To discuss the epidemiology, pathogenesis, and diagnosis of H. pylori



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To discuss the epidemiology, pathogenesis, and diagnosis of H. pylori

  • To discuss the epidemiology, pathogenesis, and diagnosis of H. pylori

  • To highlight test and treat practice guidelines

  • To compare and contrast clinical trial results between quadruple and triple therapy

  • To review antibiotic treatments



MB is 29 Cambodian and has been in the US for 5 years.

  • MB is 29 Cambodian and has been in the US for 5 years.

  • She lives in the inner city of Los Angeles.

  • History: 1 - month of moderate mid-epigastric, upper abdominal pain.

  • No complaints of gas, darkening stool, or heartburn.

  • Non-smoker, no other medical problems, occasional ibuprofen usage.



Describe the epidemiology of H. pylori.

  • Describe the epidemiology of H. pylori.

  • Review the pathogenesis of H. pylori and associated symptoms.



Estimated 50-60% of the world population is infected

  • Estimated 50-60% of the world population is infected

  • Person to Person Transmission

    • fecal-oral, oral-oral, gastro-oral
  • Increased risk of infection

    • younger age
    • underdeveloped countries
    • lower socioeconomic status




1890’s: Spirochetes in animal stomachs

  • 1890’s: Spirochetes in animal stomachs

  • 1900’s: Spirochetes in human stomachs

  • 1954: No bacteria in gastric biopsies of 1000 patients

  • 1975: Gram negative bacteria in 80% of GU’s (Pseudomonas)

  • 1983: Warren and Marshall characterize H. pylori

  • 2005 Nobel prize in 2005









Demographics – Cambodian, inner city



SH is 34 y/o middle income social worker in Austin, TX.

  • SH is 34 y/o middle income social worker in Austin, TX.

  • Receiving proton pump inhibitor (PPI).

  • 6 - month history of dyspepsia with no improvement in symptoms.

  • Smoker and no family history of GI cancer.

  • Never had endoscopy.



Describe active and passive tests for detection of H. pylori .

  • Describe active and passive tests for detection of H. pylori .

  • Discuss various diagnostic tests for H. pylori .

  • Review practice guidelines and application for test and treat.









Results

  • Results

    • 1/3 antibiotics for H. pylori had no test
    • 1/3 post-treatment PCPs used serologic test
    • 2/3 ages 50 - 64 years underwent endoscopy
    • 1/3 ages 18 - 49 years had an endoscopy within 30 days of their index date
    • 18% GERD patients tested for H. pylori
  • “Substantial noncompliance with guidelines”

  • “Better understanding of test and treat”



High prevalence area – Austin.

  • High prevalence area – Austin.

  • Test and treat guidelines apply.

  • PPI therapy false negative on UBT and SAT.

  • Hold PPI 2 weeks prior to UBT and SAT.

  • Wait 1 month post eradication therapy to recheck.







“ The modern treatment of peptic ulcers places emphasis on diet and rest.

  • “ The modern treatment of peptic ulcers places emphasis on diet and rest.

  • The patient is fed a bland diet, and small meals are given at frequent intervals.

  • Milk, cream and protein hydrolysates are often prescribed between meals.

  • Rest is essential. Some gastroenterologist routinely recommend hospitalization for several weeks…..

  • Mild sedatives are frequently beneficial.”







Bismuth subcitrate potassium, metronidazole tetracycline (BMT)

  • Bismuth subcitrate potassium, metronidazole tetracycline (BMT)

    • not bismuth subsalicylate
    • 3-in-1 capsule
  • Four studies with BMT 2-3 capsules QID for 7-10 days ± PPI1-4

  • Up to 93% compliance, >75% medication taken3















In vitro resistance varies with test method

  • In vitro resistance varies with test method

    • 39% (690/1768) E-test
    • 25.7% (317/1234) agar dilution
  • Strategies to combat resistance



Objectives

  • Objectives

    • to assess the efficacy and safety BMT + omeprazole in the eradication of H. pylori
    • to investigate effect of MTZ resistance and disease type (peptic ulcer vs. non-ulcer dyspepsia) on the eradication rates


Methods

  • Methods

    • open label, international multicenter
    • dyspepsia +/- PUD, testing positive for H. pylori by 13C-UBT
    • histology and ⁄ or culture of 5 pre-treatment biopsies
    • 3 BMT QID + OME 20mg BID X 10 days
    • 29 & 57 days post therapy 2 negative 13C-UBT after treatment


DU = duodenal ulcer

  • DU = duodenal ulcer







DU healing with histamine-2 receptor antagonist (H2RA) vs. H2RA based quadruple therapy

  • DU healing with histamine-2 receptor antagonist (H2RA) vs. H2RA based quadruple therapy

  • Bismuth subsalicylate

  • Patients were assessed for H. pylori infection via:

    • 13C UBT
    • serology (IgG)
    • culture
    • histologic evaluation
  • Low eradication rates (81%)







Pylera contains the following in each capsule:

  • Pylera contains the following in each capsule:

    • metronidazole 125 mg
    • tetracycline 125 mg
    • bismuth subcitrate potassium 140 mg
  • 3-in-1 capsule available with these ingredients in the US







Known hypersensitivity or intolerance to:

  • Known hypersensitivity or intolerance to:

    • bismuth subcitrate potassium
    • metronidazole or other nitroimidazoles
    • tetracyclines
    • components of the formulation
  • Renal or hepatic impairment

  • Pregnant and nursing women

  • Pediatric patients







Bismuth: darkening of tongue and/or black stool

  • Bismuth: darkening of tongue and/or black stool

  • Metronidazole: history of blood dyscrasias

  • Tetracycline: candidiasis

  • Avoid tanning booths, use sunscreen

  • Avoid alcohol

  • Missed doses continuing dosing schedule until the medication is gone and do not take double doses

  • If more than 4 doses are missed, the prescriber should be contacted



Tetracycline:

  • Tetracycline:

    • prolonged INR in patients on warfarin
    • reduced absorption with antacids, including calcium, magnesium, aluminum.
    • reduced absorption with iron, zinc, multivitamins
    • concurrent use of may render oral contraceptives less effective and patients should be advised to use a different or additional form of contraception


Metronidazole:

  • Metronidazole:

    • may increase lithium levels
    • Disulfiram reaction with alcohol
    • prolonged INR in patients on warfarin
    • metabolism may be increased by phenytoin or phenobarbital


Most common adverse events

  • Most common adverse events

    • Stool abnormality (15.6%)
    • Diarrhea (8.8%)
    • Dyspepsia (8.8%)
    • Abdominal Pain (8.8%)
    • Nausea (8.2%)
    • Headache (8.2%)
    • Taste perversion (4.8%)
    • Vaginitis (4.1%)




H. pylori is the major cause of DU and it should be eradicated in all patients testing positive

  • H. pylori is the major cause of DU and it should be eradicated in all patients testing positive

  • H. pylori relationship with the development of MALT and gastric cancer

  • As high as 93% (158/170) eradication rate of H. pylori when quadruple therapy is used1

  • Eradication rates vary between triple and quadruple therapies



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