Ulcers and their Cure
This is a summary of these articles:
- 25% of cases of H. Pilori is acquired by adulthood.
- The best test now for diagnosis and determining if it is cured is a
new stool test. It is run on
a 2-3 inch stool frozen and sent to the lab.
- H Pilori relates to stomach cancer and should be treated.
Read these summaries of three medical studies.
Dr. Knapp
Age at Acquisition of Helicobacter pylori Infection:
Malaty HM, El‑Kasabany A, Graham DY, et al
Lancet 359:931‑935, 2002
Helicobacter pylori infection is common worldwide.
The age at which the acquisition rate of H pylori infection is highest was
examined, and the effects of race and sex on the acquisition of the infection
were determined. 224 children
were followed up from 1975 when they were 1 to 3 years of age, to 1995. Eight
percent of the children had H pylori antibodies at 1 to 3 years of age. By 18
to 23 years of age, the prevalence of the infection was 24.5% overall.
Nineteen percent of the 206 participants uninfected at baseline became
infected by 21 to 23 years of age. Overall, the crude incidence rate per year
was 1.4%, ranging from 2.1 % at 4 years of age and 1.5% at the ages of 7years.
The Stool Antigen Test for Detection of Helicobacter
pylori After Eradication Therapy
Vaira D, Vakil N, Menegatti M, et al
Ann Intern Med 136:280‑287, 2002
Patients underwent endoscopy with histologic
assessment, rapid urease test and cutture, urea breath test, and a stool
antigen test at baseline and on day 35 after completing triple eradication
treatment. In addition, the stool antigen test was done on days 3, 7, 15, 21,
28, and.35 after treatment completion. A positive result on stool antigen
testing 7 days after treatment completion identifies patients in whom H pylori
eradication was unsuccessful. Current
guidelines therefore recommend the use of the urea breath test 4 weeks after
completion of therapy to determine whether the organism has truly been
eradicated. The fecal antigen
test is a relatively new noninvasive test for detection of H pylori. The test
detects the presence of infection by measuring the fecal excretion of H pylori
antigens.
Helicobacter Pylorilnfection and the Development of
Gastric Cancer
Uemura N, Okamoto S, Yamamoto S, et al
N Engl J Med345:784‑789, 2001
Many researchers have documented an association
between Helicobacter pylori infection and the development of gastric cancer.
A prospective study included 1526 Japanese patients with duodenal
ulcers, gastric ulcers, gastric hyperplasia, or non-ulcer-related dyspepsia.
Of these patients, 1246 had H pylori infection; 280 did not. Patients were
followed up for a mean 7.8 years. Endoscopy with biopsy was performed at
enrollment and 1 to 3 years later. Gastric
cancer developed in 2.9% of infected patients and in none of the uninfected
patients. Worldwide, gastric cancer is the second most frequent cancer,
and is also the second leading cause of death from cancer. Since the discovery
of Hpylori just 20 years ago, an association between this bacterium and
gastric cancer has been suspected. Whether better anti‑H pylori therapy
will reduce the long‑term risk for gastric cancer remains unknown. Many of these doubts about the link between Hpylori and
gastric cancer can now be put to rest. The question of who should actually
undergo complete H pylori eradication still remains largely unresolved. Most
patients with chronic H pylori infection have no symptoms. Previous studies
have indicated that screening for and treating Hpylori infection to prevent
gastric cancer is potentially cost‑effective if it prevents at least 30%
of cancers attributable to H pylori. Evidence is rapidly accumulating that
anti‑H pylori therapy is effective, and gastric cancer may in the future
be viewed, like colon cancer, as largely preventable.
Also be aware that H pylori infection can trigger
apparently unrelated problems. For example, some think that H pylori is a
causal factor in various dermatologic disorders. Wedi et al have shown that
Helicobacter infection can be a causal factor for such diverse dermatologic
disorders as rosacea, urticaria, angioneurotic edema, and atopic dermatitiS.2
Recently, investigators in Budapest studied 65 patients with hereditary
angioneurotic edema and found that approximately one-third had H pylori
infection. When this was eradicated, the episodes of periodic edema were
virtually eliminated in the majority of treated subjects.
This is an interesting link between the gastrointestinal tract and the
skin. You may recall that President Clinton had rosacea, which somewhat
miraculous disappeared during his presidency. One wonders if someone slipped
him a little ampicillin and Pepto-Bismol.
R. Knapp MD
Article from the CDC:
CDC
Fact Sheet for Health Care Providers Updated: July 1998
What is H. pylori?
Helicobacter pylori (H. pylori) is a spiral-shaped bacterium that is found in the
gastric mucous layer or adherent to the epithelial lining of the stomach. H pylori
causes more than 90% of duodenal ulcers and up to 80% of gastric ulcers.
Before 1982, when this bacterium was discovered, spicy food, acid, stress, and
lifestyle were considered the major causes of ulcers. The majority of patients were given
long-term medications, such as H2 blockers, and more recently, proton pump inhibitors,
without a chance for permanent cure. These medications relieve ulcer-related symptoms,
heal gastric mucosal inflammation, and may heal the ulcer, but they do NOT treat the
infection. When acid suppression is removed, the majority of ulcers, particularly those
caused by H pylori, recur. Since we now know that most ulcers are caused by H pylori,
appropriate antibiotic regimens can successfully eradicate the infection in most patients,
with complete resolution of mucosal inflammation and a minimal chance for recurrence of
ulcers.
How common is H. pylori infection?
Approximately two-thirds of the world's population is infected with H. pylori.
In the United States, H. pylori is more prevalent among older adults, African
Americans, Hispanics, and lower socioeconomic groups.
What illnesses does H. pylori cause?
Most persons who are infected with H pylori never suffer any symptoms related to
the infection; however, H. pylori causes chronic active, chronic persistent, and
atrophic gastritis in adults and children. Infection with H. pylori also causes
duodenal and gastric ulcers.
Infected persons have a 2- to 6-fold increased risk of developing gastric cancer and
mucosal associated-lymphoid-type (MALT) lymphoma compared with their uninfected
counterparts. The role of H. pylori in non-ulcer dyspepsia remains unclear.
What are the symptoms of ulcers?
Approximately 25 million Americans suffer from peptic ulcer disease at some point in
their lifetime. Each year there are 500,000 to 850,000 new cases of peptic ulcer disease
and more than one million ulcer-related hospitalizations.
The most common ulcer symptom is gnawing or burning pain in the epigastrium. This pain
typically occurs when the stomach is empty, between meals and in the early morning hours,
but it can also occur at other times. It may last from minutes to hours and may be
relieved by eating or by taking antacids.
Less common ulcer symptoms include nausea, vomiting, and loss of appetite. Bleeding can
also occur; prolonged bleeding may cause anemia leading to weakness and fatigue. If
bleeding is heavy, hematemesis, hematochezia, or melena may occur.
Who should be tested and treated for H. pylori ?
Persons with active gastric or duodenal ulcers or documented history of ulcers should
be tested for H. pylori, and if found to be infected, they should be treated. To
date, there has been no conclusive evidence that treatment of H. pylori infection
in patients with non-ulcer dyspepsia is warranted.
Testing for and treatment of H pylori infection are recommended following
resection of early gastric cancer and for low-grade gastric MALT lymphoma. Retesting after
treatment may be prudent for patients with bleeding or otherwise complicated peptic ulcer
disease.
Treatment recommendations for children have not been formulated. Pediatric patients who
require extensive diagnostic work-ups for abdominal symptoms should be evaluated by a
specialist.
How is H. pylori infection diagnosed?
Several methods may be used to diagnose H pylori infection. Serological tests
that measure specific H pylori IgG antibodies can determine if a person has been
infected. The sensitivity and specificity of these assays range from 80% to 95% depending
upon the assay used.
Another diagnostic method is the breath test. In this test, the patient is given either
13C- or 14C-labeled urea to
drink. H pylori metabolizes the urea rapidly, and the labeled carbon is absorbed.
This labeled carbon can then be measured asC02in the patient's expired breath to determine
whether H pylori is present. The sensitivity and specificity of the breath test
ranges from 94% to 98%.
Upper esophagogastroduodenal endoscopy is considered the reference method of diagnosis.
During endoscopy, biopsy specimens of the stomach and duodenum are obtained and the
diagnosis of H. pylori can be made by several methods:
• The biopsy urease test - a colorimetric test based on the ability of H. pylori
to produce urease; it provides rapid testing at the time of biopsy.
• Histologic identification of organisms considered the gold standard of
diagnostic tests.
• Culture of biopsy specimens for H pylori, which requires an experienced
laboratory and is necessary when antimicrobial susceptibility testing is desired.
(Now a new stool test for the germ.)
What are the treatment regimens used for H. pylori eradication?
Therapy for H pylori infection consists of 10 days to 2 weeks of one or two
effective antibiotics, such as amoxicillin, tetracycline (not to be used for children <
12 yrs.), metronidazole, or clarithromycin, plus either ranitidine bismuth citrate,
bismuth subsalicylate, or a proton pump inhibitor. Acid suppression by the H2blocker or
proton pump inhibitor in conjunction with the antibiotics helps alleviate ulcer-related
symptoms (i.e., abdominal pain, nausea), helps heal gastric mucosal inflammation, and may
enhance efficacy of the antibiotics against H pylori at the gastric mucosal
surface.
Currently, eight H pylori treatment regimens are approved by the Food and Drug
Administration (FDA) (Table 1); however, several other combinations have been used
successfully. Antibiotic resistance and patient noncompliance are the two major reasons
for treatment failure.
Eradication rates of the eight FDA-approved regimens range from 61 % to 94% depending
on the regimen used. Overall, triple therapy regimens have shown better eradication rates
than dual therapy. Longer length of treatment (14 days versus 10 days) results in better
eradication rates.
Are there any long-term consequences of H. pylori infection?
Recent studies have shown an association between long-term infection with H pylori
and the development of gastric cancer. Gastric cancer is the second most common cancer
worldwide; it is most common in countries such as Colombia and China, where H pylori
infects over half the population in early childhood. In the United States, where H pylori
is less common in young people, gastric cancer rates have decreased since the 1930s.
How do people get infected with H. pylori?
It is not known how H pylori is transmitted or why some patients become symptomatic
while others do not. The bacteria are most likely spread from person to person through
fecal-oral or oral-oral routes. Possible environmental reservoirs include contaminated
water sources. latrogenic spread through contaminated endoscopes has been documented but
can be prevented by proper cleaning of equipment.
What can people do to prevent H. pylori infection?
Since the source of H. pylori is not yet known, recommendations for avoiding
infection have not been made. In general, it is always wise for persons to wash hands
thoroughly, to eat food that has been properly prepared, and to drink water from a safe,
clean source.
Table 1. FDA-approved treatment options(as of July 98)
Omeprazole + clarithromycin x 2 wks, then
omeprazole x 2 wks
-OR
Ranitidine bismuth citrate(RBC) + clarithromycin x
2 wks, then RBC x 2 wks
-OR
Bismuth subsalicylate (Pepto Bismol') + metronidazole + tetracycline x 2 wks + H2 receptor antagonist
(Tegamet) therapy as directed x 4 wks
-OR
Lansoprazole + amoxicillin + clarithromycin x 10 days
-OR
Lansoprazole + arnoxicillin x 2 wks**
-OR
Rantidine bismuth citrate + clarithromycin x 2
wks, then RBC x 2 wks
_OR
Omeprazole + clarithromycin + amoxicillin x 10 days
-OR
Lansoprazole + clarithromycin + amoxicillin x 10 days
Or other combinations of the above.
What is the Centers for Disease Control and Prevention (CDC) doing to prevent H. pylori
infection?
CDC, with partners in other government agencies, academic institutions, and industry,
is conducting a national education campaign to inform health care providers and consumers
of the link between H. pylori and stomach and duodenal ulcers. CDC is also working
with partners to study routes of transmission and possible prevention measures, and to
establish an antimicrobial resistance surveillance system to monitor the changes in
resistance among H. pylori strains in the United States.
How can I get more information about H. pylori?
Links for more info:
http://www.aap.org/policy/helicpylori.html
http://www.helico.com/
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