Managing Helicobacter pylori infection in primary care
Helicobacter pylori (H. pylori) infection is associated with conditions such as gastritis, peptic ulcer, gastric cancer, and certain types of lymphoma. A common presenting complaint among all these H. pylori-related illnesses is dyspepsia. Roshini Claire Anthony speaks to Dr Desmond Wai from the Desmond Wai Liver and Gastrointestinal Diseases Centre, Mount Elizabeth Novena Specialist Centre, Singapore, on the important role general practitioners (GPs) play in recognizing, diagnosing, and treating H. pylori.
The prevalence of H. pylori infection is related to the socioeconomic status and hygiene level of a country. In countries such as India, Bangladesh, and Vietnam, the prevalence exceeds 70 percent, while in countries such as China, Korea, Hong Kong, and Taiwan, the prevalence is 50 to 70 percent.
Singapore is considered a low prevalent country with a prevalence of about 31 percent. However, Singapore is also a regional medical hub where patients come from all over Asia. Furthermore, many foreigners from neighbouring countries live in Singapore for work and study purposes, enabling most doctors in Singapore to have exposure to patients with H. pylori infection.
Diagnosing H. pylori
A diagnosis of H. pylori can be made by noninvasive investigations such as serology or a urea breath test which are available in many laboratories and most hospitals. In suitable patients, for example, young patients with dyspeptic symptoms, it is reasonable for GPs to use the “Test and Treat” strategy and refer the patients to gastroenterologists should they fail this strategy.
According to the 2007 guidelines from the American College of Gastroenterology, general population screening for H. pylori infection is generally not recommended. Screening for H. pylori should only be performed when treatment is considered. Screening for H. pylori should be performed in patients with dyspepsia, history of peptic ulcer, or gastric cancer, as well as those on nonsteroidal anti-inflammatory drugs (NSAIDs) or antiplatelet agents. This is because the presence of H. pylori infection in patients on antiplatelet agents or NSAIDs would increase their risk of peptic complications.
Screening of family members for H. pylori infection is controversial. On one hand, re-infection of H. pylori may occur if family members are also infected. However, studies have shown that intra-familial transmission of H. pylori is more related to socioeconomic status of the families involved.
Challenges in diagnosing H. pylori
Most GPs are well-versed with the latest guidelines on H. pylori infection as well as many other common gastrointestinal conditions. This is due to the wide availability of continuing medical education (CME) talks, as well as the availability of most treatment guidelines online.
A major challenge is reimbursement. Currently, most insurance policies do not cover investigation and treatment of H. pylori infection at the primary care setting. Integrated shield plans only cover medical care leading to and after admission. H. pylori infection is often diagnosed with gastroscopy examination, which is a day-surgical admission. Therefore, treatment at specialist level after endoscopy is reimbursed, whereas treatment at primary care level is self-paid. This is really not ideal as it unnecessarily increases the overall medical cost. Good treatment at the primary care level could help reduce overall medical cost as only patients with difficult-to-treat cases need to be referred to gastroenterologists.
Another challenge is treatment-related complications, mainly diarrhoea and abdominal discomfort. These are common and are observed in up to 50 percent of patients undergoing treatment. This leads to poor compliance to treatment, which may eventually lead to higher resistance to antibiotics.
Treating H. pylori
Generally speaking, treatment consists of a proton pump inhibitor plus two antibiotics, for 7–14 days. With the rise in prevalence of antibiotic resistance for H. pylori infection in the region, the treatment is often extended to 2 weeks. Knowing the background resistance of H. pylori to various antibiotics enables the use of antibiotics with less resistance.
An important aspect in treating this condition is the management of patients’ expectation. Up to 50 percent of patients may experience adverse effects during treatment yet it is paramount that they complete treatment in order to achieve a 90-percent cure rate.
When should patients be referred to a specialist?
H. pylori infection and gastrointestinal diseases are two separate entities. While most H. pylori-related diseases such as gastritis and peptic ulcers heal upon H. pylori eradication, patients with gastric or hepatobiliary cancer can also have concomitant H. pylori infection and present with upper abdominal pain. Patients who have persistent symptoms after H. pylori treatment and those who present with “alarm” symptoms should be referred to gastroenterologists for endoscopy and further examination.
The Singapore Ministry of Health (MOH) last issued treatment guidelines on H. pylori management in 2004. GPs can also follow guidelines from the Asia Pacific Digestive Week, American College of Gastroenterologists, and the American Gastroenterology Association. The latest set of guidelines is the Toronto Consensus written by the Canadian Association of Gastroenterology which was published in 2016.
H. pylori infection is relatively common in Singapore and it is associated with many digestive diseases. The eradication of the condition will help reduce gastrointestinal complications in patients taking antiplatelet agents and NSAIDs; therefore, screening of suitable patients is advisable.
American College of Gastroenterology
Canadian Association of Gastroenterology