H. Pylori, when to test and treat

If you haven’t already noticed by our posts, this week we start the GI block of our curriculum. This morning in MR, we reviewed a board question related to H pylori and MALT lymphoma. Here are some highlights, answers to questions posed in MR and a great review article from NEJM.

Our case was a 48 yo with sx of dyspepsia for 6 months with no weight loss, fever or night sweats, no medications and normal labs.

What is dyspepsia?

  • Non specific term that refers to recurrent upper abdominal pain and discomfort and includes:
    • Epigastric fullness, belching, bloating, gnawing pain, heartburn
  • Most often non severe and pts remain functional

What is the differential diagnosis?

  • Peptic ulcer disease, gastritis, biliary colic, gastroparesis, pancreatitis, GI malignancy

What work up needs to be done?

  • Take a full H&P looking for etiologies for the above differential including medications (NSAIDs and aspirin) and alcohol use as well as warning signs such as evidence of malignancy or upper GI bleeding
  • On labs, check for IDA that may be a sign of ulcerative lesion or gastritis
  • Consider checking for H pylori
  • Withdraw offending agents
  • Initiate a PPI

When do we use the “test and treat” strategy for H pylori infection?

  • H pylori is contracted in childhood and prevalent in 50% of the US population
  • It is asymptomatic in many, but of infected people, 1-10% will develop gastric or duodenal ulcers, 0.3-3% gastric cancer and < 0.01% MALT lymphoma
  • American College of Gastroenterology recommends testing and treating patients that are <55 and have no alarm symptoms as well as patients that have known PUD, MALT lymphoma or gastric cancers

What test do I use?

  • Biopsy and histologic examination
    • Gold standard
    • Invasive
  • Urease breath tests
    • Good for active disease and response to treatment
    • Sensitivity 95%, specificity 95%
    • Less sensitive if on PPI and antibiotics
  • Fecal antigen test
    • Sensitivity 94%, specificity 98%
    • Test of choice if on PPI
  • Serologic tests
    • No longer recommended due to their low predictive value <50%
    • Also cannot determine the effectiveness of treatment

When do patients need EGD?

  • Endoscopy is indicated for patients with alarm symptoms:
    • Weight loss, persistent N/V, odynophagia/dysphagia, GI bleeding or IDA
    • Or older patients at greater risk of malignancy, age cutoffs vary based on guidelines from 45-55 years old
    • Patients not responding to PPI, medication withdrawal or triple therapy for H pylori

What follow up is required?

  • Patients with uncomplicated duodenal ulcers with resolution of sx do not need follow up endoscopy. Patients with large duodenal ulcers should have repeat endoscopy.
  • The follow up for gastric ulcers is under wide debate and may depend on the experience of the endoscopist and the adequacy of initial biopsy.
    • Consider the following approach: Do not repeat an upper endoscopy on patients with benign-appearing gastric ulcers that have been adequately biopsied with no evidence of malignancy or dysplasia on biopsies. In patients at high-risk for malignancy, perform a follow-up endoscopy (with biopsies of the ulcer if still present) after six weeks of therapy. High-risk gastric ulcers include the following:
      • Occurrence in ethnic groups raised in endemic areas (eg, Asians, Latinos), or a family history of gastric cancer
      • The absence of recent NSAID use
      • The presence of H. pylori, particularly if associated with gastric atrophy
      • Age greater than 50 years
      • The absence of either a concomitant duodenal ulcer or a prior history of duodenal ulcer (duodenal ulcers require higher acid secretion, which is incompatible with the pangastritis typical of most gastric cancers)
      • Giant ulcers (>2 to 3 cm)
  • Non invasive confirmation of eradication is recommended in all patients by European consensus group and for the following by the American College of Gastroenterology:
    • Associated ulcer, persistent sx, MALT lymphoma, resection of early gastric cancer

Tomorrow will cover an overview of MALT lymphoma so stay tuned!

Refer to the NEJM for further reading:

https://myutsouthwestern.swmed.edu/doi/pdf/10.1056/,DanaInfo=www.nejm.org+NEJMcp1001110