Helicobacter Pylori The Stranger Among Us

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Helicobacter PyloriThe Stranger Among Us
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• 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.

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• ...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

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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?

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Practice Challenges

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

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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

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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

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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

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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?

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Prevalence

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

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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
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Transmission

• Fecal-Oral
• Oral-Oral/ Dental Plaque/Kissing
• Environmental reservoirs (water/fish?)
• Iatrogenic
• Family contacts
• Still poorly understood

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Symptoms

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

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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)

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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.

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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.

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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.

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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.