Gastroenterology Book

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Helicobacter PyloriAka: H. pylori, Helicobacter Pylori Treatment, H. pylori Managament, Non-NSAID Associated Peptic Ulcer

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  1. Pathophysiology: Helicobacter pylori
    1. Spiral-shaped Gram Negative Bacteria
    2. Colonizes gastric mucosa or epithelial lining
  2. Associated conditions
    1. Dyspepsia
    2. Peptic Ulcer Disease
      1. Duodenal Ulcers: 95% related to H. pylori
      2. Gastric Ulcers: 80% related to H. pylori
    3. Stomach Cancer (epithelial or lymphoid)
      1. IARC considers H. pylori a Group I Carcinogen
  3. Symptoms (Asymptomatic in 90% of cases)
    1. See Dyspepsia
    2. See Peptic Ulcer Disease
  4. Differential Diagnosis
    1. See Dyspepsia Causes
    2. See Medication Causes of Dyspepsia
  5. Labs
    1. See Helicobacter pylori Noninvasive Testing
    2. See Urea Breath Test
    3. See Helicobacter pylori Invasive Testing
  6. Management: General
    1. Do not indiscriminately test and treat H. Pylori
    2. Resistance is increasing markedly
      1. Metronidazole resistance is very common
        1. Resistance overcome by the following measures
          1. Increase acid suppression
          2. Increase Metronidazole dose
          3. Increase therapy duration
      2. Clarithromycin resistance is growing (8-12%)
        1. Resistance can not be overcome
    3. Benefits of treating H. pylori
      1. Significantly drops ulcer recurrence, rebleeding risk
      2. Improves symptoms in Nonulcer Dyspepsia (variable)
      3. Unclear evidence for Gastric Cancer prevention
      4. No evidence for benefit in GERD
    4. Test for H. pylori before treatment
      1. See Helicobacter pylori Noninvasive Testing
    5. Test after treatment if persistant symptoms
      1. Urea Breath Test
      2. H. pylori Stool Antigen (HpSA)
      3. Endoscopic Biopsy for H. pylori
    6. Protocol pearls
      1. Treatment duration: usually 7 to 14 days
      2. Use at least 3 agents (do not use 2 agent regimens)
      3. If failed therapy - see resistant cases below
  7. Protocols: Adults Long
    1. LAC Protocol (82-90% efficacy)
      1. Treat for 10-14 days
      2. Lansoprazole (Prevacid) 30 mg PO bid
        1. May substitute Omeprazole (Prilosec) 20 mg PO bid
      3. Amoxicillin 1000 mg bid
        1. May substitute Metronidazole (Flagyl) 500 mg PO bid
      4. Clarithromycin (Biaxin) 500 mg PO bid
    2. Quadruple Therapy (up to 98% efficacy)
      1. Treat for 14 days
      2. Metronidazole (Flagyl) 250 mg PO qid
      3. Tetracycline 500 mg PO qid
      4. Bismuth subcitrate (Pepto-Bismol) 525 mg PO qid
      5. Ranitidine (Zantac) 300 mg PO qd for 6 weeks
        1. May substitute Proton Pump Inhibitor for 14 days
        2. Continue Ranitidine for additional 14 days alone
    3. Modified Quadruple Therapy (80-86% efficacy)
      1. Treat for 14 days
      2. Ranitidine bismuth citrate (Tritec) 400 mg PO bid
      3. Clarithromycin (Biaxin) 500 mg bid
        1. May substitute Metronidazole (Flagyl) 500 mg PO bid
      4. Tetracycline 500 mg PO bid
        1. May substitute Amoxicillin 1000 mg bid
    4. Triple Therapy (80-86% efficacy)
      1. Treat for 14 days
      2. Omeprazole (Prilosec) 20 mg PO bid
      3. Amoxicillin 1 gram po bid
      4. Clarithromycin (Biaxin) 500 mg PO bid
  8. Protocols: Adults Short
    1. Single day regimen (95% efficacy)
      1. Treat qid for 1 day with all four drugs
      2. Bismuth Subsalicylate 262 mg, 2 tabs PO qid
      3. Metronidazole (Flagyl) 500 mg PO qid
      4. Amoxicillin 2 grams suspension PO qid
      5. Lansoprazole 60 mg PO taken only once
      6. Lara (2003) Arch Intern Med 163:2079
    2. PBTM7 Protocol (88% efficacy)
      1. Treat for 7 days
      2. Pantaprazole 40 mg po bid
      3. Bismuth subcitrate (Pepto-Bismol) 2 tabs PO qid
      4. Tetracycline 500 mg PO qid
      5. Metronidazole 200 mg PO tid with 400 mg qhs
    3. Five day regimen (89% efficacy)
      1. Amoxicillin 1 gram twice daily
      2. Metronidazole 400 mg PO bid
      3. Clarithromycin 250 mg PO bid
      4. Lansoprazole 30 mg PO bid or Ranitidine 300 mg PO bid
    4. LAC Protocol: 7 day 90% efficacy)
      1. Treat for 7 days (contrast with above)
      2. Lansoprazole (Prevacid) 30 mg PO bid
        1. May substitute Omeprazole (Prilosec) 20 mg PO bid
      3. Amoxicillin 1000 mg bid
        1. May substitute Metronidazole (Flagyl) 500 mg PO bid
      4. Clarithromycin (Biaxin) 500 mg PO bid
  9. Protocols: Adults Resistant Cases
    1. General for failed therapy
      1. Step Up to 4-5 agent therapy without Metronidazole
      2. Consider adding Rifabutin (Mycobutin)
        1. Qasim (2005) Aliment Pharmacol Ther 21:91
    2. Triple drug therapy for 10 days
      1. Pantoprazole (Protonix)
      2. Amoxicillin
      3. Levofloxacin
    3. Quadruple therapy
      1. See Quadruple therapy above under adults long
  10. Protocols: Children
    1. Treat for 7-14 days
    2. Omeprazole 1 mg/kg/day divided bid (max: 20 mg bid) and
    3. Choose 2 of the following 3 antibiotics:
      1. Amoxicillin 50 mg/kg/day divided bid (max: 1 g bid)
      2. Clarithromycin 15mg/kg/day div bid (max: 500 mg bid)
      3. Metronidazole 20 mg/kg/day div bid (Max: 500 mg bid)
    4. References
      1. Gold (2000) J Pediatr Gastroenterol Nutr 31:490
  11. Management: Consider maintenance antisecretory therapy
    1. Maintenance management: 50% of treatment dose
    2. Indicated in
      1. Complicated Peptic Ulcer Disease
      2. Elderly or frail
  12. References
    1. Ables (2007) Am Fam Physician 75:351
    2. Cohen (2000) Gastroenterol Clin North Am 29(4):775
    3. Meurer (2002) Am Fam Physician 65(7):1327

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