Episode Details

Episode 64: H. pylori. 

Dr Lorenzo explains testing, diagnosis, and treatments for H. pylori, a bacterium that can cause peptic ulcer disease and other complications.

By Anabell Lorenzo, MD, and Hector Arreaza, MD.  

This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home.

Today we are going to discuss a topic that may be very basic for many of our listeners, but it is important to check our knowledge foundation to keep building on it. Helicobacter pylori was discovered in 1982 by Barry Marshall and Robin Warren from Australia. They received the Nobel prize in 2005 for their discovery of “the bacterium Helicobacter pylori and its role in gastritis and peptic ulcer disease”.

1. What is H. pylori?

It’s a gram-negative bacteria found in the stomach causing infection and GI symptoms such as dyspepsia. It is a chronic infection and it’s usually acquired in childhood. Incidence and prevalence of H. pylori infection are generally higher in people born outside of North America than among people born here. About 50% of humans are infected by H. pylori in the world. The infection can be life-long and cause no symptoms. The infection can cause peptic ulcers too.

2. When do you test for H. pylori and treat it?

Test these patients for H. pylori: 

-All patients with active peptic ulcer disease (PUD).

-Patients with history of PUD (unless previous cure of H. pylori infection has been documented).

-Patients diagnosed with low-grade gastric mucosa-associated lymphoid tissue (MALT) lymphoma.

-Patients with a history of endoscopic resection of early gastric cancer (EGC).

In a few words, test patients with PUD and stomach malignancies. 

Controversial indications include:

- Consider non-endoscopic test (stool or breath) in patients with unexplained dyspepsia who are younger than 60 years old without red flags.

- Patients with typical symptoms of gastroesophageal reflux disease (GERD) who do not have a history of PUD do not need to be tested for H. pylori infection. However, for those who are tested and found to be infected, treatment should be offered, but to the patient that the effects of treatment of H. pylori on GERD symptoms are unpredictable. This means that eradication of H. pylori may or may not affect GERD symptoms. 

-Patients taking long-term, low-dose aspirin (to reduce the risk of ulcer bleeding)

-Prior to initiation of chronic treatment with NSAIDs

-Patients with unexplained iron deficiency anemia despite an appropriate evaluation 

3. What are the testing options for H. pylori?

-In patients is having an EGD, they can be tested with gastric biopsy histology and biopsy urease (best options). Endoscopy biopsy is the best diagnostic test for H. pylori.

-In patients who do not require EGD, NONINVASIVE TESTING like STOOL ANTIGEN ASSAY and UREA BREATH TEST are a great option

-Before performing the test, it is important to stop PPIs (proton pump inhibitors) for 2-4 weeks and Bismuth/antibiotics use within 4 weeks to avoid false negative results. 

4. What ar ethe recommended first-line treatments for H. pylori?

Triple therapy: Clarithromycin triple therapy is the recommended option. This treatment includes PPI, clarithromycin, and amoxicillin OR metronidazole for 14 days. This is the recommended in areas where clarithromycin