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Helicobacter pylori Management |
Helicobacter pylori (H. pylori) is a bacterium that infects the surface of the stomach. Helicobacter pylori can cause peptic ulcer disease and non-ulcer dyspepsia. We now recognise Helicobacter pylori as an essential component in the formation of peptic ulcers, as well as a proportion of patients with non-ulcer dyspepsia.
The most common symptom is indigestion. However, having Helicobacter pylori doesn't necessarily mean you will have indigestion, and having indigestion doesn't necessarily mean you have the bacteria. In most people, there are no symptoms. Those who do have symptoms may experience indigestion, abdominal pain, nausea, bloating and burping.
No one is completely sure how it spreads but it passes between individuals and the most likely route is hand to mouth. It runs in families and is more common in spouses but it is not transmitted by sexual intercourse.
In Australia, Helicobacter pylori infection is often acquired in late childhood. By age 30, one in five people have it, and by age 60, almost half the population is affected.
Helicobacter pylori is a gram-negative spiral bacterium. The organism grows on the gastric mucosal surface and has been identified as risk factor for Gastritis, Duodenal ulcer, Gastric ulcer, Cancer of the stomach and Lymphoma of the stomach.
Inflammation of the stomach (gastritis).
At the time of infection, there may be acute symptoms of nausea, vomiting and indigestion. Later, when the inflammation becomes chronic, symptoms may be mild or non-existent. The gastritis usually disappears if the infection is successfully treated. Symptoms secondary to Gastritis may not disappear after treatment for Helicobacter pylori. It is not possible to predict who will respond to therapy. Treatment is usually offered to all because even though symptoms may not improve, eradication of the bacteria may prevent development of ulcers and eliminate one risk factor for stomach cancer.
Duodenal ulcer.
Helicobacter pylori is the major cause of this disease (in more than 90 per cent of cases). Symptoms include indigestion and upper abdominal pain. Occasionally there may be bleeding. Successful treatment of the Helicobacter pylori infection allows the ulcer to heal and usually prevents recurrence so that other treatment is no longer necessary. Eradicating Helicobacter pylori infection will permanently cure duodenal ulcer in more than 90 per cent of people. If the symptoms were due to other co-existing conditions such as acid reflux, they may persist and need continuing therapy with acid-reducing drugs.
Gastric ulcer.
Helicobacter pylori is the main cause of this disease in up to 80 per cent of cases. The other common causes are drugs used for treating arthritis and aspirin. Symptoms are similar to those of duodenal ulcer. Eradicating Helicobacter pylori infection will permanently cure most gastric ulcers. As gastric ulcers can also be due to taking aspirin and anti-inflammatory drugs, eradicating the Helicobacter pylori will not cure ulcers caused by these drugs.
Stomach (gastric) cancer.
Helicobacter pylori is one factor in the development of stomach cancer. Other factors such as family history and diet are also likely to be involved. Even though Helicobacter pylori is common in Australia today, stomach cancer is not. Symptoms may resemble those of ulcer, but there may also be nausea, loss of appetite and weight loss.
Lymphoma.
This is a much less common malignancy of the stomach and
Helicobacter pylori infection is usually present. Symptoms are similar to those of
peptic ulcer. Successful treatment of the Helicobacter pylori infection may cure the lymphoma.
Many doctors support the diagnosis of Helicobacter pylori in patients under the age of 45 years by non-invasive blood tests or breath tests. This view is supported by guidelines developed by an international group of experts meeting in Holland, known as the 'Maastrecht Guidelines'. Gastroscopy (were a flexible tube is passed into the stomach and a sample of stomach taken by a biopsy) is still recommended as the primary investigation in patients older than 45 years. This is to allow detection of very early carcinoma of the stomach at a stage when cure is possible.
A number of studies have confirmed that non-invasive diagnostic tests in patients with dyspepsia under the age of 45 years, can reduce the need for Gastroscopy by 30-50%. The advantage of non-invasive diagnosis is that it is safer less expensive and may have greater sensitivity in patients with low levels of infection.
Patients under the age of 45 years, experiencing dyspepsia, can have a blood test to detect H. pylori antibody. There is a second test called a Urea Breath Test that is mainly of value in demonstrating that treatment has been effective.
Patients over 45 years are encouraged to undergo Endoscopy, to avoid missing detection of early cancers of the stomach.
Detection of serum antibody has a sensitivity and specificity of about 90%, but is an insensitive method for detecting post therapy eradication. It is cheap and is unaffected by concurrent acid suppression therapy. However, a serum antibody test can remain positive for many months or years after successful eradication therapy.
The antibody test is simple blood tests and requires no preparation. Blood can be collected at our pathology collection centre and no booking is required.
The breath test has a high sensitivity and specificity but has a number of practical difficulties, including a requirement to cease some medication for several days, a potential problem of oral contamination with urease-producing bacteria and a problem of unrecognised use of antibiotics (which suppress H. pylori growth). However, currently it is the only available sensitive technique to determine effective eradication of Helicobacter pylori without using endoscopy. The role for the urea breath test is to validate eradication of H. pylori several weeks after completion of therapy.
The Urea Breath Test has some specific preparation requirements and you should always make a booking with the pathology collection centre. If you are taking antibiotics, these will need to be completed four weeks prior to testing. Losec and Zantac and similar medications (known as Proton Pump Inhibitors and H2 Receptor Antagonists) must not be taken in the 10 days prior testing. In the interim, Mylanta, Gaviscon, or QuickEze may be substituted. You will need to fast from midnight on the night before your test appointment.
- You will be asked to rinse your mouth with a mouth wash solution before beginning the procedure.
- You will then be required to breathe into a plastic tube. Your breath will be collected into a clear solution.
- You will then be asked to drink a tasteless solution of a radioactive substance (C14 Urea). You can be reassured that the amount of radioactivity to which you will be exposed is similar to that of a chest x-ray, and this is not dangerous.
- Step 2 will be repeated 20 minutes after finishing the drink.
- You may wish to have light refreshment before leaving the pathology collecting centre.
The principle of the Urea Breath Test is that the Helicobacter pylori bacteria contain an enzyme, which breaks down the special chemical solution that you have swallowed. Carbon dioxide is produced, absorbed from the stomach, passes through the lungs and is expired in the breath. After breathing into a machine, the quantity of gas can be measured and confirms the presence or absence of the Helicobacter pylori bacteria.
You should always book a follow up appointment to discuss treatment options after your tests. Results are usually available in seven days. If the test is positive there is an antibiotic treatment program available on prescription.
There are several ways to treat Helicobacter pylori infection. The two common choices are with bismuth (De-Nol) or potent acid-lowering drugs in combination with two antibiotics (usually metronidazole plus one of several antibiotics such as tetracycline, amoxycillin or clarithromycin).
No one drug is successful in treating Helicobacter pylori infection. Treatment is complex and involves taking all the medications for up to two weeks. The greatest success is achieved with at least three medications (triple therapy).
Side effects occur in one in three people, however, these are usually not severe. They may include some nausea, vomiting, diarrhoea and thrush.
Rarely, a more severe diarrhoea associated with colitis and rectal bleeding may occur. In clinical studies, less than 5 per cent of people withdrew from treatment because they were unable to tolerate side effects. There are fewer side effects with a combination of only two medications but this therapy is less successful.
Adding a potent acid-lowering drug to bismuth triple therapy may reduce the side effects and increase the success. This is known as quadruple therapy.
After treatment, you may need tests to check that the treatment has been successful with a breath test or another gastroscopy. If treatment is unsuccessful, you may need a further course, perhaps using a different combination of drugs or for a longer period.
In Australia, the risk of reinfection with Helicobacter pylori infection is low.
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