1. Helicobacter Pylori The Stranger Among Us

2. Formerly Campylobacter Ulcer link 1982 by Australians J. Robin Warren (Pathologist), and Barry Marshall, MD. Marshall dramatically demonstrated Koch’s postulates by voluntary ingestion. Reportedly took more than two years to clear, trying numerous treatment regimens,. Not accepted as cause of ulcers until 1994.

3. “...certain patterns of relationships were more common in ‘ulcer’ families. Thus the mothers of ulcer patients tended to have psychogenic symptoms, and to be striving, obsessional, and dominant in the home; fathers tended to be steady, unassertive, and passive.” “The description of these families...emphasizes the conflict in duodenal ulcer patients between dependence engendered by a powerful mother and demands of adult roles.” Excerpts from Causes of Peptic Ulcer: a Selective Epidemiological Review by M. Susser, published in the Journal of Chronic Dis- eases, Vol. 20 pp. 435-456, 1967

4. Practice Issues Where does it come from? Is it contagious? How many go undiagnosed? What is the best treatment? How do we know if it worked?

5. Practice Challenges Guidelines vague and variable Specialists often reluctant to manage Patient questions difficult to answer

6. Patient #1 54 y/o female with unexplained anemia (Hgb 9.8) and iron deficiency. EGD: Diffuse gastritis. CloTest pos. Rx: 2 wks Amox/Clairyth/PPI Sx recurred after 6 mos. Breath test positive Rx: 2wks Amox/Metro/PPI Sx recurred after 1 year. Stool antigen negative EGD: CloTest neg., Gastric biopsy positive Rx: 2 wks Doxy/Metro/PPI/Pepto Bismol No recurrence in 2 years

7. Patient #2 32 y/o Ecuadoran male with 2 years unexplained intermittent post-prandial cramps/loose stool. Minimal peptic sx. Hx of acute gastroenteritis after Asado feast in S. America prior to onset of symptoms. Stool antigen pos. Rx: Rx: 2 wks Amox/Clairith/PPI/Pepto

8. Patient #3 62 y/o female with hx of “3 or 4 ulcers,” the first at age 18, with recurrent peptic sx. GI Consult/EGD: Duodenal ulcer. CloTest neg. Rx: PPI - No antibiotic rx by GI. 6 mos later sx recurred. H. Pylori serum antibody pos. (1.4) Rx: Rx: 2 wks Amox/Clairith/PPI/Pepto

9. Health Impact Ulcers: 80-95% DU and 70-80% GU 5-6000 deaths/yr; $6 billion cost 80% of Gastric cancers. 6X risk for carrier. 3-4X risk of NSAID gastropathy. Gastric B-cell Lymphoma (“MALT”) Non-Ulcer Dyspepsia More suspected - vascular/migraine/autoimmune Colon and Pancreatic cancers?

10. Prevalence 66% of world population. 80-90% in third world countries Marked socioeconomic correlation Estimated 50% of Americans over 65

11. 100 80 60 40 20 0 Individuals infected % 01020304050607080 years Age Marshall 1994 Developing countries Western countries 'Carrier state' from childhood infection (before 1945) Rapid acquisition in childhood

12. Transmission Fecal-Oral Oral-Oral/ Dental Plaque/Kissing Environmental reservoirs (water/fish?) Iatrogenic Family contacts Still poorly understood

14. Symptoms Most are asymptomatic Peptic gastroenteropathy Ulcers NSAID sensitivity Acute gastroenteritis Nonspecific gastrocolic complaints

15. Diagnostic tests Stool Antigen/Culture Serum IgG/IgA Antibody 13/14 C-urea breath test (UBT) (Most Sensitive) Biopsy Urease Test (Clotest) Biopsy Microscopy (Gold standard)

17. Treatment of Choice PPI twice daily Amoxicillin 1gm twice daily Clairythromycin 500mg twice daily Pepto-Bismol tablets, 2 four times a day Two weeks preferred 80-90% effective. One week and single dose regimens under study.

18. Treatment Alternatives Metronidazole 500mg BID (increasing Metro resistance) or Tetracycline 500mg QID for Amoxicillin Ranitidine Bismuth Citrate with Amoxicillin and Clairithromycin is first line in Europe and appears as good as PPI regimen. Rifabutin 300mg daily in place of Clairythromycin for treatment failures may be promising.

19. Confirming Cure Breath test still most accurate, but expensive and impractical. Stool antigen after 6 weeks minimum. Beware of antibiotic, PPI or bismuth use within 4 wks of test. Antibody declines 50% in 3 months with cure, and is undetectable in 60% after 18 months. EGD/Bx for culture if two failures suggest antibiotic resistance.

20. Take Home Points Testing is too insensitive - often need multiple tests, such as stool antigen, serum antibody and/or endoscopic screening to make Dx. Don’t accept negative results from a single-test when suspicion is high. Consider primary infection when symptoms persist after acute gastroenteritis Consider NSAID sensitivity a possible indicator of H. Pylori infection Test all ulcer patients Test for cure after treatment.

21. 1.http://www.helico.com/http://www.helico.com/ 2.Helicobacter pylori and Ulcers: a Paradigm Revised by Nancy A. Lynch, Ph.D. @ http://www.faseb.org/opar 3.http://www.gastrosource.com/frameset_GI_NEW.asphttp://www.gastrosource.com/frameset_GI_NEW.asp 4.http://www.utdol.com/security/login/licensehttp://www.utdol.com/security/login/license 5.http://www.cdc.gov/ulcer Bibliography