helicobacter%20pylori%20infection
HELICOBACTER PYLORI INFECTION
Helicobacter pylori is a spiral-shaped gram-negative bacterium involved in the development of gastritis, duodenal and gastric ulcers, and gastric cancer.
Infection is strongly associated with the development of gastric epithelial and lymphoid malignancies.
Acute infection is mostly asymptomatic and is acquired through human-to-human contact via gastro-oral and fecal-oral routes.
Adaptability in gastric conditions and production of urease allow it to colonize the stomach.

Evaluation

  • Thorough history and physical exam should be done to rule out other causes for dyspeptic symptoms [eg cardiac, hepatobiliary, medication induced eg nonsteroidal anti-inflammatory drugs (NSAIDs), dietary indiscretion, lifestyle, etc]
  • Patients with dominant symptoms of heartburn or acid regurgitation without a history of peptic ulcer disease (PUD) need not be tested for H pylori infection but should be treated for gastroesophageal reflux disease (GERD)
    • See Gastroesophageal Reflux Disease Disease Management Chart for details
  • In H pylori-infected patients, the risk of ulcer disease is increased with NSAID and aspirin use 
    • Eradication of H pylori in patients on long-term NSAID use does not enhance the healing of gastric or duodenal ulcers and these patients should be treated appropriately for NSAID-induced ulcer
    • See Peptic Ulcer Disease Disease Management Chart for details

Assessment

Patients with alarm symptoms require prompt endoscopic investigation

  • Unexplained weight loss or anorexia
  • Recurrent vomiting
  • >50 years old (cut-off age will depend on national cancer incidence rates)
  • Evidence of gastrointestinal bleeding, iron-deficiency anemia, idiopathic thrombocytopenic purpura, vitamin B12 deficiency, or positive occult blood test 
  • Dysphagia or odynophagia
  • Failure of multiple treatments
  • Jaundice
  • Presence of abdominal mass

Screening

“Test and Treat” for Helicobacter pylori in Primary Care

  • Routine testing is not recommended, performed only in patients who will require therapy if results are positive
  • Two positive tests are required for H pylori diagnosis
  • Urea breath test (UBT) and stool antigen test are the preferred methods of diagnosis in the primary care setting
    • If UBT and stool antigen test are not available, serological test (mainly IgG) is a satisfactory alternative
  • A delayed test (either a UBT or histology) should be done within 4-8 weeks of an acute upper gastrointestinal bleed following a negative endoscopy
  • In cases where an endoscopy is indicated and biopsy is not contraindicated, a rapid urease test is recommended as primary diagnostic test  
  • Pepsinogen serology is a useful non-invasive test to evaluate the status of the gastric mucosa
METHODS OF H PYLORI TESTING
MODALITY ADVANTAGES DISADVANTAGES
Noninvasive
Urea breath test (UBT) Reliable, rapid, quantitative
Highly specific sensitive
Most valuable for assessing response to therapy after 4-8 weeks
Expensive instrumentation radioisotope
Stool antigen test Enzyme-linked immunosorbent assay (ELISA) is the most accurate Requires withholding of some medications prior to testing
Serology Rapid, quantitative, inexpensive Low sensitivity specificity
Not for eradication confirmation
Invasive
Endoscopy with biopsy Permits inspection of pathology
Allows detection of ulcers, neoplasm
Invasive, expensive
Unable to visualize H pylori
Culture Permits determination of antimicrobial susceptibility Low sensitivity
Requires several days for result
Histology More sensitive than culture
Allows direct visualization of organism extent
Several days for result
Nature of tissue involvement
Observer variability
Urease detection Rapid (most positive within 2 hours) Increased sensitivity
Requires longer incubation
Requires withholding of some medications prior to testing
Polymerase chain reaction (PCR) Very good specificity sensitivity
Permits determination of antimicrobial susceptibility
Not widely available
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