Peptic Ulcer Disease, H.Pylori and GORD Flashcards
Helicobacter Pylori - Gold Standard Treatment: Example Question
A 63-year-old man is referred for an OGD after a 5 month history of epigastric pain after eating. He is also suffering from significant reflux and dyspepsia. His OGD shows 2 duodenal ulcers, and a CLO test taken at the time is positive. He also suffers from hypertension and type 2 diabetes, which are controlled with amlodipine and metformin. He is allergic to penicillin.
What is the current gold standard treatment for H. pylorieradication for this patient?
Pantoprazole, metronidazole and levofloxacin Amoxicillin, clarithromycin and omeprazole > Omeprazole, clarithromycin and metronidazole Bismuth, tetracycline, metronidazole, omeprazole Clarithromycin, levofloxacin and lansoprazole
Helicobacter pylori (H. pylori) is a gram negative bacteria which is commonly found in the stomach lining. Infection has been associated with gastritis, gastric ulceration and duodenitis. At OGD a CLO (Campylobacter-Like Organism) test is performed to detect H. pylori using a biopsy sample of gastric mucosa, and a reagent that acts as a pH indicator.
If H. pylori infection is confirmed then eradication is needed to prevent further damage and ulceration of the gastric and duodenal mucosa. The standard first line treatment for someone who has not received eradication therapy before is one week of ‘triple therapy’ with a PPI, amoxicillin and clarithromycin. If a patient is allergic to penicillin then metronidazole is a good substitute. The other options listed are sometimes used as second and third line options if previous treatment has failed.
H.Pylori - Associations
Helicobacter pylori is a Gram negative bacteria associated with a variety of gastrointestinal problems, principally peptic ulcer disease
Associations:
- peptic ulcer disease (95% of duodenal ulcers, 75% of gastric ulcers)
- gastric cancer
- B cell lymphoma of MALT tissue (eradication of H pylori results causes regression in 80% of patients)
- atrophic gastritis
NB: The role of H pylori in Gastro-oesophageal reflux disease (GORD) is unclear - there is currently no role in GORD for the eradication of H pylori
H.Pylori - Mx
Management - eradication may be achieved with a 7 day course of :
- a proton pump inhibitor + amoxicillin + clarithromycin, or
- a proton pump inhibitor + metronidazole + clarithromycin
2nd Line = PPI + Amoxicillin + Clarithromycin/Metronidazole (Whichever one they didn’t have before)
NB: In a patient with a uncomplicated duodenal ulcer and positive Helicobacter pylori, 1 week of therapy is sufficient. If pt recently received metronidazole, it should be avoided and an alternative used instead.
H.Pylori Mx - Example Question
A 54-year-old gentleman present to the general medical clinic with feelings of bloatedness, rising acid in his chest and pain associated with mealtime. He is investigated with endoscopy and found to have a peptic ulcer and further testing demonstrates evidence of Helicobacter pylori. He has a past medical history of depression. He does not take any regular medications. He specifically denies any use of NSAIDs. He is known to be allergic to penicillin having suffered a systemic rash as a child following treatment for an inner ear infection. How should he be treated?
> Proton pump inhibitor, metronidazole and clarithromycin Proton pump inhibitor, amoxicillin and clarithromycin Proton pump inhibitor, bismuth, metronidazole and tetracycline Metronidazole and clarithromycin Proton pump inhibitor, and metronidazole
The correct answer is a proton pump inhibitor, metronidazole and clarithromycin. This is a patient with a peptic ulcer associated with Helicobacter pylori. NICE advises an eradication strategy, which should take allergies and recent antibiotic use into account.
FIrst-line treatment over seven days:
If no allergies: PPI, amoxicillin and clarithromycin or metronidazole
If penicillin allergic: PPI, clarithromycin and metronidazole
If penicillin allergic and previous clarithromycin exposure: PP, bismuth, metronidazole and tetracycline
As he may be penicillin allergic he should be treated as per the second option.
Source:
‘Gastro-oesophageal Reflux Disease and Dyspepsia in Adults: Investigation and Management.’ Clinical Guideline [CG184]. The National Institute for Health and Care Excellence, Nov. 2014.
H.Pylori - 2nd Line Treatment - Example Question
A 62-year-old woman returns to the gastroenterology clinic after having completed eradication treatment for Helicobacter pylori associated peptic ulcer disease. She had a week of omeprazole, amoxicillin and clarithromycin. Symptoms remain and she confirms good concordance with the treatment. She finished her course yesterday evening and is concerned as she feels that the treatment has not worked. What is the most appropriate plan?
> Change the clarithromycin to metronidazole and continue for one more week Stop the antibiotics and continue omeprazole Stop the antibiotics and omeprazole and start ranitidine Continue with the same medications for another week Change the clarithromycin to levofloxacin and continue for one more week
The correct answer is to change the amoxicillin to metronidazole and continue for one more week. This patient has had first-line treatment for Helicobacter pylori eradication which has failed to clear her symptoms. She should be further treated as Helicobacter pylori is commonly resistant. NICE advises to change between clarithromycin and metronidazole; whichever has not been used should be tried in combination. As this patient has had one week of treatment which included clarithromycin she should have treatment with metronidazole as second line treatment. NICE guidelines are described below.
FIrst-line treatment over seven days:
If no allergies: PPI, amoxicillin and clarithromycin or metronidazole
If penicillin allergic: PPI, clarithromycin and metronidazole
If penicillin allergic and previous clarithromycin exposure: PPI, bismuth, metronidazole and tetracycline
Second-line treatment over seven days:
If no allergies: PPI, amoxicillin and clarithromycin or metronidazole (whichever was not used as first-line treatment)
If penicillin allergic: PPI, metronidazole and levofloxacin
If penicillin allergic and previous quinolone exposure: PPI, bismuth, metronidazole and tetracycline
Source:
‘Gastro-oesophageal Reflux Disease and Dyspepsia in Adults: Investigation and Management.’ Clinical Guideline [CG184]. The National Institute for Health and Care Excellence, Nov. 2014.
Tests for H. Pylori
UREA BREATH TEST= Most accurate
Sensitivity 95-98%, Specificity 97-98%
- Patients consume a drink containing carbon isotope 13(13c) enriched urea
- Urea is broken down by H.Pylori urease
- After 30 mins, patients exhale into glass tube and mass spec calculates amount of 13cC02
NB: Should not be performed within 4w of Abx treatment or 2w of PPI - has to be 4w after treatment
RAPID UREASE TEST
Sensitivity 90-95%, Specificity 95-98%
- Biopsy sample, mixed w urea and pH indicator
- Colour change if H.Pylori urease activity
SERUM ANTIBODY
Sensitivity 85%, Specificity 100%
- Remains +ve after eradication
CULTURE OF GASTRIC BIOPSY
Sensitivity 70%, Specificity 95-99%
- Provide info on antibiotic sensitivity
CULTURE OF GASTRIC BIOPSY
Sensitivity 70%, Specificity 95-99%
- Histological evaluation alone, no culture
STOOL ANTIGEN TEST
Sensitivity 90%, Specificity 95%
NB If symptomatic after initial H.Pylori eradication treatment, experts recommend RE-TESTING before 2nd line treatment (is this true?)
GORD Ix
Poor correlation between Sx and Endoscopy appearance
Indications for Upper GI Endoscopy
- age > 55
- Sx > 4 weeks or persistent Sx despite treatment
- Dysphagia
- Relapsing Sx
- Weight loss
If endoscopy is negative consider 24h oesophageal pH monitoring = Gold Standard Test for diagnosis
Posteriorly Sited Duodenal Ulcer
Can invade the Gastroduodenal artery and present with MAJOR BLEEDING
H.Pylori - Eradication
Helicobacter pylori (H. pylori) is a gram negative bacteria which is commonly found in the stomach lining. Infection has been associated with gastritis, gastric ulceration and duodenitis. At OGD a CLO (Campylobacter-Like Organism) test is performed to detect H. pylori using a biopsy sample of gastric mucosa, and a reagent that acts as a pH indicator.
If H. pylori infection is confirmed then eradication is needed to prevent further damage and ulceration of the gastric and duodenal mucosa. The standard first line treatment for someone who has not received eradication therapy before is one week of ‘triple therapy’ with a PPI, amoxicillin and clarithromycin. If a patient is allergic to penicillin then metronidazole is a good substitute.
NICE advises an eradication strategy, which should take allergies and recent antibiotic use into account.
FIrst-line treatment over seven days:
If no allergies: PPI, amoxicillin and clarithromycin or metronidazole
If penicillin allergic: PPI, clarithromycin and metronidazole
If penicillin allergic and previous clarithromycin exposure: PP, bismuth, metronidazole and tetracycline
Second-line treatment over seven days:
If no allergies: PPI, amoxicillin and clarithromycin or metronidazole (whichever was not used as first-line treatment)
If penicillin allergic: PPI, metronidazole and levofloxacin
If penicillin allergic and previous quinolone exposure: PPI, bismuth, metronidazole and tetracycline
First and Second Line Treatments for H.Pylori
FIrst-line treatment over seven days:
If no allergies: PPI, amoxicillin and clarithromycin or metronidazole
If penicillin allergic: PPI, clarithromycin and metronidazole
If penicillin allergic and previous clarithromycin exposure: PP, bismuth, metronidazole and tetracycline
Second-line treatment over seven days:
If no allergies: PPI, amoxicillin and clarithromycin or metronidazole (whichever was not used as first-line treatment)
If penicillin allergic: PPI, metronidazole and levofloxacin
If penicillin allergic and previous quinolone exposure: PPI, bismuth, metronidazole and tetracycline
