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Helicobacter Pylori The Stranger Among Us

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Helicobacter Pylori The Stranger Among Us Formerly Campylobacter Ulcer link 1982 by Australians J. Robin Warren (Pathologist), and Barry Marshall, MD. – PowerPoint PPT presentation

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Title: Helicobacter Pylori The Stranger Among Us


1
Helicobacter PyloriThe Stranger Among Us
2
  • Formerly Campylobacter
  • Ulcer link 1982 by Australians J. Robin Warren
    (Pathologist), and Barry Marshall, MD.
  • Marshall dramatically demonstrated Kochs
    postulates by voluntary ingestion. Reportedly
    took more than two years to clear, trying
    numerous treatment regimens,.
  • Not accepted as cause of ulcers until 1994.

3
  • ...certain patterns of relationships were more
    common in ulcer families. Thus the mothers of
    ulcer patients tended to have psychogenic
    symptoms, and to be striving, obsessional, and
    dominant in the home fathers tended to be
    steady, unassertive, and passive.
  • The description of these families...emphasizes
    the conflict in duodenal ulcer patients between
    dependence engendered by a powerful mother and
    demands of adult roles.
  • Excerpts from Causes of Peptic Ulcer a Selective
    Epidemiological
  • Review by M. Susser, published in the Journal of
    Chronic Dis-
  • eases, Vol. 20 pp. 435-456, 1967

4
Practice Issues
  • Where does it come from?
  • Is it contagious?
  • How many go undiagnosed?
  • What is the best treatment?
  • How do we know if it worked?

5
Practice Challenges
  • Guidelines vague and variable
  • Specialists often reluctant to manage
  • Patient questions difficult to answer

6
Patient 1
  • 54 y/o female with unexplained anemia (Hgb 9.8)
    and iron deficiency.
  • EGD Diffuse gastritis. CloTest pos.
  • Rx 2 wks Amox/Clairyth/PPI
  • Sx recurred after 6 mos. Breath test positive
  • Rx 2wks Amox/Metro/PPI
  • Sx recurred after 1 year. Stool antigen negative
  • EGD CloTest neg., Gastric biopsy positive
  • Rx 2 wks Doxy/Metro/PPI/Pepto Bismol
  • No recurrence in 2 years

7
Patient 2
  • 32 y/o Ecuadoran male with 2 years unexplained
    intermittent post-prandial cramps/loose stool.
    Minimal peptic sx.
  • Hx of acute gastroenteritis after Asado feast in
    S. America prior to onset of symptoms.
  • Stool antigen pos.
  • Rx Rx 2 wks Amox/Clairith/PPI/Pepto

8
Patient 3
  • 62 y/o female with hx of 3 or 4 ulcers, the
    first at age 18, with recurrent peptic sx.
  • GI Consult/EGD Duodenal ulcer. CloTest neg.
  • Rx PPI - No antibiotic rx by GI.
  • 6 mos later sx recurred.
  • H. Pylori serum antibody pos. (1.4)
  • Rx Rx 2 wks Amox/Clairith/PPI/Pepto

9
Health Impact
  • Ulcers 80-95 DU and 70-80 GU
  • 5-6000 deaths/yr 6 billion cost
  • 80 of Gastric cancers. 6X risk for carrier.
  • 3-4X risk of NSAID gastropathy.
  • Gastric B-cell Lymphoma (MALT)
  • Non-Ulcer Dyspepsia
  • More suspected - vascular/migraine/autoimmune
  • Colon and Pancreatic cancers?

10
Prevalence
  • 66 of world population.
  • 80-90 in third world countries
  • Marked socioeconomic correlation
  • Estimated 50 of Americans over 65

11
Individuals infected
100
80
Developingcountries
'Carrier state' fromchildhood infection(before
1945)
60
Rapid acquisitionin childhood
40
20
Westerncountries
0
0
10
20
30
40
50
60
70
80
yearsAge
Marshall 1994
12
Transmission
  • Fecal-Oral
  • Oral-Oral/ Dental Plaque/Kissing
  • Environmental reservoirs (water/fish?)
  • Iatrogenic
  • Family contacts
  • Still poorly understood

13
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14
Symptoms
  • Most are asymptomatic
  • Peptic gastroenteropathy
  • Ulcers
  • NSAID sensitivity
  • Acute gastroenteritis
  • Nonspecific gastrocolic complaints

15
Diagnostic tests
  • Stool Antigen/Culture
  • Serum IgG/IgA Antibody
  • 13/14C-urea breath test (UBT) (Most Sensitive)
  • Biopsy Urease Test (Clotest)
  • Biopsy Microscopy (Gold standard)

16
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17
Treatment of Choice
  • PPI twice daily
  • Amoxicillin 1gm twice daily
  • Clairythromycin 500mg twice daily
  • Pepto-Bismol tablets, 2 four times a day
  • Two weeks preferred
  • 80-90 effective.
  • One week and single dose regimens under study.

18
Treatment Alternatives
  • Metronidazole 500mg BID (increasing Metro
    resistance) or Tetracycline 500mg QID for
    Amoxicillin
  • Ranitidine Bismuth Citrate with Amoxicillin and
    Clairithromycin is first line in Europe and
    appears as good as PPI regimen.
  • Rifabutin 300mg daily in place of Clairythromycin
    for treatment failures may be promising.

19
Confirming Cure
  • Breath test still most accurate , but expensive
    and impractical.
  • Stool antigen after 6 weeks minimum. Beware of
    antibiotic, PPI or bismuth use within 4 wks of
    test.
  • Antibody declines 50 in 3 months with cure, and
    is undetectable in 60 after 18 months.
  • EGD/Bx for culture if two failures suggest
    antibiotic resistance.

20
Take Home Points
  • Testing is too insensitive - often need multiple
    tests, such as stool antigen, serum antibody
    and/or endoscopic screening to make Dx. Dont
    accept negative results from a single-test when
    suspicion is high.
  • Consider primary infection when symptoms persist
    after acute gastroenteritis
  • Consider NSAID sensitivity a possible indicator
    of H. Pylori infection
  • Test all ulcer patients
  • Test for cure after treatment.
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