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Helicobacter Pylori: When should you diagnose and treat?

Helicobacter Pylori: When should you diagnose and treat?. Christopher M. Mathews, M.D. Wake Forest University Department of Internal Medicine. Patient # 1.

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Helicobacter Pylori: When should you diagnose and treat?

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  1. Helicobacter Pylori: When should you diagnose and treat? Christopher M. Mathews, M.D. Wake Forest University Department of Internal Medicine

  2. 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?

  3. Helicobacter pylori

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

  5. It’s all about Urease • Urea -> • Ammonia + CO2 • Neutralizes acid • Forms protective cloud around Hp

  6. pH dependent urea channel • Opened with acidic environment • Increase the pH with PPI or H2 blocker affects urease activity • Decrease the urease activity -> decrease the sensitivity of urease base test • Off meds for 2 – 4 weeks • Can affect UBT, Bx, & histology

  7. Diagnostic Tests • Noninvasive • Invasive

  8. 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

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

  10. Tests available at the Baptist • Serology • Histology

  11. Key Point • Order the test only if you plan to treat a positive result

  12. Guidelines for testing • Active peptic disease • Documented h/o peptic ulcer disease • Mucosal-associated-lymphoid-type lymphoma (MALT) • ?

  13. Lassen et alTest and Treat Compared to Prompt EGD • Randomized trial • Patients referred by GP in Denmark to university hospital • > two weeks of dyspepsia

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

  15. Alarm symptoms • Anorexia • Anemia • Weight loss • Gross/occult GI bleed • Dysphagia • Severe/recurrent emesis

  16. Methods • Randomized to test and treat or prompt EGD + biopsy

  17. Test and Treat • Hp (+) -> two weeks of erad. Tx • Hp (-) , NSAID use one month prior to study -> EGD • Hp (-) with predominat GERD -> PPI • Hp (-), NSAID (-), & GERD (-) -> reassure

  18. Prompt EGD • EGD + biopsy -> treatment based on findings

  19. EGD Findings • 129 (52%) – Normal • 70 (28%) – Reflux esophagitis • 25 (10%) – Gastric ulcer • 22 (9%) – Duodenal ulcer • 2 (1%) – Gastric cancer

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

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

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

  23. Results after one year

  24. Numbers of EGD in Test and Treat • 59 % of the patients underwent EGD for continued symptoms

  25. Problems • No age limit • Referred to university hospital

  26. Chiba & ColleaguesEradication of Hp vs acid suppression • Double blind placebo controlled trial • Recruitment/intervention in primary care setting in Canada • Patient had to be > 18 y.o. and have uninvestigated dyspepsia for > 3 months

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

  28. 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

  29. ResultsTreatment outcomes

  30. ResultEradication vs. Placebo Cost

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

  32. 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

  33. ConclusionsTest and Treat • < 45 years of age • No alarm symptoms • Dyspepsia symptoms > 3 – 4 weeks • If symptoms persist refer for EGD

  34. Patient # 1 H2 blocker, lifestyle changes, and follow up

  35. Patient #1 with 4 weeks of dyspepsia Test for H. pylori (+) then eradicate (-) then PPI trial

  36. Patient # 2 49 yo male with 4 weeks of dyspepsia Refer for EGD

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