COMMENTARY

Literature Commentary by Dr. John G. Bartlett: Helicobacter pylori Management Guidelines, January 2008

John G. Bartlett, MD

Disclosures

January 23, 2008

Chey WD, Wong BC; Practice Parameters Committee of the American College of Gastroenterology. American College of Gastroenterology Guideline on the Management of Helicobacter pylori Infection. Am J Gastroenterol. 2007;102:1808-1825. These are the guidelines from the American College of Gastroenterology (ACG) for managing infections caused by Helicobacter pylori. The following points are emphasized:

  • Conditions caused by H pylori include peptic ulcer disease, gastric malignancy, and dyspeptic symptoms. These represent the major indications for testing. Controversial areas include: functional dyspepsia, gastroesophageal reflux disease (GERD), patients taking nonsteroidal anti-inflammatory drugs (NSAIDs), iron deficiency anemia, and patients considered at risk for gastric cancer.

  • Diagnostic methods include endoscopic or nonendoscopic methods. The use depends to a large extent on availability, cost, and differences in test performance, including a distinction between tests used to establish the diagnosis vs establishing eradication of the pathogen.

  • Treatment considered "first line" includes a proton-pump inhibitor (PPI), clarithromycin, and amoxicillin. Eradication rates have decreased to 75% to 85% owing in part to a decrease in clarithromycin activity. The 14-day regimens are preferred to the 7-day treatment due to higher rates of eradication. The sequential regimen using a PPI plus amoxicillin for 5 days followed by a PPI plus clarithromycin and tinidazole for 5 days has shown good outcomes in Europe, but has not been tested in the United States. The usual salvage regimen with persistent H pylori is bismuth quadruple therapy.

  • The specific indications for diagnostic studies, types of tests, and FDA-approved regimens are listed below. Recommendations for first-line and salvage treatment are shown in Table 1 and Table 2 .

Definite

  • Peptic ulcer disease (PUD)

  • History of PUD not previously treated for H pylori

  • Gastric mucosa-associated lymphoid tissue (MALT) lymphoma

  • Postendoscopic treatment of early gastric carcinoma

  • Uninvestigated dyspepsia (depending on H pylori prevalence)

Controversial

  • Nonulcer dyspepsia

  • GERD

  • Patients using NSAIDs

  • Unexplained iron deficiency anemia

  • Populations at high risk for gastric carcinoma

Endoscopic tests

  • Histology: sensitivity and specificity > 95%

  • Urease test: rapid, cheap, sensitive (> 95%), but sensitivity reduced posttreatment

  • Culture: specific, permits in vitro sensitivity testing but poor sensitivity, difficult to do, expensive, and often not available

  • Polymerase chain reaction (PCR): sensitive, specific, and permits antibiotic sensitivity testing, but methods not standardized and are considered experimental

Nonendoscopic tests

  • Antibody enzyme-linked immunosorbent assay (ELISA) or latex agglutination (LA): Both can be quantitative. Cheap, readily available, sensitivity 85%, specificity 79%, but antibody persists - not recommended post therapy.

  • Urea breath test (13C or radioactive 14C): Both have sensitivity and specificity > 95% and can be used posttreatment, but availability and reimbursement are variable.

  • Stool antigen: Sensitivity and specificity > 90% before and after treatment

  • Bismuth 525 mg 4 times daily (QID) + metronidazole 250 QID, tetracycline 500 mg QID x 2 weeks + H2-receptor antagonist (H2RA) x 4 weeks

  • Lansoprazole* 30 mg twice daily (twice daily) + clarithromycin 500 mg twice daily + amoxicillin 1 g twice daily x 10 days

*Or substitute omeprazole 20 mg twice daily x 10 days or esomeprazole 40 mg once daily x 10 days or rabeprazole 20 mg twice daily x 7 days

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