Diseases and Procedures

Helicobacter Pylori

RATIONAL TREATMENT OF HELICOBACTER PYLORI

By Peter G. Mavrelis, M.D.

Upon completion of this article the reader should understand how to:

• Diagnose H. pylori infection when gastroscopy is not indicated
• Treat H. pylori infection with the simplest antibiotic regimen
• Decide if H. pylori follow up testing is indicated

The old adage "no acid, no ulcer" has been modified to "no H. pylori, no recurrence of ulcer disease". This discovery has changed the way we diagnose and treat peptic ulcer disease. The organism H. Pylori is associated and implicated as one of the causal factors in over 90% of duodenal ulcers and in 75% of gastric ulcers. It is also causal for chronic gastritis, and associated with non-ulcer dyspepsia and possibly gastric carcinoma. The infection is one of the most common chronic infections in humans affecting almost half the earth's inhabitants. Its accurate diagnosis and treatment are essential. For those patients where gastroscopy is performed H. Pylori can be diagnosed either with a quick urease detection method that is performed in the endoscopy lab or by histologic biopsy. Both tests are accurate and 90 to 95% sensitive. In the primary care setting, a history of peptic ulcer disease or active peptic disease on UGI should prompt the use of the IgG antibody test for H. Pylori. This blood test costs $70 and is 90% sensitive for current or past infection. In H. pylori seropositive patients with dyspepsia, anti H. pylori therapy is the most cost-effective management strategy.

Only multi-drug (three drug) combination therapies are effective in eradicating H. pylori infection, offering cure rates in the 90% range. The most cost effective approach is to use bismuth tabs 2 q.i.d., metronidazole 250 mg. q.i.d., and tetracycline 500mg. q.i.d. for two full weeks. The cost is $45.00, but poor patient compliance may decrease effectiveness. The same three drugs can be given for just one week with the addition of a proton pump inhibitor added twice daily. This shorter regimen increases the cost by only $50. I personally like the "3-2-1" regimen: three drugs, twice a day for one week {Omeprazole (20mg) or lansoprazole (30mg) b.i.d., clarithromycin (500mg) b.i.d., tetracycline (500mg) b.i.d., and amoxicillin (1 gm) p.o., b.i.d.}. All these treatments eradicate the organism and insure no recurrence of symptoms. This will ultimately be the best cost effective option.

Once treatment is complete, the IgG antibody test will remain positive for several months, so re-testing is not recommended. The urea breath test, which will soon become available is the easiest method to check eradication. Careful questioning of symptoms will also help determine if the problem has resolved. Patients with persistent symptoms should receive gastroscopy and biopsy. If infection persists, retreating is recommended, with two antibiotics, bismuth, and a proton pump inhibitor. The incidence of reinfection is thought to be only 1-2% per year.