Helicobacter pylori Gastritis

Essentials of Diagnosis

• Helicobacter pylori is a spiral gram-negative rod that causes gastric mucosal inflammation

General Considerations

• Acute infection causes a transient illness of nausea and abdominal pain for several days associated with acute histologic gastritis with polymorphonuclear neutrophils (PMNs)

• After these symptoms resolve, the majority progress to chronic infection with chronic, diffuse mucosal inflammation characterized by PMNs and lymphocytes

• Eradication achieved with antibiotics in > 85% leads to resolution of the chronic gastritis

• Majority of those with chronic infection are asymptomatic and suffer no sequelae

• Patients with inflammation that predominates in the gastric antrum but spares the gastric body (where acid is secreted) have

  • Increased gastrin

  • Increased acid production

  • Increased risk of developing peptic ulcers, especially duodenal ulcers

• Long-term treatment with proton pump inhibitors can potentiate the development of H pylori-associated atrophic gastritis

• Chronic H pylori gastritis leads to the development of

  • Duodenal or gastric ulcers up to 10%

  • Gastric cancer in 0.1-3%

  • Low-grade B cell gastric lymphoma (mucosa-associated lymphoid tissue lymphoma; MALToma) in < 0.01%

Demographics

• Infection usually acquired in childhood through person-to-person spread

• In the United States, the prevalence of infection is < 10% in nonimmigrants younger than 30 years to > 50% in those older than 60 years

• Prevalence is higher in nonwhites and immigrants from developing countries

Symptoms and Signs

• Acute infection: transient epigastric pain, nausea, vomiting

• Chronic infection

  • Usually asymptomatic

  • Symptoms arise in patients in whom peptic ulcer disease or gastric cancer develops

  • Controversial whether chronic infection may cause dyspepsia

Differential Diagnosis

• Peptic ulcer disease

• Functional dyspepsia

• Gastroesophageal reflux disease or hiatal hernia

• Biliary disease or pancreatitis

• Gastric or pancreatic cancer

• Viral gastroenteritis

• "Indigestion" from overeating, high-fat foods, coffee

• Angina pectoris

Laboratory Tests

Noninvasive testing for H pylori

• Serologic tests no longer endorsed because they are less accurate than other noninvasive tests

• Fecal antigen immunoassay and ¹³C-urea breath tests

  • Have sensitivity and specificity of > 90–95%

  • Positive test indicates active infection

  • Although more expensive than serology, they may be more cost-effective because they reduce unnecessary treatment in patients without active infection

• Laboratory-based serologic ELISA test has overall accuracy of 80%

• Proton pump inhibitors significantly reduce the sensitivity of urea breath tests and fecal antigen assays (but not serologic tests) and should be discontinued 7–14 days prior to testing

Endoscopic testing for H pylori

• Gastric biopsy specimens can be obtained for histology and detection of H pylori with a sensitivity and specificity of > 95%

Diagnostic Procedures

• Upper endoscopy with biopsy for urease production and/or histology is diagnostic

• In patients under age 60 years with dyspepsia without signs of complications (dysphagia, weight loss, vomiting, anemia), noninvasive testing and empiric treating for H pylori are recommended

• In patients over age 60 years with chronic dyspepsia or patients of any age with signs of complications (dysphagia, weight loss, vomiting, anemia), endoscopy is recommended to exclude other organic disease

Medications

• Treat with anti–H pylori regimen for 10–14 days with one of the following

  • Triple-therapy: proton pump inhibitor: omeprazole, 20 mg twice daily orally; lansoprazole, 30 mg twice daily orally; rabeprazole, 20 mg twice daily orally; pantoprazole, 40 mg twice daily orally; or esomeprazole, 40 mg once daily orally; plus clarithromycin, 500 mg twice daily orally and amoxicillin, 1 g twice daily orally or metronidazole, 500 mg twice daily orally (in penicillin-allergic patients)

  • Quadruple-therapy: proton pump inhibitor: omeprazole, 20 mg twice daily orally; lansoprazole, 30 mg twice daily orally; rabeprazole, 20 mg twice daily orally; or pantoprazole, 40 mg twice daily orally; plus bismuth subsalicylate two tablets four times daily orally, plus tetracycline, 500 mg four times daily orally plus metronidazole, 250 mg four times daily orally

  • Quadruple therapy is recommended for patients who did not respond to initial attempt at eradication with triple-therapy

• Proton pump inhibitors should be administered before meals

• Avoid metronidazole regimens in areas of known high resistance or in patients who did not respond to a course of treatment that included metronidazole

Follow-Up

• After antibiotic therapy, routine follow-up not recommended

• In patients with history of peptic ulcer disease with complications (bleeding) successful eradication should be confirmed with urea breath test or fecal antigen test

Prognosis

• All recommended treatment regimens achieve > 85% eradication

• Eradication decreases the risk of gastric cancer in patients with peptic ulcer disease

• Risk of reinfection with H pylori is only 1%/year

When to Refer

• Patients with persistent infection after one or two attempts at treatment should be referred to a gastroenterologist or infectious disease specialist

When to Admit

• Complications of H pylori–associated peptic ulcer disease