Episode 64: H. pylori.
Dr Lorenzo explains testing, diagnosis, and treatments for H. pylori, a bacterium that can cause peptic ulcer disease and other complications.
By Anabell Lorenzo, MD, and Hector Arreaza, MD.
This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home.
Today we are going to discuss a topic that may be very basic for many of our listeners, but it is important to check our knowledge foundation to keep building on it. Helicobacter pylori was discovered in 1982 by Barry Marshall and Robin Warren from Australia. They received the Nobel prize in 2005 for their discovery of “the bacterium Helicobacter pylori and its role in gastritis and peptic ulcer disease”.
1. What is H. pylori?
It’s a gram-negative bacteria found in the stomach causing infection and GI symptoms such as dyspepsia. It is a chronic infection and it’s usually acquired in childhood. Incidence and prevalence of H. pylori infection are generally higher in people born outside of North America than among people born here. About 50% of humans are infected by H. pylori in the world. The infection can be life-long and cause no symptoms. The infection can cause peptic ulcers too.
2. When do you test for H. pylori and treat it?
Test these patients for H. pylori:
-All patients with active peptic ulcer disease (PUD).
-Patients with history of PUD (unless previous cure of H. pylori infection has been documented).
-Patients diagnosed with low-grade gastric mucosa-associated lymphoid tissue (MALT) lymphoma.
-Patients with a history of endoscopic resection of early gastric cancer (EGC).
In a few words, test patients with PUD and stomach malignancies.
Controversial indications include:
- Consider non-endoscopic test (stool or breath) in patients with unexplained dyspepsia who are younger than 60 years old without red flags.
- Patients with typical symptoms of gastroesophageal reflux disease (GERD) who do not have a history of PUD do not need to be tested for H. pylori infection. However, for those who are tested and found to be infected, treatment should be offered, but to the patient that the effects of treatment of H. pylori on GERD symptoms are unpredictable. This means that eradication of H. pylori may or may not affect GERD symptoms.
-Patients taking long-term, low-dose aspirin (to reduce the risk of ulcer bleeding)
-Prior to initiation of chronic treatment with NSAIDs
-Patients with unexplained iron deficiency anemia despite an appropriate evaluation
3. What are the testing options for H. pylori?
-In patients is having an EGD, they can be tested with gastric biopsy histology and biopsy urease (best options). Endoscopy biopsy is the best diagnostic test for H. pylori.
-In patients who do not require EGD, NONINVASIVE TESTING like STOOL ANTIGEN ASSAY and UREA BREATH TEST are a great option
-Before performing the test, it is important to stop PPIs (proton pump inhibitors) for 2-4 weeks and Bismuth/antibiotics use within 4 weeks to avoid false negative results.
4. What ar ethe recommended first-line treatments for H. pylori?
Triple therapy: Clarithromycin triple therapy is the recommended option. This treatment includes PPI, clarithromycin, and amoxicillin OR metronidazole for 14 days. This is the recommended in areas where clarithromycin resistance is less than 15%, and in patients with no exposure to macrolides. The two antibiotics and PPI twice a day are given for 2 weeks, and the PPI is continued once daily for one month. PPI may be omeprazole, pantoprazole, or others.
Quadruple therapy: Bismuth quadruple therapy consisting of a PPI, bismuth, tetracycline, and a nitro imidazole for 10–14 days is another treatment option. Bismuth quadruple therapy is particularly attractive in patients with any previous macrolide exposure or who are allergic to penicillin.
5. Should we test for H. pylori eradication?
Confirmation of eradication should be performed in all patients treated for H. pylori because of increasing antibiotic resistance. There is not a lot of information about antibiotic resistance in the US. The test should be done 4 weeks after completing treatment.
6. What is refractory H. pylori infection?
Refractory H. pylori infection is defined by a persistent positive H. pylori test (no serologic), at least 4 weeks after 1 or more full course(s) of a recommended first-line therapy, and when the patient has been off any medications, such as proton-pump inhibitors (PPIs), that may impact the test sensitivity.
Refractory H. pylori infection should be differentiated from recurrent infection. A recurrent infection happens when a no serologic test was negative after treatment, then becomes positive again.
7. What tests can be done to evaluate H. pylori antibiotic resistance?
We can test for resistance with culture or molecular testing, but these tests are currently not widely available in US.
8. What are the option for salvage therapy after failure of treatment?
In patients with persistent H. pylori infection, try to avoid antibiotics that have been previously taken by the patient. Bismuth quadruple therapy or levofloxacin salvage regimens are the preferred treatment options if a patient received a first-line treatment containing clarithromycin.
Regimens that contain clarithromycin or levofloxacin are the preferred treatment options if a patient received bismuth quadruple therapy.
Rifabutin triple regimen consisting of a PPI, amoxicillin, and rifabutin for 10 days is a suggested salvage regimen.
Conclusion:
H. pylori is an infection that can be asymptomatic, but it needs to be eradicated if symptoms are present. Detection of H. pylori is fairly easy, but we may need to perform an EGD if patient has red flags. Antibiotics and PPIs are the first line of treatment. Test of cure is recommended for all patients.
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Now we conclude our episode number 64 “H. pylori.” Dr Lorenzo explained when and how to test patients for H. pylori. She explained that patients with GERD symptoms to not need to be tested for H. pylori, but if they are tested and have positive results, then we should eradicate H. pylori. Remember to stop PPIs 2-4 weeks before non-endoscopic tests for H. pylori. Even without trying, every night you go to bed being a little wiser.
Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza and Anabell Lorenzo. Audio edition: Suraj Amrutia. See you next week!
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References:
William D. Chey, Grigorios I. Leontiadis, Colin W. Howden, and Steven F. Moss. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol 2017; 112:212–238. https://pubmed.ncbi.nlm.nih.gov/28071659/
Shailja C. Shah, Prasad G. Iyer, and Steven F. Moss. AGA Clinical Practice Update on the Management of Refractory Helicobacter pylori Infection: Expert Review. Gastroenterology 2021;160:1831–1841. https://pubmed.ncbi.nlm.nih.gov/33524402/
J. Thomas Lamont. Treatment regimens for Helicobacter pylori in adults. Up to date, last updated on May, 20, 2021. https://www.uptodate.com/contents/treatment-regimens-for-helicobacter-pylori-in-adults?search=h%20pylori%20treatment&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1.
