been on PPI within 1-2 wk OR Abx or bismuth within 4 wk of EGD, the rapid urease test provides an accurate, inexpensive means of identifying H. pylori
For pt who have been taking a PPI, Abx, or bismuth, EGD testing for H. pylori should include bx from the gastric body and antrum for histology +/- rapid urease testing
Primary means by which Abx sensitivities can be determined
Primary means by which Abx sensitivities can be determined
Neither is widely available for clinical use
Not routinely recommended
Eradication
Eradication
Results in ulcer healing
Decreases risk of ulcer recurrence—more than a 30% reduction in the risk for recurrent ulcer at 1 year
Reduces risk for serious ulcer complications (perforation or bleeding)
Leads to regression of MALT lymphoma
Eradication of H pylori is less robust in reducing rates of dyspepsia and gastric cancer.
H. pylori regimens should have cure rates of at least 80% (desirable)
H. pylori regimens should have cure rates of at least 80% (desirable)
Dual therapy (PPI + one abx) regimens have eradication rates of 60-85% and are not recommended
Triple therapy: combination of antibiotics and PPI or H2 blocker or bismuth
Previously 3 regimens consistently eradicated H. pylori with rates >90% now may be dropping to ~75-80% b/c of clarithromycin resistance
Previously 3 regimens consistently eradicated H. pylori with rates >90% now may be dropping to ~75-80% b/c of clarithromycin resistance
First Line (ACG and Maastricht Consensus—European)
PPI (lansoprazole 30 mg po BID), amoxicillin 1 gram po BID, clarithromycin 500 mg po BID x 14 days (Prevpac)
Above but change amoxicillin to metronidazole 500 mg po BID for PCN allergic
Alternative: PPI or H2, bismuth 525 mg po QID, 2 antibiotics (metronidazole 500 mg po QID, tetracycline 500 mg po QID) x10-14 days
Course of 7-14 days
Course of 7-14 days
7-day course more common in Europe
10-14-day course recommended in US
Triple therapy: 14 days
Quadruple therapy: 10-14 days
Trial of quadruple therapy for non-responsive cases (ie, salvage)
Trial of quadruple therapy for non-responsive cases (ie, salvage)
Regimens with levofloxacin instead of clarithromycin
Sequential therapy
5 days of one regimen (PPI + amoxicillin) followed by 5 days of a second regimen (PPI, clarithromycin, tinidazole)
Lactoferrin and Probiotics
New studies adding these agents to triple therapy
New studies adding these agents to triple therapy
De Bortoli et al in Italy
206 patients
Esomeprazole 20 mg, amoxicillin 1000 mg, and clarithromycin 500 mg, all twice daily for 7 days
To confirm eradication of H pylori infection, testing should be performed in
patients with PUD
persistent dyspeptic symptoms following the test-and-treat strategy
H pylori-associated MALT lymphoma
status post resection of early gastric cancer
H. pylori infection increases risk of PUD, chronic gastritis, gastric CA, and MALT lymphoma
H. pylori infection increases risk of PUD, chronic gastritis, gastric CA, and MALT lymphoma
Check for H. pylori in pt with PUD, MALT lymphoma, undifferentiated dyspepsia
Serology less reliable test; urea breath test and fecal antigen testing preferred
Consider EGD for alarm sx or age >50 yrs
Triple therapy for treatment has decreasing efficacy—now ~75-80%
Test for eradication if PUD, persistent sx, MALT lymphoma, s/p gastric CA resection
Chey WD, Wong BC et al. American College of Gastroenterology Guideline on the Management of Helicobacter pylori Infection. Am J Gastroenterol 2007 Aug; 102(8):1808-25.
Chey WD, Wong BC et al. American College of Gastroenterology Guideline on the Management of Helicobacter pylori Infection. Am J Gastroenterol 2007 Aug; 102(8):1808-25.
De Bortoli N, Leonardi G, Ciancia E, et al. Helicobacter pylori Eradication: A Randomized Prospective Study of Triple Therapy Versus Triple Therapy Plus Lactoferrin and Probiotics. Am J Gastroenterol. 2007; 102: 951-956.
Fisschbach L and Evans E. Meta-analysis: The Effect of Antibiotic Resistance Status on the Efficacy of Triple and Quadruple First-line Therapies for Helicobacter pylori. Aliment Pharmacol Ther 2007; 26(3): 343-357.
Gisbert J. The Recurrence of Helicobacter pylori Infection: Incidence and Variables Influencing It. A Critical Review. Am J Gastroenterol 2005; 100: 2083-2099.
Gisbert J. The Recurrence of Helicobacter pylori Infection: Incidence and Variables Influencing It. A Critical Review. Am J Gastroenterol 2005; 100: 2083-2099.
Meurer L et al. Management of Helicobacter pylori Infection. American Family Physician 2002; 65 (7): 1327-1336.
Salles N and Megraud F. Current Management of Helicobacter pylori Infections in the Elderly. Expert Rev Anti Infect Ther. 2007; 5(5): 845-856.
Suerbaum S and Michetti P. Helicobacter Pylori Infection. NEJM 2002; 347 (15): 1175-1186.
