GPAC: Guidelines and Protocols Advisory Committee

Helicobacter pylori Infection Detection - Treatment in Adult Patients

Effective Date: March 1, 2003

Summary | Flow Sheet | Patient Guide | Full Guideline in PDF

Recommendations and Topics

Scope

1. Ulcer-like dyspepsia

2. Previous ulcer disease

3. Current ulcer disease

4. To diagnose infection

5. Testing not indicated

6. Treatment

7. Repeat testing

Rationale

References

Sponsors

Scope

This guideline applies to adults (age 19 and over) and should be read in conjunction with the guideline, Clinical Approach to Adult Patients with Dyspepsia.

RECOMMENDATION 1: Ulcer-like dyspepsia

Adults younger than 50 years who have persistent or recurrent ulcer-like dyspepsia (epigastric pain that is alleviated by eating and that may awaken the patient at night) in the absence of "alarm features" (dysphagia, vomiting, early satiety, anemia, weight loss, etc.) may be tested for H. pylori and treated if tests are positive.

Investigations with upper gastrointestinal endoscopy or barium X-rays should be reserved for those who fail to respond to H. pylori therapy or whose H. pylori test is negative.

Patients 50 years and older, or who have "alarm features", should be investigated according to the guideline, Clinical Approach to Adult Patients with Dyspepsia.

RECOMMENDATION 2: Previous ulcer disease

Individuals who have had an endoscopically or radiographically confirmed duodenal or gastric ulcer within the past five years should be tested for H. pylori infection if previously untreated for H.Pylori.

If test is positive, treat as per Recommendation 6.

RECOMMENDATION 3: Current ulcer disease

Adults with a proven active peptic ulcer should be tested for H. pylori and treated if positive.

RECOMMENDATION 4: To diagnose infection

To diagnose H. pylori infection, the C13 urea breath test is currently recommended in BC because of its sensitivity. Serology is used where the C13 urea breath test is not available. Fecal antigen testing can be used where available.

Urine and saliva antigen testing is no longer recommended.

Gastroscopy for the sole purpose of detecting H. pylori is not cost-effective. However, the added cost of a gastric biopsy is minimal if endoscopy is being undertaken for other indications.

RECOMMENDATION 5: Testing not indicated

Screening of healthy asymptomatic individuals (including close contacts of infected patients) for H. pylori is not indicated.

The value of testing and treating for H. pylori is not proven in the following circumstances:

1. family history of peptic ulcer disease or gastric malignancy
2. gastroesophageal reflux
3. remote partial gastrectomy for gastric cancer
4. chronic NSAID use without evidence of an ulcer

RECOMMENDATION 6: Treatment

For treatment of H. pylori infection, one of the following three regimens is currently recommended, all of which have approximately 80 – 90% efficacy. Ongoing symptoms after an adequate course of therapy are seldom due to persistent H. pylori infection and therefore retesting is not usually indicated.

RECOMMENDATION 7: Repeat testing

Confirmation of eradication of H. pylori is only justified following treatment of a complicated ulcer (i.e., hemorrhage, perforation or gastric outlet obstruction). Confirmation requires gastric biopsy or C13 urea breath test, which should be performed 4 weeks after stopping therapy. Because of persistent antibodies, positive serology does not indicate ongoing infection. If H. pylori persists after treatment, an alternative regimen should be used. PBMT is recommended as the second regimen if not used initially (see Table 2). The risk of re-infection is very low after a completed course of therapy, hence repeat testing is generally unnecessary.

Rationale

Infection with H. pylori is generally a chronic indolent process causing asymptomatic gastritis. H. pylori is the major cause of both duodenal and gastric ulcers. Although NSAIDs are the second leading cause of both types of ulcers and may be copathogenic with H. pylori, the role of testing and treating in this situation is controversial. Eradication of H. pylori reduces the rate of ulcer recurrence from over 90% to less than 10%.

Gastric ulcers are potentially malignant and require endoscopic biopsy. H. pylori is a risk factor for the development of gastric carcinoma and MALT-type gastric lymphoma (Mucosa Associated Lymphoid Tissue). However, the rarity of such malignancies does not justify population screening for H. pylori.

H. pylori does not play a role in gastroesophageal reflux disease. The role of H. pylori in functional or nonulcer dyspepsia (NUD) is controversial as outlined in Clinical Approach to Adult Patients with Dyspepsia.

The association between H. pylori and NUD is weak, but up to 15% of patients may improve after treatment.

Treatment entails certain risks including Clostridium difficile colitis, allergic reactions, gastrointestinal disturbance, and increased antibiotic resistance (including H. pylori).

Biopsy and C13 Urea Breath Test will reliably confirm eradication, but only if the patient has not taken any antibiotics, bismuth containing compounds (e.g., Pepto-Bismol^®) for 4 weeks or proton pump inhibitors for 2 weeks preceding the test. Dyspepsia following treatment of H. pylori is more likely the result of causes other than persistent H. pylori infection (e.g., gastroesophageal reflux or non-ulcer dyspepsia).

References

1. Hunt R, Thomson AB. Canadian Helicobacter pylori consensus conference. Can J Gastroenterol 1998;12:31-41.
2. Hunt RH, Fallone CA, Thomson ABR. Canadian Helicobacter pylori consensus conference update: infections in adults. Can J Gastroenterol 1999;13:213-7.
3. Megraud F. Advantages and disadvantages of current diagnostic tests for the detection of Helicobacter pylori. Scand J Gastroenterol Suppl 1996;215:57-62.
4. Perri F, Manes G, Neri M, Vaira D, Nardone G. Helicobacter pylori antigen stool test and 13C-urea breath test in patients after eradication treatments. Am J Gastroenterol 2002;97:2756-62.
5. Sadowski DC, Fedorak RN, Bailey RJ, Smith L. Alberta Society of Gastroenterology consensus statement: Helicobacter pylori in peptic ulcer disease. Can J Gastroenterol 1997;11:544-7.
6. Veldhuyzen van Zanten SJ, Cleary C, Talley NJ, Peterson TC, Nyren O, Bradley LA, et al. Drug treatment of functional dyspepsia: a systematic analysis of trial methodology with recommendations for design of future trials. Am J Gastroenterol 1996;91:660-73.
7. Veldhuyzen van Zanten SJ, Sherman PM, Hunt RH. Helicobacter pylori: new developments and treatments. CMAJ 1997;156:1565-74.
8. Versalovic J. Helicobacter pylori: Pathology and diagnostic strategies. Am J Clin Pathol 2003;199: 403-412.

Sponsors

This guideline was developed by the Guidelines and Protocols Advisory Committee, approved by the British Columbia Medical Association and adopted by the Medical Services Commission. Funding for this guideline was provided in full or part through the Primary Health Care Transition Fund.

Revised Date: April 1, 2007

This guideline is based on scientific evidence current as of the effective date.

Disclaimer

The Clinical Practice Guidelines (the "Guidelines") have been developed by the Guidelines and Protocols Advisory Committee on behalf of the Medical Services Commission. The Guidelines are intended to give an understanding of a clinical problem, and outline one or more preferred approaches to the investigation and management of the problem. The Guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problems.

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