H.pylori gastritis guideline recommendation: Difference between revisions

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| colspan="4" |
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* ''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.''
* ''Testing for''[[H. pylori]]''infection is indicated in patients with active [[peptic ulcer disease]], a past history of documented [[peptic ulcer]], or [[MALT lymphoma|gastric MALT lymphoma]].''
|-
|-
| colspan="4" |
| colspan="4" |
* ''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).''
* ''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 gastrointestinal cancer, previous esophagogastric malignancy).''
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{| class="wikitable"
{| class="wikitable"
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|-
|-
|
|
* Active peptic ulcer disease (gastric or duodenal ulcer)
* Active [[peptic ulcer disease]] ([[gastric ulcer|gastric]] or [[duodenal ulcer]])
|-
|-
|
|
* Confirmed history of peptic ulcer disease (not previously treated for ''H. pylori'')
* Confirmed history of [[peptic ulcer disease]] (not previously treated for ''[[H. pylori]]'')
|-
|-
|
|
* Gastric MALT lymphoma (low grade)
* [[MALT lymphoma|Gastric MALT lymphoma]] (low grade)
|-
|-
|
|
* After endoscopic resection of early gastric cancer
* After endoscopic resection of early [[gastric cancer]]
|-
|-
|
|
* Uninvestigated dyspepsia (depending upon ''H. pylori'' prevalence)
* Uninvestigated [[dyspepsia]] (depending upon ''[[H. pylori]]'' prevalence)
|-
|-
|'''Controversial'''
|'''Controversial'''
|-
|-
|
|
* Nonulcer dyspepsia
* Nonulcer [[dyspepsia]]
|-
|-
|
|
* Gastroesophageal reflux disease
* [[Gastroesophageal reflux disease]]
|-
|-
|
|
* Persons using nonsteroidal antiinflammatory drugs
* Persons using nonsteroidal antiinflammatory drugs ([[NSAIDs]])
|-
|-
|
|
* Unexplained iron deficiency anemia
* Unexplained [[iron deficiency anemia]]
|-
|-
|
|
* Populations at higher risk for gastric cancer
* Populations at higher risk for [[gastric cancer]]
|}
|}


===Diagnostic Testing for H.pylori Infection===
===Diagnostic Testing for H.pylori Infection===
*Testing for H.pylori should only be performed if the clinician plans to offer treatemnt for positive results.
*Testing for ''[[H. pylori]]'' should only be performed if the clinician plans to offer treatment for positive results.
*Deciding which test to use in which situation relies heavily upon whether a patient requires evaluation with upper endoscopy and an understanding of the strengths, weaknesses, and costs of the individual tests.
*Deciding which test to use in which situation relies heavily upon whether a patient requires evaluation with upper [[endoscopy]] and an understanding of the strengths, weaknesses, and costs of the individual tests.


{| class="wikitable"
{| class="wikitable"
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!Disadvantages
!Disadvantages
|-
|-
|*1. Histology
|*1. [[Histology]]
|
|
** Excellent sensitivity (>95%) and specificity (95%)
** Excellent sensitivity (>95%) and specificity (95%)
|
|
* Expensive and requires infrastructure and trained personnel
* Expensive and requires infrastructure and trained personnel
* Detection improved by use of special stains- e.g. the Warhin-Starry silver stain, or the cheaper Giemsa staining protocol
* Detection improved by use of special stains- e.g. the [[Warhin-Starry silver stain]], or the cheaper [[giemsa stain|giemsa staning]] protocol
|-
|-
|*2. Rapid urease testing
|*2. Rapid urease testing
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* Sensitivity significantly reduced in the posttreatment setting
* Sensitivity significantly reduced in the posttreatment setting
|-
|-
|*3. Culture
|*3. [[Culture]]
|
|
* Excellent specificity
* Excellent specificity
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* Experience/ expertise required
* Experience/ expertise required
|-
|-
|*4. Polymerase chain reaction
|*4. [[Polymerase chain reaction|Poplymerase chain reaction (PCR)]]
|
|
* Excellent sensitivity and specificity  
* Excellent sensitivity and specificity  
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!Disadvantages
!Disadvantages
|-
|-
|1. ELISA serology (quantitative and qualitative)
|1. [[ELISA|ELISA serology]] (quantitative and qualitative)
|
|
* Inexpensive and widely available
* Inexpensive and widely available
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* Sensitivity (85-92%) and specificity (70-83%)
* Sensitivity (85-92%) and specificity (70-83%)
|
|
* PPV dependent upon background ''H. pylori'' prevalence
* PPV dependent upon background ''[[H. pylori]]'' [[prevalence]]
* Not recommended after ''H. pylori''therapy
* Not recommended after ''[[H. pylori]]''therapy
* Less accurate and does not identify infection
* Less accurate and does not identify [[infection]]
|-
|-
|*2. Urea breath tests (13C and 14C)
|*2. Urea breath tests (13C and 14C)
|
|
* Identifies active ''H. pylori'' infection
* Identifies active ''[[H. pylori]]'' infection
* Excellent PPV and NPV regardless of ''H. pylori'' prevalence
* Excellent PPV and NPV regardless of ''[[H. pylori]]'' [[prevalence]]
* Useful before and after ''H. pylori'' therapy
* Useful before and after ''[[H. pylori]]'' therapy
* Sensitivity (95%) and specificity (96%
* Sensitivity (95%) and specificity (96%
|
|
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|*3. Fecal antigen test
|*3. Fecal antigen test
|
|
* Identifies active ''H. pylori'' infection
* Identifies active ''[[H. pylori]]'' infection
* Excellent positive and negative predictive values regardless of ''H. pylori'' prevalence  
* Excellent positive and negative predictive values regardless of ''[[H. pylori]]'' prevalence  
* Useful before and after ''H. pylori'' therapy
* Useful before and after ''[[H. pylori]]'' therapy
* Sensitivity (95%) and specificity (94%)
* Sensitivity (95%) and specificity (94%)
|
|
* Polyclonal test less well validated than the UBT in the posttreatment setting  
* Polyclonal test less well validated than the urea breath test (UBT)  in the post-treatment setting  
* Monoclonal test appears reliable before and after antibiotic therapy
* Monoclonal test appears reliable before and after [[antibiotic therapy]]
* Unpleasantness associated with collecting stool
* Unpleasantness associated with collecting stool
|-
|-
| colspan="3" |
| colspan="3" |
|-
|-
| colspan="3" |*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
| colspan="3" |*The sensitivity of all endoscopic and nonendoscopic tests that identify active ''[[H. pylori]]'' [[infection]] is reduced by the recent use of [[proton pump inhibitors|PPIs]], bismuth, or antibiotics
PPI = proton pump inhibitor; PPV = positive predictive value; NPV = negative predictive value; UBT = urea breath test.
PPI = proton pump inhibitor; PPV = positive predictive value; NPV = negative predictive value; UBT = urea breath test.
|}
|}
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|-
|-
| colspan="4" |
| colspan="4" |
* ''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.''
* ''In the United States, the recommended primary therapies for''[[H. pylori]]''infection include: a [[proton pump inhibitor|PPI]], [[clarithromycin]], and [[amoxicillin]], or [[metronidazole]] (clarithromycin-based triple therapy) for 14 days or a [[proton pump inhibitor|PPI]] or H2RA, [[bismuth]], [[metronidazole]], and [[tetracycline]] (bismuth quadruple therapy) for 10–14 days.''
|-
|-
| colspan="4" |
| colspan="4" |
* ''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.''
* ''Sequential therapy consisting of a [[proton pump inhibitor|PPI]] and [[amoxicillin]] for 5 days followed by a [[proton pump inhibitor|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.''
|}
|}
{| class="wikitable"
{| class="wikitable"
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!Comments
!Comments
|-
|-
|Standard dose PPI b.i.d. (esomeprazole is q.d.),
|Standard dose [[proton pump inhibitor|PPI]] b.i.d. ([[esomeprazole]] is q.d.),


clarithromycin 500 mg b.i.d., amoxicillin 1,000 mg b.i.d.
[[clarithromycin]] 500 mg b.i.d., [[amoxicillin]] 1,000 mg b.i.d.
|10–14
|10–14
|70–85%
|70–85%
|Consider in nonpenicillin allergic patients who have not previously received a macrolide
|Consider in non-penicillin allergic patients who have not previously received a [[macrolide]]
|-
|-
|Standard dose PPI b.i.d., clarithromycin 500 mg b.i.d.
|Standard dose [[proton pump inhibitor|PPI]] b.i.d., [[clarithromycin]] 500 mg b.i.d.


metronidazole 500 mg b.i.d.
[[metronidazole]] 500 mg b.i.d.
|10–14
|10–14
|70–85%
|70–85%
|Consider in penicillin allergic patients who have not previously received a macrolide or are unable to tolerate bismuth quadruple therapy
|Consider in [[penicillin]] allergic patients who have not previously received a [[macrolide]] or are unable to tolerate bismuth quadruple therapy
|-
|-
|Bismuth subsalicylate 525 mg p.o. q.i.d. metronidazole
|[[Bismuth subsalicylate]] 525 mg p.o. q.i.d. [[metronidazole]]
250 mg p.o. q.i.d., tetracycline 500 mg p.o. q.i.d.,
250 mg p.o. q.i.d., [[tetracycline]] 500 mg p.o. q.i.d.,


ranitidine 150 mg p.o. b.i.d. or standard dose
[[ranitidine]] 150 mg p.o. b.i.d. or standard dose


PPI q.d. to b.i.d.
[[proton pump inhibitor|PPI]] q.d. to b.i.d.
|10–14
|10–14
|75–90%
|75–90%
|Consider in penicillin allergic patients
|Consider in [[penicillin]] allergic patients
|-
|-
|PPI + amoxicillin 1 g b.i.d. followed by:
|[[proton pump inhibitor|PPI]] + [[amoxicillin]] 1 g b.i.d. followed by:
|5
|5
|>90%
|>90%
|Requires validation in North America
|Requires validation in North America
|-
|-
|PPI, clarithromycin 500 mg, tinidazole 500 mg b.i.d.
|[[proton pump inhibitor|PPI]], [[clarithromycin]] 500 mg, [[tinidazole]] 500 mg b.i.d.
|5
|5
|
|
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| colspan="4" |
| colspan="4" |
|-
|-
| colspan="4" |PPI = proton pump inhibitor; pcn = penicillin; p.o. = orally; q.d. = daily; b.i.d. = twice daily; t.i.d. = three times daily; q.i.d. = four times daily.
| colspan="4" |PPI = [[proton pump inhibitor]]; pcn = [[penicillin]]; p.o. = orally; q.d. = daily; b.i.d. = twice daily; t.i.d. = three times daily; q.i.d. = four times daily.
<nowiki>*</nowiki>Standard dosages for PPIs are as follows:
<nowiki>*</nowiki>Standard dosages for PPIs are as follows:


lansoprazole 30 mg p.o., omeprazole 20 mg p.o., pantoprazole 40 mg p.o., rabeprazole 20 mg p.o., esomeprazole 40 mg p.o.
[[lansoprazole]] 30 mg p.o., [[omeprazole]] 20 mg p.o., [[pantoprazole]] 40 mg p.o., [[rabeprazole]] 20 mg p.o., [[esomeprazole]] 40 mg p.o.


Note: the above recommended treatments are not all FDA approved. The FDA approved regimens are as follows:
Note: the above recommended treatments are not all FDA approved. The FDA approved regimens are as follows:


1. Bismuth 525 mg q.i.d. + metronidazole 250 mg q.i.d. + tetracycline 500 mg q.i.d. × 2 wk + H2RA as directed × 4 wk.
1. [[Bismuth]] 525 mg q.i.d. + [[metronidazole]] 250 mg q.i.d. + [[tetracycline]] 500 mg q.i.d. × 2 wk + [[H2RA]] as directed × 4 wk.


2. Lansoprazole 30 mg b.i.d. + clarithromycin 500 mg b.i.d. + amoxicillin 1 g b.i.d. × 10 days.
2. [[Lansoprazole]] 30 mg b.i.d. + [[clarithromycin]] 500 mg b.i.d. + [[amoxicillin]] 1 g b.i.d. × 10 days.


3. Omeprazole 20 mg b.i.d. + clarithromycin 500 mg b.i.d. + amoxicillin 1 g b.i.d. × 10 days.
3. [[Omeprazole]] 20 mg b.i.d. + [[clarithromycin]] 500 mg b.i.d. + [[amoxicillin]] 1 g b.i.d. × 10 days.


4. esomeprazole 40 mg q.d. + clarithromycin 500 mg b.i.d. + amoxicillin 1 g b.i.d. × 10 days.
4. [[esomeprazole]] 40 mg q.d. + [[clarithromycin]] 500 mg b.i.d. + [[amoxicillin]] 1 g b.i.d. × 10 days.


5. Rabeprazole 20 mg b.i.d. + clarithromycin 500 mg b.i.d. + amoxicillin 1 g b.i.d. × 7 days.
5. [[Rabeprazole]] 20 mg b.i.d. + [[clarithromycin]] 500 mg b.i.d. + amoxicillin 1 g b.i.d. × 7 days.
|}
|}


====Salvage Therapy for Persistent H.pylori Infection====
====Salvage Therapy for Persistent H.pylori Infection====
* In patients with persistent H.pylori infection, every effort should be made to avoid antibiotics that have been previously taken by the patient.
* In patients with persistent ''[[H. pylori]]'' infection, every effort should be made to avoid antibiotics that have been previously taken by the patient.
* Bismuth-based quadruple therapy for 7-14 days is an accepted salvage therapy.
* Bismuth-based quadruple therapy for 7-14 days is an accepted salvage therapy.
* Levofloxacin-based triple therapy for 10 days is another option in patients with persistent infection, which requires validation in the United States.
* [[Levofloxacin]]-based triple therapy for 10 days is another option in patients with persistent infection, which requires validation in the United States.
{| class="wikitable"
{| class="wikitable"
! colspan="4" |Recommendations
! colspan="4" |Recommendations
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|Bismuth quadruple therapy  
|Bismuth quadruple therapy  


PPI q.d. tetracycline, Pepto Bismol, metronidazole q.i.d.
[[proton pump inhibitor|PPI]] q.d. [[tetracycline]], [[Pepto Bismol]], [[metronidazole]] q.i.d.
|7
|7
|68% (95% CI 62–74%)
|68% (95% CI 62–74%)
|Accessible, cheap but high pill count and frequent mild side effects
|Accessible, cheap but high pill count and frequent mild side effects
|-
|-
|Levofloxacin triple therapy
|[[Levofloxacin]] triple therapy
PPI, amoxicillin 1 g b.i.d., levofloxacin 500 mg q.d.
[[PPI]], [[amoxicillin]] 1 g b.i.d., [[levofloxacin]] 500 mg q.d.
|10
|10
|10 87% (95% CI 82–92%)
|10 87% (95% CI 82–92%)
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| colspan="4" |
| colspan="4" |
|-
|-
| colspan="4" |For recommendations regarding rifabutin and furazolidone, please refer to the text.
| colspan="4" |For recommendations regarding [[rifabutin]] and [[furazolidone]], please refer to the text.
PPI = proton pump inhibitor; q.d. = daily; q.i.d. = four times daily; b.i.d. = twice daily.
PPI = proton pump inhibitor; q.d. = daily; q.i.d. = four times daily; b.i.d. = twice daily.
|}
|}

Revision as of 18:44, 23 January 2017

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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
  • The test-and-treat strategy for H. pyloriinfection 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 gastrointestinal cancer, previous esophagogastric malignancy).
Indications for Diagnosis and Treatment of H.pylori Infection
Established
Controversial
  • Persons using nonsteroidal antiinflammatory drugs (NSAIDs)

Diagnostic Testing for H.pylori Infection

  • Testing for H. pylori should only be performed if the clinician plans to offer treatment for positive results.
  • Deciding which test to use in which situation relies heavily upon whether a patient requires evaluation with upper endoscopy and an understanding of the strengths, weaknesses, and costs of the individual tests.
Endoscopic testing Advantages Disadvantages
*1. Histology
    • Excellent sensitivity (>95%) and specificity (95%)
*2. Rapid urease testing
  • Inexpensive and provides rapid results.
  • Excellent specificity (99%) and very good sensitivity (98%) 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 availabl
  • Poor sensitivity if adequate transport media are not available
  • Experience/ expertise required
*4. Poplymerase chain reaction (PCR)
  • Excellent sensitivity and specificity
  • Allows determination of antibiotic sensitivities
  • Methodology not standardized across laboratories and not widely available
  • Considered experimental
Nonendoscopic testing Advantages Disadvantages
1. ELISA serology (quantitative and qualitative)
  • Inexpensive and widely available
  • Very good NPV
  • Sensitivity (85-92%) and specificity (70-83%)
*2. Urea breath tests (13C and 14C)
  • 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
  • Sensitivity (95%) and specificity (94%)
  • Polyclonal test less well validated than the urea breath test (UBT) in the post-treatment 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.

For more information on endoscopic diagnostic studies please click here

For more information on nonendoscopic diagnostic studies please click here

Treatment of H.pylori Infection

Primary Treatment of H.pylori Infection
  • 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.
First-Line Regimens for Helicobacter pylori Eradication
Regimen Duration Eradication Rates Comments
Standard dose PPI b.i.d. (esomeprazole is q.d.),

clarithromycin 500 mg b.i.d., amoxicillin 1,000 mg b.i.d.

10–14 70–85% Consider in non-penicillin allergic patients who have not previously received a macrolide
Standard dose PPI b.i.d., clarithromycin 500 mg b.i.d.

metronidazole 500 mg b.i.d.

10–14 70–85% Consider in penicillin allergic patients who have not previously received a macrolide or are unable to tolerate bismuth quadruple therapy
Bismuth subsalicylate 525 mg p.o. q.i.d. metronidazole

250 mg p.o. q.i.d., tetracycline 500 mg p.o. q.i.d.,

ranitidine 150 mg p.o. b.i.d. or standard dose

PPI q.d. to b.i.d.

10–14 75–90% Consider in penicillin allergic patients
PPI + amoxicillin 1 g b.i.d. followed by: 5 >90% Requires validation in North America
PPI, clarithromycin 500 mg, tinidazole 500 mg b.i.d. 5
PPI = proton pump inhibitor; pcn = penicillin; p.o. = orally; q.d. = daily; b.i.d. = twice daily; t.i.d. = three times daily; q.i.d. = four times daily.

*Standard dosages for PPIs are as follows:

lansoprazole 30 mg p.o., omeprazole 20 mg p.o., pantoprazole 40 mg p.o., rabeprazole 20 mg p.o., esomeprazole 40 mg p.o.

Note: the above recommended treatments are not all FDA approved. The FDA approved regimens are as follows:

1. Bismuth 525 mg q.i.d. + metronidazole 250 mg q.i.d. + tetracycline 500 mg q.i.d. × 2 wk + H2RA as directed × 4 wk.

2. Lansoprazole 30 mg b.i.d. + clarithromycin 500 mg b.i.d. + amoxicillin 1 g b.i.d. × 10 days.

3. Omeprazole 20 mg b.i.d. + clarithromycin 500 mg b.i.d. + amoxicillin 1 g b.i.d. × 10 days.

4. esomeprazole 40 mg q.d. + clarithromycin 500 mg b.i.d. + amoxicillin 1 g b.i.d. × 10 days.

5. Rabeprazole 20 mg b.i.d. + clarithromycin 500 mg b.i.d. + amoxicillin 1 g b.i.d. × 7 days.

Salvage Therapy for Persistent H.pylori Infection

  • In patients with persistent H. pylori infection, every effort should be made to avoid antibiotics that have been previously taken by the patient.
  • Bismuth-based quadruple therapy for 7-14 days is an accepted salvage therapy.
  • Levofloxacin-based triple therapy for 10 days is another option in patients with persistent infection, which requires validation in the United States.
Recommendations
Regimen Duration Eradication Rates Comments
Bismuth quadruple therapy

PPI q.d. tetracycline, Pepto Bismol, metronidazole q.i.d.

7 68% (95% CI 62–74%) Accessible, cheap but high pill count and frequent mild side effects
Levofloxacin triple therapy

PPI, amoxicillin 1 g b.i.d., levofloxacin 500 mg q.d.

10 10 87% (95% CI 82–92%) Requires validation in North America
For recommendations regarding rifabutin and furazolidone, please refer to the text.

PPI = proton pump inhibitor; q.d. = daily; q.i.d. = four times daily; b.i.d. = twice daily.

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