1. H PYLORI NEGATIVE ULCER Paul Nacier MD Fellow American College of Physicians Fellow American Gastroenterology Association AMA Member AMHE Member Chief of Endoscopy KJMC, Brooklyn, NY

2. H PYLORI NEGATIVE ULCER  Introduction

3. H PYLORI NEGATIVE ULCER  Introduction  Until 1983, most peptic ulcers were considered “idiopathic”

4. H PYLORI NEGATIVE ULCER  Introduction  Until 1983, most peptic ulcers were considered “idiopathic”  “Ulcer disease is an infectious disease” as proven by Warren and Marshall

5. H PYLORI NEGATIVE ULCER  Introduction  Until 1983, most peptic ulcers were considered “idiopathic”  “Ulcer disease is an infectious disease” as proven by Warren and Marshall  The pendulum is swinging: increase incidence of H Pylori negative ulcer.

6. H PYLORI NEGATIVE ULCER  Incidence

7. H PYLORI NEGATIVE ULCER  Incidence  The frequency is not exactly known but it is rising as the treatment or eradication of H Pylori is more successful.

8. H PYLORI NEGATIVE ULCER  Causes

9. H PYLORI NEGATIVE ULCER  Causes  The more common are false negative H Pylori results such as

10. H PYLORI NEGATIVE ULCER  Causes  The more common are false negative H Pylori results such as Testing while on proton pump inhibitor, or recently on Bismuth or antibiotic

11. H PYLORI NEGATIVE ULCER  Causes  The more common are false negative H Pylori results such as Testing while on proton pump inhibitor, or recently on Bismuth or antibiotic Sampling error from biopsy site

12. H PYLORI NEGATIVE ULCER  Causes  The more common are false negative H Pylori results such as Testing while on proton pump inhibitor, or recently on Bismuth or antibiotic Sampling error from biopsy site Biopsy from a “burn out” atrophic body gastritis with H pylori serology positive and lower serum pepsinogen I level

13. H PYLORI NEGATIVE ULCER  Causes  The more common are false negative H Pylori results such as H Pylori biopsy negative, but histological evidence of past infection or recently treated infection False negative by CHLO test in upper GI bleeding.

14. H PYLORI NEGATIVE ULCER  Causes  And other more common causes are

15. H PYLORI NEGATIVE ULCER  Causes  And other more common causes are NSAID’s prescribed or OTC or surreptitious.

16. H PYLORI NEGATIVE ULCER  Causes  The less common are

17. H PYLORI NEGATIVE ULCER  Causes  The less common are Chron’s disease and other granulomatous conditions

18. H PYLORI NEGATIVE ULCER  Causes  The less common are Chron’s disease and other granulomatous conditions Sarcoidosis

19. H PYLORI NEGATIVE ULCER  Causes  The less common are Chron’s disease and other granulomatous conditions Sarcoidosis Ischemia

20. H PYLORI NEGATIVE ULCER  Causes  The less common are Chron’s disease and other granulomatous conditions Sarcoidosis Ischemia Bile reflux

21. H PYLORI NEGATIVE ULCER  Causes  The less common are Chron’s disease and other granulomatous conditions Sarcoidosis Ischemia Bile reflux ZE syndrome

22. H PYLORI NEGATIVE ULCER  Causes  The less common are Chron’s disease and other granulomatous conditions Sarcoidosis Ischemia Bile reflux ZE syndrome Penetrating carcinoma of the pancreas

23. H PYLORI NEGATIVE ULCER  Causes  The less common are Mastocytosis

24. H PYLORI NEGATIVE ULCER  Causes  The less common are Mastocytosis Helicobacter Helmani

25. H PYLORI NEGATIVE ULCER  Causes  The less common are Mastocytosis Helicobacter Helmani Isolated H Pylori duodenal colonization (older age, diseases of the duodenal mucosa) which needs second look gastroscopy with duodenal biopsy or HPSA stools or urea breath test.

26. H PYLORI NEGATIVE ULCER  Causes  Idiopathic

27. H PYLORI NEGATIVE ULCER  Causes  Idiopathic They are exceedingly rare. It has been noted a higher gastrin level and peak acid output, and a rapid gastric emptying of solid and liquid resulting in a higher exposure of the duodenum to acid, causing mucosal ulceration. (Ke Mccoll, Gut 1993,34,762-8)

28. H PYLORI NEGATIVE ULCER  Clinical Implications and Complications

29. H PYLORI NEGATIVE ULCER  Clinical Implications and Complications  H Pylori negative ulcers can be refractory. “They lack the beneficial effect of H Pylori infection on antisecretory therapy” (James Freston, Alimentary Pharmacology Therapy, vol. 15, issue 2, pages 2-5). More long term therapy

30. H PYLORI NEGATIVE ULCER  Clinical Implications and Complications  Recurrent ulcers, obstruction and perforation. In a 12 month period: 2.5% of recurrence in patients treated for H Pylori compare to 13.4% in H Pylori negative cases

31. H PYLORI NEGATIVE ULCER  Clinical Implications and Complications  More probability of rectal bleeding: 16% of patients admitted for UGI bleeding could be H Pylori negative. (Lawrence Ct, Gastro 128, 2005, 1845-52)

32. H PYLORI NEGATIVE ULCER  Clinical Implications and Complications  In some parts of the world with an incidence of 90% positivity for H Pylori, therapy for ulcer is based on “empirical treatment and eradication without testing”. Such an approach could be subject to change.

33. H PYLORI NEGATIVE ULCER  Management

34. H PYLORI NEGATIVE ULCER  Management  Review causes

35. H PYLORI NEGATIVE ULCER  Management  Review causes  Long term therapy

36. H PYLORI NEGATIVE ULCER  Management  Review causes  Long term therapy  HPSA, C13 UBT test

37. H PYLORI NEGATIVE ULCER  Management  Review causes  Long term therapy  HPSA, C13 UBT test  Second look gastroscopy and duodenal biopsy

38. AMHE 37 th Annual Convention - Montebello, Quebec Wednesday July 28, 2010