Helicobacter Pylori

From Anvita Health Wiki

Contents 1 Introduction 2 Epidemiology 3 Pathology 4 Genetics 5 Clinical-manifestations 6 Laboratory 7 Complications 8 Management 9 More General Terms 10 Additional Terms 11 Internet Database 12 References

Introduction

• First described in 1983 by Marshall & Warren in relation to histologic gastritis. The first successful therapy for H pylori ( bismuth-based triple therapy for 2 weeks) was described in 1991.
  Response to therapy has been shown for peptic ulcer disease & gastric lymphoma.

Epidemiology

• H. pylori occurs worldwide
• reservoir of its infection & its mode of transmission are unknown
• most infection with H.pylori is acquired during childhood
• prevalence of gastritis associated with H. pylori increases with age

Pathology

• Helicobacter pylori is associated with

• major cause of chronic gastritis in US

• associated with 70-90% of gastric ulcers

• dyspepsia without ulceration
• duodenal ulcer:

• primary etiologic factor in peptic ulcer disease in the US
• associated with 95-99% of duodenal ulcers

• gastric carcinoma
• gastric lymphoma

• host factors

• smoking
• blood type O

• microbial factors

• cytotoxin or vacuolating toxin

• enhanced gastrin reponse to stimulation
• enhanced acid production in response to gastrin
• impaired somatostatin release from gastrin D cells
• inflammatory response to infection
• gastric metaplasia of duodenal bulb
• spontaneous eradication of the organism is rare

Genetics

• genetic variation in the IFNGR1 gene is associated with susceptibility to Helicobacter pylori infection

Clinical-manifestations

• atopic dermatitis
• asthma
• peptic ulcer disease ( PUD)

• only 15% of patients with H. pylori will develop PUD

Laboratory

• serologic testing (sensitivity 88-94%, specificity 74-88%)

• do not use serological testing for proof of cure after treatment
• antibody titers remain elevated > 1 year after successful eradication [3]

• testing based upon urease activity of H. pylori

• carbon-labeled urea breath testing

• sensitivity 90-96%, specificity 88-98%
• may be best test in children
• useful for follow-up testing (proof of cure) [3]

• rapid urease assay ( Clotest)
• specimen obtained during endoscopy
• sensitivity 88-95%, specificity 95-100%

• culture & histologic evaluation of endoscopic biopsies

• sensitivity 80-98%, specificity 98-100%

• stool antigen test HpSA [6,13]

• especially useful for assessment of H pylori eradication after treatment [3]
• sensitivity 94%, specificity 92%

• polymerase chain reaction (not widely available) [3]
• screening & treatment of asymptomatic individuals may benefit some patients [17]
• cost effective for patients with dyspepsia, not related to NSAID use [19]

• * patients should stop proton pump inhibitors 1 week prior to laboratory testing since proton pump inhibitors suppress growth of the organism

Complications

• increased incidence of atrophic gastritis in connection with use of proton pump inhibitor
• increased incidence of gastric adenocarcinoma [21] & lymphoma

• classified as a carcinogen by the ()
• 60-70% of gastric carcinomas causally related to H pylori
• 90% of gastric lymphomas causally related to H pylori
• no association found between H.pylori infection & gastric cancer in women [4]
• preliminary evidence that H pylori eradication will diminish risk of tumor development [8]

• increased incidence of gastric mucosa-associated lymphoid tissue MALT lymphoma - may regress following eradication of H pylori
• increased risk of peptic ulcer in combination with NSAIDs [10,11]

Management

• triple therapy ( Helidac kit, Pylera): 10-14 days [3,22]

• tetracycline 500 mg QID or amoxicillin 500 mg QID
• metronidazole 250 mg TID
• bismuth subsalicylate ( Pepto-Bismol) 2 tablets QID
• add omeprazole 20 mg BID for quadruple therapy (OBMT regimen)* [3,22,24], 80% eradication [24]

• double therapy: 14 days

• clarithromycin ( Biaxin) 500 mg BID or TID or amoxicillin 500 mg QID
• omeprazole ( Prilosec) 40 mg QD

• BMTL regimen: 7 days

• bismuth subsalicylate 2 tablets QID
• metronidazole 250 mg QID
• tetracycline 500 mg QID
• lansoprazole 15 mg QID

• ACL regimen: 10-14 days (82% cure rate) [14,22]

• amoxicillin 1000 mg BID
• clarithromycin 500 mg BID
• lansoprazole 30 mg BID

• AML regimen: 7 days

• amoxicillin 1000 mg BID
• metronidazole 500 mg BID
• lansoprazole 30 mg BID

• CML regimen: 10-14 days

• clarithromycin 500 mg BID
• metronidazole 500 mg BID
• lansoprazole 30 mg BID

• Four-drug therapy: 5 days [12,25] ( concomittant therapy)*

• amoxicillin 1000 mg BID
• metronidazole 400 mg BID
• clarithromycin 250 mg BID
• lanzoprazole 30 mg or ranitidine 300 mg BID

• resistant cases [7]

• rifabutin 300 mg PO QD for 10 days
• amoxicillin 1000 mg PO BID
• pantoprazole 40 mg PO BID or
• levofloxacin 500 mg PO QD [18]
• amoxicillin 1000 mg PO BID
• omeprazole 20 mg PO BID

• pregnant women: erythromycin 500 mg PO BID
• metronidazole resistance (10-50%)

• effects on therapy not known

• treat H pylori before beginning chronic NSAID, cortico- steroid, or anticoagulant [10]
• H pylori eradication does not relieve dyspepsia in the absence of ulcer [14]
• antibiotic resistance

• clarithromycin resistance (10%)
• metronidazole resitance (37%)

• antibiotic treatment may lead to colonization with antibiotic-resistant organisms [15]
• eradication may diminish progression of premalignant gastric lesions [20]
  
• * initial treatments of choice [25]

More General Terms

• Helicobacter

Additional Terms

• Campylobacter-like organism (CLO) test (rapid urease assay, Pylori-Tek, Hp-fast)
• carbon-labeled urea breath testing (BreathTek UBT)
• extranodal marginal zone B-cell lymphoma (low grade B-cell lymphoma of MALT [mucosa associated lymphoid tissue] type, MALToma)
• Helicobacter pylori (H pylori) serology
• Helicobacter pylori (H pylori) stool/tissue antigen assay
• urease

Internet Database

OMIM: 600263

References

1. Clinical Diagnosis & Management by Laboratory Methods, 19th edition, J.B. Henry (ed), W.B. Saunders Co., Philadelphia, PA. 1996, pg 1160
2. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 319-321
3. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15 American College of Physicians, Philadelphia 1998, 2006, 2009
4. Journal Watch 20(16):130, 2000 Yamagata et al 160:1962, 2000
5. Journal Watch 20(17):136-37, 2000
6. Journal Watch 20(16):131, 2000 Braden B et al Pediatrics 106:115, 2000
7. Prescriber's Letter 8(4):21 2001
8. Journal Watch 21(19):151, 2001 Uemura et sl N Engl J Med 345:784, 2001
9. Prescriber's Letter 8(11):65 2001
10. Prescriber's Letter 9(3):16 2002
11. Journal Watch 22(5):35, 2002 Huang J-Q et al, Lancet 359:14, 2002 Chan FKL et al, Lancet 359:9, 2001 Pounder RE, Lancet 359:3, 2001
12. Journal Watch 22(6):45, 2002 Treiber et al, Arch Intern Med 162:153, 2002 (MALCOR study)
13. Journal Watch 22(7):55, 2002 Vairi et al, Ann Intern Med 136:280, 2002
14. Journal Watch 23(21):168, 2003 Veldhuyzen van Zanten S, Fedorak RN, Lambert J, Cohen L, Vanjaka A. Absence of symptomatic benefit of lansoprazole, clarithromycin, and amoxicillin triple therapy in eradication of Helicobacter pylori positive, functional (nonulcer) dyspepsia. Am J Gastroenterol 98:1963, 2003 PMID: [1]
    - Kearney DJ, Liu CF, Crump C, Brousal A. The effect of a Helicobacter pylori treatment strategy on health care expenditures in patients with peptic ulcer disease and dyspepsia. Am J Gastroenterol 98:1952, 2003 PMID: [2]
15. McMahon BJ, Hennessy TW, Bensler JM, Bruden DL, Parkinson AJ, Morris JM, Reasonover AL, Hurlburt DA, Bruce MG, Sacco F, Butler JC. The relationship among previous antimicrobial use, antimicrobial resistance, and treatment outcomes for Helicobacter pylori infections. Ann Intern Med 139:463, 2003 PMID: [3]
    - Sjolund M, Wreiber K, Andersson DI, Blaser MJ, Engstrand L. Long-term persistence of resistant Enterococcus species after antibiotics to eradicate Helicobacter pylori. Ann Intern Med 139:483, 2003 PMID: [4]
16. Journal Watch 25(7):58, 2005 Megraud F; European Paediatric Task Force on Helicobacter pylori. Comparison of non-invasive tests to detect Helicobacter pylori infection in children and adolescents: results of a multicenter European study. J Pediatr. 2005 Feb;146(2):198-203. PMID: [5]
17. Lane JA, Murray LJ, Noble S, Egger M, Harvey IM, Donovan JL, Nair P, Harvey RF. Impact of Helicobacter pylori eradication on dyspepsia, health resource use, and quality of life in the Bristol helicobacter project: randomised controlled trial. BMJ. 2006 Jan 28;332(7535):199-204. Epub 2006 Jan 20. PMID: [6]
    - Delaney BC. Who benefits from Helicobacter pylori eradication? BMJ. 2006 Jan 28;332(7535):187-8. No abstract available. PMID: [7]
18. Prescriber's Letter 13(5): 2006 Levofloxacin for persistent Helicobacter pylori infection Detail-Document#: [8] (subscription needed) [9]
19. Jarbol DE, Kragstrup J, Stovring H, Havelund T, Schaffalitzky de Muckadell OB. Proton pump inhibitor or testing for Helicobacter pylori as the first step for patients presenting with dyspepsia? A cluster-randomized trial. Am J Gastroenterol. 2006 Jun;101(6):1200-8. PMID: [10]
20. You WC, Brown LM, Zhang L, Li JY, Jin ML, Chang YS, Ma JL, Pan KF, Liu WD, Hu Y, Crystal-Mansour S, Pee D, Blot WJ, Fraumeni JF Jr, Xu GW, Gail MH. Randomized double-blind factorial trial of three treatments to reduce the prevalence of precancerous gastric lesions. J Natl Cancer Inst. 2006 Jul 19;98(14):974-83. PMID: [11]
21. Kamangar F et al, Opposing risks of gastric cardia and non cardia gastric adenocarcinomas associated with Helicobacter pylori seropositivity. J Natl Cancer Inst 2006, 98:1445 PMID: [12]
22. Prescriber's Letter 14(6): 2007 H. Pylori Treatment Regimens Detail-Document#: [13] (subscription needed) [14]
    - Prescriber's Letter 14(11): 2007 H. Pylori Treatment Regimens Detail-Document#: [15] (subscription needed) [16]
23. Prescriber's Letter 17(12): 2010 COMMENTARY: H. Pylori Treatment: Is Quadruple Therapy Making a Comeback? CHART: H. Pylori Treatment Regimens GUIDELINES: American College of Gastroenterology Guideline on the Management of Helicobacter pylori Infection Detail-Document#: [17] (subscription needed) [18]
24. Malfertheiner P et al. Helicobacter pylori eradication with a capsule containing bismuth subcitrate potassium, metronidazole, and tetracycline given with omeprazole versus clarithromycin-based triple therapy: A randomised, open-label, non-inferiority, phase 3 trial. Lancet 2011 Feb 22 PMID: [19]
25. Prescriber's Letter 19(2): 2012 COMMENTARY: H. Pylori Treatment: An Update CHART: H. Pylori Treatment Regimens GUIDELINES: American College of Gastroenterology Guideline on the Management of Helicobacter pylori Infection (2007) Detail-Document#: [20] (subscription needed) [21]
26. H. pylori and Peptic Ulcer [22]
27. National Guideline Clearinghouse
    - Management of helicobacter pylori infection. (Singapore) ngc-guideline: [23]

Helicobacter pylori