Peptic ulcer medical therapy
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Peptic ulcer Microchapters |
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Diagnosis |
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Treatment |
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Surgery |
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Case Studies |
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2017 ACG Guidelines for Peptic Ulcer Disease |
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Guidelines for the Indications to Test for, and to Treat, H. pylori Infection |
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Guidlines for factors that predict the successful eradication when treating H. pylori infection |
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Guidelines to document H. pylori antimicrobial resistance in the North America |
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Guidelines for evaluation and testing of H. pylori antibiotic resistance |
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Guidelines for when to test for treatment success after H. pylori eradication therapy |
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Guidelines for penicillin allergy in patients with H. pylori infection |
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Peptic ulcer medical therapy On the Web |
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American Roentgen Ray Society Images of Peptic ulcer medical therapy |
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Risk calculators and risk factors for Peptic ulcer medical therapy |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Guillermo Rodriguez Nava, M.D. [2]
Overview
- Younger patients with ulcer-like symptoms are often treated with antacids or H2 antagonists before EGD is undertaken.Bismuth compounds may actually reduce or even clear organisms.
- Patients who are taking nonsteroidal anti-inflammatories (NSAIDs) may also be prescribed a prostaglandin analogue (Misoprostol) in order to help prevent peptic ulcers, which may be a side-effect of the NSAIDs.
- When H. pylori infection is present, the most effective treatments are combinations of 2 antibiotics (e.g. Erythromycin,Ampicillin, Amoxicillin, Tetracycline, Metronidazole) and 1 proton pump inhibitor (PPI). An effective combination would be Amoxicillin + Metronidazole + Pantoprazole (a PPI). In the absence of H. pylori, long-term higher dose PPIs are often used.
- Treatment of H. pylori usually leads to clearing of infection, relief of symptoms and eventual healing of ulcers. Recurrence of infection can occur and retreatment may be required, if necessary with other antibiotics. Since the widespread use of PPI's in the 1990s, surgical procedures (like "highly selective vagotomy") for uncomplicated peptic ulcers became obsolete.
Principles of Eradication Therapy for Helicobacter pylori infection
- Indications for diagnosis and treatment:[1]
- Active peptic ulcer disease.
- Confirmed history of peptic ulcer disease not previously treated for H. pylori.
- Gastric MALT lymphoma.
- After endoscopic resection of early gastric cancer.
- Uninvestigated dyspepsia (review H. pylori prevalence).
- Low clarithromycin resistance areas (<15%):[2]
- In areas of low resistance the PPI-clarithromycin-containing triple therapy is recommended as the first-line treatment as well as bismuth-containing quadruple therapy.
- In areas of low resistance after failure of a PPI-clarithromycin-containing treatment, either a bismuth-containing quadruple therapy or levofloxacin-containing triple therapy is recommended.
- High clarithromycin resistance areas (≥15%):[2]
- In areas of high resistance, bismuth-containing quadruple therapy is the first-line treatment of choice.
- Levofloxacin containing triple therapy is recommended in areas of high resistance after failure of bismuth containing quadruple therapy.
- After failure of second-line treatment, antimicrobial susceptibility testing should guide the antibiotic therapy.[2]
- FDA approved first line regimens duration:[1]
- Triple therapy: 7 days (10 days if rabeprazole).
- Quadruple therapy: 4 weeks.
- Confirmation tests to document eradication of H. pylori infection should be performed in patients who have had an H. pylori-associated ulcer or gastric MALT lymphoma or who have undergone resection for early gastric cancer.[3]
- The most reliable nonendoscopic test to demonstrate eradication of H. pylori infection is the urea breathing test is.[1]
- Testing to prove H. pylori eradication is most accurate if performed 4 weeks after the completion of the therapy.[3]
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† There is a reported prevalence of 15% in the Northeast of the US.
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Helicobacter pylori Eradication Therapies
▸ Click on the following categories to expand treatment regimens.[1][8][9][3][10][11]
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First line ▸ Triple therapy ▸ Quadruple therapy Second line ▸ Triple therapy ▸ Sequential therapy ▸ Hybrid therapy Third line therapy (Rescue therapy) ▸ Rifabutin based |
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References
- ↑ 1.0 1.1 1.2 1.3 Chey WD, Wong BC, Practice Parameters Committee of the American College of Gastroenterology (2007). "American College of Gastroenterology guideline on the management of Helicobacter pylori infection". Am J Gastroenterol. 102 (8): 1808–25. doi:10.1111/j.1572-0241.2007.01393.x. PMID 17608775.
- ↑ 2.0 2.1 2.2 Malfertheiner P, Megraud F, O'Morain CA, Atherton J, Axon AT, Bazzoli F; et al. (2012). "Management of Helicobacter pylori infection--the Maastricht IV/ Florence Consensus Report". Gut. 61 (5): 646–64. doi:10.1136/gutjnl-2012-302084. PMID 22491499.
- ↑ 3.0 3.1 3.2 McColl KE (2010). "Clinical practice. Helicobacter pylori infection". N Engl J Med. 362 (17): 1597–604. doi:10.1056/NEJMcp1001110. PMID 20427808.
- ↑ 4.0 4.1 Mégraud F (2004). "H pylori antibiotic resistance: prevalence, importance, and advances in testing". Gut. 53 (9): 1374–84. doi:10.1136/gut.2003.022111. PMC 1774187. PMID 15306603.
- ↑ 5.0 5.1 Duck WM, Sobel J, Pruckler JM, Song Q, Swerdlow D, Friedman C; et al. (2004). "Antimicrobial resistance incidence and risk factors among Helicobacter pylori-infected persons, United States". Emerg Infect Dis. 10 (6): 1088–94. doi:10.3201/eid1006.030744. PMC 3323181. PMID 15207062.
- ↑ 6.0 6.1 De Francesco V, Giorgio F, Hassan C, Manes G, Vannella L, Panella C; et al. (2010). "Worldwide H. pylori antibiotic resistance: a systematic review". J Gastrointestin Liver Dis. 19 (4): 409–14. PMID 21188333.
- ↑ 7.0 7.1 Boyanova L, Mitov I (2010). "Geographic map and evolution of primary Helicobacter pylori resistance to antibacterial agents". Expert Rev Anti Infect Ther. 8 (1): 59–70. doi:10.1586/eri.09.113. PMID 20014902.
- ↑ Garza-González E, Perez-Perez GI, Maldonado-Garza HJ, Bosques-Padilla FJ (2014). "A review of Helicobacter pylori diagnosis, treatment, and methods to detect eradication". World J Gastroenterol. 20 (6): 1438–49. doi:10.3748/wjg.v20.i6.1438. PMC 3925853. PMID 24587620.
- ↑ O'Connor A, Molina-Infante J, Gisbert JP, O'Morain C (2013). "Treatment of Helicobacter pylori infection 2013". Helicobacter. 18 Suppl 1: 58–65. doi:10.1111/hel.12075. PMID 24011247.
- ↑ Song M, Ang TL (2014). "Second and third line treatment options for Helicobacter pylori eradication". World J Gastroenterol. 20 (6): 1517–28. doi:10.3748/wjg.v20.i6.1517. PMC 3925860. PMID 24587627.
- ↑ Majumdar, Debabrata; Bebb, James; Atherton, John (2007). "Helicobacter pylori infection and peptic ulcers". Medicine. 35 (4): 204–209. doi:10.1016/j.mpmed.2007.01.006. ISSN 1357-3039.