Gastric Ulcer due to Helicobacter pylori Hyesim Moon Penn State University

Diagnosis Ulceration of the lining of the mucosa of the stomach caused by Helicobacter pylori (H. pylori) infection. Helicobacter pylori – Gram negative rod bacterium

Pathogenesis

Clinical Manifestations - History Age of onset in 50-70s Family history - usually negative for gastric ulcers but H. pylori clusters often found in families Gender prevalence – equal in women and men Usually asymptomatic related to H.pylori infection Sx related to gastric ulcer: N/V, burping, bloating, loss of appetite, weight loss Pain/discomfort – Intermittent upper abdominal pain Pain-antacid-relief pattern Food-pain pattern

Clinical Manifestations - Physical exam Tender epigastric area on palpation. Patients may feel dyspeptic or abdominal discomfort during an acute episode of gastritis, there are no specific clinical signs that have been described in patients with H pylori infection In some cases, patients may feel hungry in the morning and have halitosis (Santacroce, 2015).

Diagnostic Tests NON-INVASIVE TEST 13C Urea Breath test - Pt. with or without hx of prior peptic ulcer disease H. pylori Stool Antigen (HpSA) - Pt. with or without hx of prior peptic ulcer disease Serology – H. pylori antibody titers Used for pt. with NO hx of prior H. pylori infection INVASIVE TEST Endoscopy – Biopsy and histological study Pt. with or without hx of prior peptic ulcer disease

Differential Diagnosis Stomach perforation – surgical emergency, rigid abdomen, rebound tenderness UGI bleed – melena or hematemesis Gastric Cancer – needs EGD to view the lesion and for histologic exam of the biopsy specimens Gastritis – negative physical exam, consistent burning epigastric pain GERD/Esophagitis - epigastric pain after eating and improves with antacids . Negative physical exams Duodenal Ulcer – pain is nocturnal and occurs after 30 minutes to 2 hours after eating when stomach is empty. Relieved with food or antacid intake.

Treatment Triple therapy Quadruple therapy Sequential therapy

Triple therapy First line treatment of H. pylori Initial treatment if clarithromycin resistance of the area is low ( < 15%) PPI ( lansoprazole 30mg BID, omeprazole 20mg BID, pantoprazole 40mg BID or esomeprazole 40mg daily) Two antibiotics : Clarithromycin 500mg BID + Amoxicillin 1g BID ( Metronidazole 500mg BID if PCN allergy ) For 10 to 14 days

Quadruple therapy For 10 to 14 days if failed triple treatment Initial treatment if clarithromycin or metronidazole resistance of the area is high (> 15%) If pt. had recent treatment of clarithromycin or metronidazole PPI Bismuth subsalicylate (524mg QID) Two antibiotics : metronidazole 250mg QID + tetracycline 500mg QID (if unavailable, doxycycline 100mg BID )

Sequential therapy For 10 to 14 days A 14 day treatment is more effective in areas where clarithromycin resistance is high and metronidazole resistance is low. PPI BID + Amoxicillin 1g BID for 5 days (or 7days) followed by, PPI BID + clarithromycin 500mg BID + metronidazole 500mg BID for 5 days (or 7 days) If Pt. is allergic to PCN or clarithromycin resistance > 15%, then use levofloxacin 250mg BID

Follow-up: - Eradiation Confirmation It is recommended in patients who had H. pylori- associated ulcer. It may be confirmed by a urea breath test, fecal antigen test, or upper endoscopy performed 4 to 12 weeks after completion of therapy Confirmation of eradication should be strongly considered for all patients receiving treatment for H. pylori because of the availability of accurate, relatively inexpensive, noninvasive tests (stool and breath tests) and increasing antibiotic resistance

Patient teaching Compliance with medication Side effects of antibiotics : Mild Amoxillin – diarrhea, skin rash Clarithromycin – metallic taste, nausea, vomiting, abdominal pain, rarely QT prolongation Doxycyline/tetracycline – photosensitivity reaction Levofloxacin - anorexia, nausea, vomiting, and abdominal discomfort, development of C. difficile-associated diarrhea, central nervous system toxicities of levofloxacin including mild headache and dizziness have predominated, followed by insomnia and alterations in mood. Other adverse effects include rashes and other allergic reactions, tendinitis and tendon rupture, QT prolongation, hypoglycemia and hyperglycemia, and hematologic toxicity Metronidazole – metallic taste, peripheral neuropathy, seizures, and a disulfiram-like reaction when taken with alcohol Probiotics – can reduce diarrhea which is a side effect of antibiotics Avoid potential interactions that can worsen GU such as NSAIDs, alcohol, smoking, steroids, aspirin, caffeine intake

Treatment Outcome Varied depending on patient’s compliance and their susceptibility to the particular treatment regimen. Limited evidence suggests that smoking, alcohol, and diet may also adversely affect the likelihood of successful eradication of H. pylori. Consider utilizing a sequential therapy or a quadruple therapy with a PPI in individuals who have previously been treated with clarithromycin or metronidazole: higher rate of eradication with these regimens. The outcomes for H. pylori therapies can be

References Crowe, S. E. (2015, March 12). Indications and diagnostic tests for Helicobacter pylori infection. Retrieved March 14, 2016, from http://www.uptodate.com/contents/indications-and- diagnostic-tests-for-helicobacter-pylori-infection Crowe, S. E. (2016, March 8). Treatment regimens for Helicobacter pylori. Retrieved March 10, 2016, from http://www.uptodate.com/contents/treatment-regimens-for-helicobacter- pylori?source=machineLearning Dains, Joyce E., Linda Ciofu. Baumann, and Pamela Scheibel. Advanced Health Assessment and Clinical Diagnosis in Primary Care. 4th ed. St. Louis: Mosby, 2012. Print. Glass, C. A., & Cash, J. C. (2014). Family Practice Guidelines (3rd ed.). New York, NY: Springer Publishing Company. Goroll, Allan H., and Albert G. Mulley. Primary Care Medicine: Office Evaluation and Management of the Adult Patient. 7th ed. Wolters Kluwer Health, 2014. Print. Jockers, D. (n.d.). The Damaging Effects of H Pylori Infections. Retrieved March 14, 2016, from http://drjockers.com/damaging-effects-h-pylori-infections/ McCance, Kathryn L., and Sue E. Huether. Pathophysiology: The Biologic Basis for Disease in Adults and Children. 7th ed. Maryland Heights, MO: Mosby Elsevier, 2014. Print. Mel & Enid Zuckerman College of Public Health (n.d.). H. Pylori Transmission and Spread of Infection. Retrieved March 14, 2016, from https://publichealth.arizona.edu/outreach/health- literacy-awareness/hpylori/transmission

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