helicobacter%20pylori%20infection
HELICOBACTER PYLORI INFECTION
Treatment Guideline Chart
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.

Helicobacter%20pylori%20infection Diagnosis

Evaluation

  • Thorough history and physical exam should be done to rule out other causes for dyspeptic symptoms (eg cardiac, hepatobiliary, medication induced eg 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)
    • Please see Gastroesophageal Reflux Disease disease management chart for further information
  • 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 ulcer1
    • Please see Peptic Ulcer Disease disease management chart for further information

1Various H pylori-associated PUD combination preparations are available. Please see the latest MIMS for specific formulations and prescribing information.

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

Clinical Consideration

  • Eradication of H pylori leads to ulcer healing and significantly diminished incidence of recurrence
    • Elimination of infection reduces gastric cancer incidence; it improves gastritis and gastric atrophy but not intestinal metaplasia
    • Multidrug regimen, adequate duration of treatment, and adherence to therapy are needed for eradication
  • A screen and treat strategy is recommended in individuals and communities at increased risk for gastric cancer

“Test and Treat” for Helicobacter pylori

It is strongly recommended that the following patients should be tested for H pylori and if they test positive for H pylori, treatment to eradicate the infection should be instituted:

  • Before starting NSAID treatment on patients with previous history of PUD or ulcer complication
    • NSAIDs increase the risk of developing complications in patients with concomitant H pylori infection
  • Patients on NSAID and Aspirin with a history of PUD 
  • Patients with GERD requiring long-term proton pump inhibitor (PPI) therapy
    • Long-term PPI use of patients infected with H pylori may be associated with acceleration of atrophic gastritis
  • Complicated and uncomplicated peptic ulcers (active or healed)
  • Gastric mucosa-associated lymphoid tissue (MALT) lymphoma
  • Previous history of lymphoma while on NSAID therapy
  • Uninvestigated dyspepsia
  • After resection of early gastric cancer
  • Family history of gastric cancer

Other Patients

  • Adult patients <50 years (<40 years in areas with high prevalence of gastric cancer) that present with persistent dyspepsia and without predominant GERD symptoms, NSAID therapy and no alarm symptoms may be approached in 2 different ways:

Empiric therapy

  • Treat empirically x 2-4 weeks with appropriate antisecretory agent and/or prokinetic agent
  • If symptoms do not improve with appropriate trials of PPI, histamine2-receptor antagonists (H2RAs) or prokinetic agents, consider endoscopy

May test for H pylori prior to trial of medication

  • These patients may be considered for “test and treat” but this is controversial in non-ulcer dyspepsia
  • It is unlikely that eradication of H pylori will reduce symptoms but it may decrease future risk of PUD
  • Endoscopy may be performed 1st to identify PUD and treat H pylori only in PUD patients

Diagnostic Tests

“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 may be considered in patients with antrum-restricted atrophy to evaluate the status of the gastric mucosa and as a marker for atrophic gastritis
METHODS OF H PYLORI TESTING
MODALITY ADVANTAGES DISADVANTAGES
Noninvasive
Urea breath test (UBT)
  • Highly specific and sensitive
  • Reliable, inexpensive, rapid, quantitative
  • Gold standard test for asymptomatic patients
  • Most valuable for assessing response to therapy after 4-8 weeks
  • Useful for eradication confirmation
  • Rarely with false-positive results due to urease-positive organisms
  • Provides no information about antibiotic resistance
Stool antigen test
  • Highly specific and sensitive
  • Rapid, simple and can be modified
  • Enzyme-linked immunosorbent assay (ELISA) is the most accurate
  • Requires withholding of some medications prior to testing
Serology
  • Rapid, quantitative, inexpensive
  • Recommended for initial screening
  • Not affected by gastric bleeding
  • Low sensitivity specificity
  • Not for eradication confirmation
  • Does not distinguish between active and past infection
Invasive
Endoscopy with biopsy and rapid urease test (RUT)

Endoscopy:

  • Permits inspection of pathology
  • Allows detection of ulcers, neoplasm
  • Allows detection of bleeding

RUT:

  • Highly sensitive and specific
  • Rapid
  • Inexpensive
  • Most handful test in a clinical setting

Endoscopy:

  • Invasive, expensive
  • Unable to visualize H pylori

RUT:

  • Requires withholding of some medications prior to testing
Culture
  • Highly specific
  • Permits determination of antimicrobial susceptibility
  • Low sensitivity
  • Expensive
  • Time-consuming
  • Expert personnel and care during transport required
  • PPI and antibiotic use increase chances of false-negative result
Histology
  • Highly specific, simple and inexpensive
  • More sensitive than culture
  • Allows direct visualization of organism extent
  • Several days for result
  • Nature of tissue involvement
  • With high rate of false-negative results
Polymerase chain reaction (PCR)
  • Very good specificity sensitivity
    • Liquid phase (DNA-enzyme immunoassay) and reverse dot blot probe assay (LiPA) increase PCR's specificity and sensitivity
  • Rapid and accurate results
  • Permits determination of antimicrobial susceptibility and virulence typing
  • Expensive
  • Expert personnel and longer time to process required
  • Not widely available
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