H.pylori gastritis guideline recommendation

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Yamuna Kondapally, M.B.B.S[2]

Overview

American collage of gastroenterology guidelines for the management of Helicobacter pylori infection.

ACG recommendations

Diagnosis

Recommendation
Testing for H. pylori infection is indicated in patients with active peptic ulcer disease, a past history of documented peptic ulcer, or gastric MALT lymphoma.
The test-and-treat strategy for H. pylori infection is a proven management strategy for patients with uninvestigated dyspepsia who are under the age of 55 yr and have no “alarm features” (bleeding, anemia, early satiety, unexplained weight loss, progressive dysphagia, odynophagia, recurrent vomiting, family history of GI cancer, previous esophagogastric malignancy).

Indications for Diagnosis and Treatment of H.pylori Infection
Established
Active peptic ulcer disease (gastric or duodenal ulcer)
Confirmed history of peptic ulcer disease (not previously treated for H. pylori)
Gastric MALT lymphoma (low grade)
After endoscopic resection of early gastric cancer
Uninvestigated dyspepsia (depending upon H. pylori prevalence)
Controversial
Nonulcer dyspepsia
Gastroesophageal reflux disease
Persons using nonsteroidal antiinflammatory drugs
Unexplained iron deficiency anemia
Populations at higher risk for gastric cancer

Diagnostic Testing for H.pylori Infection

Endoscopic testing	Advantages	Disadvantages
*1. Histology	Excellent sensitivity and specificity	Expensive and requires infrastructure and trained personnel
*2. Rapid urease testing	Inexpensive and provides rapid results. Excellent specificity and very good sensitivity in properly selected patients	Sensitivity significantly reduced in the posttreatment setting
*3. Culture	Excellent specificity. Allows determination of antibiotic sensitivities	Expensive, difficult to perform, and not widely available. Only marginal sensitivity
*4. Polymerase chain reaction	Excellent sensitivity and specificity. Allows determination of antibiotic sensitivities	Methodology not standardized across laboratories and not widely available
Nonendoscopic testing	Advantages	Disadvantages
1. Antibody testing (quantitative and qualitative)	Inexpensive, widely available, very good NPV	PPV dependent upon background H. pyloriprevalence. Not recommended after H. pyloritherapy
*2. Urea breath tests (13C and 14C)	Identifies active H. pylori infection. Excellent PPV and NPV regardless of H. pylori prevalence. Useful before and after H. pylori therapy	Reimbursement and availability remain inconsistent
*3. Fecal antigen test	Identifies active H. pylori infection. Excellent positive and negative predictive values regardless of H. pylori prevalence. Useful before and after H. pylori therapy	Polyclonal test less well validated than the UBT in the posttreatment setting. Monoclonal test appears reliable before and after antibiotic therapy. Unpleasantness associated with collecting stool
*The sensitivity of all endoscopic and nonendoscopic tests that identify active H. pylori infection is reduced by the recent use of PPIs, bismuth, or antibiotics PPI = proton pump inhibitor; PPV = positive predictive value; NPV = negative predictive value; UBT = urea breath test.

Treatment of H.pylori Infection

Primary Treatment of H.pylori Infection
In the United States, the recommended primary therapies for H. pylori infection include: a PPI, clarithromycin, and amoxicillin, or metronidazole (clarithromycin-based triple therapy) for 14 days or a PPI or H2RA, bismuth, metronidazole, and tetracycline (bismuth quadruple therapy) for 10–14 days.
Sequential therapy consisting of a PPI and amoxicillin for 5 days followed by a PPI, clarithromycin, and tinidazole for an additional 5 days may provide an alternative to clarithromycin-based triple or bismuth quadruple therapy but requires validation within the United States before it can be recommended as a first-line therapy.