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Management of Helicobacter Pylori Infection LINDA N COVER ARTICLE PRACTICAL THERAPEUTICS Management of Helicobacter pylori Infection LINDA N. MEURER, M.D., M.P.H., and DOUGLAS J. BOWER, M.D., Medical College of Wisconsin, Milwaukee, Wisconsin Helicobacter pylori is the cause of most peptic ulcer disease and a primary risk factor for gastric cancer. Eradication of the organism results in ulcer healing and reduces the risk of O A patient infor- ulcer recurrence and complications. Testing and treatment have no clear value in patients mation handout on H. pylori infection, with documented nonulcer dyspepsia; however, a test-and-treat strategy is recommended written by the authors but for patients with undifferentiated dyspepsia who have not undergone endoscopy. In of this article, is pro- the office setting, initial serology testing is practical and affordable, with endoscopy vided on page 1339. reserved for use in patients with alarm symptoms for ulcer complications or cancer, or those who do not respond to treatment. Treatment involves 10- to 14-day multidrug regimens including antibiotics and acid suppressants, combined with education about avoidance of See page 1246 other ulcer-causing factors and the need for close follow-up. Follow-up testing (i.e., urea for definitions of breath or stool antigen test) is recommended for patients who do not respond to therapy strength-of-evidence or those with a history of ulcer complications or cancer. (Am Fam Physician 2002;65:1327- levels contained in 36,1339. Copyright© 2002 American Academy of Family Physicians.) this article. he spiral-shaped, gram-neg- toms in 90 percent of infected persons. ative bacterium Heliocoba- The prevalence of H. pylori infection cater pylori is found in colo- varies geographically and has been nized gastric mucosa or demonstrated to be as high as 52 percent adherent to the epithelial lin- in the United States.4 Factors associated Ting of the stomach. Acute infection, with higher infection rates are increasing acquired most likely by ingestion of the age, African-American or Hispanic race, organism, is most commonly asympto- lower levels of education, and birth in a matic but may be associated with epi- developing country. gastric burning, abdominal distention The pathogenic role of H. pylori in Members of various family or bloating, belching, nausea, flatulence, peptic ulcer disease, both duodenal and practice departments develop and halitosis.1 Virtually all patients gastric, is well recognized—up to 95 per- articles for “Practical Thera- infected with H. pylori who have had cent of patients with duodenal ulcers and peutics.” This article is one in endoscopic biopsies are found to have 80 percent of patients with gastric ulcers a series developed by the 2 5 Department of Family and histologic gastritis. H. pylori infec- are infected. Eradication of the organ- Community Medicine at the tion can lead to ulceration of the gastric ism leads to ulcer healing and a markedly Medical College of Wisconsin, mucosa and duodenum and has been lower incidence of recurrence. The role Milwaukee. Guest editors of found to be strongly associated with the of H. pylori in nonulcer dyspepsia has the series are Linda N. development of epithelial and lym- not been proved and, in most patients, Meurer, M.D., M.P.H., and Douglas J. Bower, M.D. phoid malignancies of the stomach. It eradication is not associated with im- has been classified by the International provement of symptoms.6 Most patients, Agency for Research on Cancer3 as a however, present to the family physician group I carcinogen and a definite cause with undifferentiated dyspepsia, not of gastric cancer in humans. knowing whether an ulcer exists. H. pylori gastritis produces no symp- When to Test and Treat The decision to test for the presence of H. pylori is closely tied to the intention to Treatment of patients with H. pylori infection typically requires a treat, as there is no benefit in identifying multidrug regimen given for 10 to 14 days. the presence of the organism without having a plan to eradicate it.7 In the APRIL 1, 2002 / VOLUME 65, NUMBER 7 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 1327 almost always cures the disease and reduces the TABLE 1 risk for serious complications (e.g., perforation Alarm Signs for Risk of Gastric Cancer or bleeding).9,10 [Evidence level A, meta-analy- or Complicated Ulcer Disease ses/RCTs]. Compared with acid suppression therapy alone, eradication of H. pylori results Older than 45 years Jaundice in a dramatic reduction in recurrence of duo- Rectal bleeding or melena Family history of denal ulcers and gastric ulcers that are not gastric cancer Weight loss of >10 percent related to the use of nonsteroidal anti-inflam- Previous history of of body weight matory drugs (NSAIDs)—12 percent versus Anemia peptic ulcer 95 percent at one year.11 A previously docu- Dysphagia Anorexia/early satiety Abdominal mass mented peptic ulcer in a patient who has never been treated for H. pylori infection is an indi- 7 Information from American Gastroenterological cation for testing and treatment. Association medical position statement: evaluation of dyspepsia. Gastroenterology 1998;114:579-81. NONULCER DYSPEPSIA To date, there is no convincing evidence that empiric eradication of H. pylori in patients with nonulcer dyspepsia improves symptoms. absence of alarm symptoms for cancer or One recent meta-analysis12 showed no im- complicated ulcer disease (Table 1),8 the ap- provement of symptoms with H. pylori eradi- proach to testing in patients with dyspepsia cation, and another13 revealed a statistically (Table 2)7,9-16 can be divided into four clinical significant benefit, but the effect was small, scenarios: (1) known peptic ulcer disease, cur- with one patient cured for every 19 treated rently or previously documented; (2) known (NNT = 19). nonulcer dyspepsia; (3) undifferentiated dys- pepsia, and (4) gastroesophageal reflux dis- UNDIFFERENTIATED DYSPEPSIA ease (GERD). In primary care, the typical patient who presents with dyspepsia will not have had PEPTIC ULCER DISEASE endoscopy performed and, therefore, the The best evidence for the effectiveness of presence of an underlying lesion will be H. pylori eradication exists for the treatment of unknown. Symptom complexes have not H. pylori-associated ulcers. In this case, treat- been shown to predict endoscopic findings, ment of H. pylori infection in patients with ulcers and the high prevalence of dyspeptic symp- toms makes definitive testing of all patients impractical. Several consensus panels have advocated a The Authors test-and-treat strategy in which patients with LINDA N. MEURER, M.D., M.P.H., is associate professor in the Department of Family dyspepsia are tested for the presence of and Community Medicine and director of the academic fellowship in primary care research at the Medical College of Wisconsin, Milwaukee. Dr. Meurer obtained her H. pylori with serology and treated with erad- medical degree from Wayne State University School of Medicine, Detroit, and com- ication therapy if the results are positive.14,15 pleted a residency in family practice at MacNeal Hospital, Berwyn, Ill. This strategy reserves endoscopy for use in DOUGLAS J. BOWER, M.D., is associate professor of family medicine and director of pre- patients with alarm signs or those with per- doctoral education at the Medical College of Wisconsin. Dr. Bower obtained his medical sistent symptoms despite appropriate empiric degree from the University of Wisconsin Medical School, Madison, and completed a res- idency in family practice at the Grand Rapids (Mich.) Family Practice Residency. therapy, and is supported by cost-benefit analysis. One such approach is shown in Fig- Address correspondence to Linda N. Meurer, M.D., M.P.H., Department of Family and Community Medicine, Medical College of Wisconsin, P.O. Box 26509, Milwaukee, WI ure 1.This approach is supported by cost- 53226-0509 (e-mail: [email protected]). Reprints are not available from the authors. benefit analysis.16 1328 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 65, NUMBER 7 / APRIL 1, 2002 H. Pylori TABLE 2 Evaluation for Helicobacter pylori–Related Disease Clinical scenario Recommended test Levels of evidence† and comments Dyspepsia* in patient with alarm Promptly refer to a gastroenterologist A symptoms for cancer or complicated for endoscopy. ulcer (e.g., bleeding, perforation) Known PUD, uncomplicated Serology antibody test; treat if result is A—Best evidence for eradication in presence of positive. documented gastric or duodenal ulcer Dyspepsia in patient with previous Serology antibody test; treat if result is A history of PUD not previously treated positive. with eradication therapy Dyspepsia in patient with PUD previously Stool antigen or urea breath test; if B—Urea breath test should be delayed for four treated for H. pylori positive, treat with regimen different weeks following treatment, as acid from the one previously used; retest suppression can lead to false-positive results. to confirm eradication. Consider endoscopy. Undifferentiated dyspepsia (without Serology antibody test; treat if result is B—Supported by cost-benefit analyses and endoscopy) positive. recent small RCTs Documented nonulcer dyspepsia (after Unnecessary B—RCTs and meta-analyses on this topic are endoscopy) mixed but indicate that few patients benefit from treatment. GERD Unnecessary B—GERD is not associated with H. pylori infection. Asymptomatic with history of Serology antibody test; treat if result C documented PUD not previously is positive. treated with eradication therapy Asymptomatic Screening unnecessary C PUD = peptic ulcer disease; GERD = gastroesophageal reflux disease; RCT = randomized controlled clinical trial. *—Defined as pain or discomfort centered in the upper abdomen and persisting or recurring for more than four weeks. †—Levels of evidence: A = strong evidence, based on good-quality RCTs or meta-analysis of RCTs; B = moderate evidence, based on high-quality cohort studies, case control studies or systematic reviews of observational studies or lower-quality RCT; C = based on consensus or expert opinion.
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