When Not to Skip H pylori Testing

Matthew F. Watto, MD; Paul N. Williams, MD


August 16, 2022

This transcript has been edited for clarity.

Matthew F. Watto, MD: Welcome back to the Curbsiders. I'm Dr Matthew Watto, here with my great friend, Dr Paul Nelson Williams. Tonight, we're going to be talking about Helicobacter pylori, recapping some great pearls from a recent podcast we did with Dr George Saffouri. Paul, would you start us off? When should we be thinking about H pylori? What sort of symptoms are we looking out for?

Paul N. Williams, MD: This is something that I was never really clear on for years. We talked a little bit about differentiating gastroesophageal reflux disease (GERD) from dyspepsia. I may have tended to lump together all of the upper gastrointestinal (GI) stuff. If you had burning somewhere above the diaphragm, I prescribed a proton pump inhibitor (PPI) and prayed for the best. But Dr Saffouri recommended separating those things out, particularly because you can empirically treat GERD — which is classically heartburn symptoms and regurgitation — with the PPI and feel good about it. But dyspepsia is this epigastric distress or pain after meals, or a sensation of early satiety — basically, discomfort that happens after meals. That is an indication that you actually do H pylori testing, because it's a carcinogen. And if you treat it, you can actually prevent cancer, which is seems important and is in line with what we do as internists.

Watto: Exactly. It's a simple thing, but I had not made that differentiation. I was also lumping GERD and dyspepsia together. But it is a different workup because as you said, GERD is GERD. Those patients can be treated empirically. This speaks to the testing we talked about. You don't want someone on a PPI it before they go for testing. You want them off PPIs for at least a month. And ideally, Paul, they wouldn't be on antibiotics either for at least a month before you're testing for H pylori, because that could lower the yield of your test. So for people under age 60, if they have dyspepsia, then you can send an H pylori breath test or H pylori stool antigen. But Paul, what if they're over 60? How does it differ?

Williams: You don't age out of H pylori testing is basically the point that he made. If the patient is over the age of 60, it's more likely to be malignancy or something else scary. So that's the reason you do upper endoscopy, but you're still going to be doing biopsies for H pylori if you're under the age of 60, when it's statistically less likely to be a malignancy — in which case you can get away with things like the H pylori breath test or stool test. You have to do a little bit of coordination but the tests are otherwise pretty good.

Watto: We have a figure talking about a little bit about the testing.

Dyspepsia or peptic ulcer disease, those would be reasons to test for H pylori. There are two types of cancers. If someone has a low-grade gastric mucosa–associated lymphoid tissue lymphoma (MALToma), you test for H pylori, because if you treat it, it might go away. And then early gastric cancer is another time you should test for H pylori. And then there are some other softer recommendations, like unexplained iron deficiency anemia or immune thrombocytopenia (ITP). There are others, but those are the real strong ones. I would also have a low threshold in a first-generation immigrant from a country where there's a high prevalence of H pylori — you should think about testing them.

I want to ask you about the treatment. What's the big consideration? Our guest made a big point that you always have to retest. Can you talk about why that is?

Williams: He also made the point you're supposed to know the antibiogram for the area in which you practice, and he joked that he had never actually seen his, and I'm not sure I've seen mine — certainly for H pylori. He did not like the triple regimen (clarithromycin, amoxicillin, and PPI) to start with. He basically starts the quadruple regimen that includes bismuth (bismuth + PPI + tetracycline + metronidazole), and then he would use a levofloxacin-based regimen as sort of salvage therapy, or if you needed to use a different regimen. But he almost never started with the traditional triple regimen, if memory serves.

Watto: In the West for right now, the levofloxacin-containing therapies seem to be okay. Elsewhere, depending on where you are in the world, there is some resistance to the fluoroquinolone-containing regimens, but there is a lot of resistance uniformly across the board to the clarithromycin triple therapy. There are some newer therapies coming out, so keep an ear out for those. A new potassium blocker (vonoprazan) has been in the conversation. So please keep an eye out for all those things.

This was a great episode; we talked about so much, but we're going to have to leave it there. Click on H pylori Infection if you want to hear our full podcast with Dr Saffouri. Until next time, this has been another episode of the Curbsiders, bringing you a little knowledge food for your brain hole. I'm Dr Matthew Frank Watto.

Williams: And I'm Dr Paul Nelson Williams. Thank you.

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