Updated: 1/15/2019

Helicobacter pylori

Topic
Review Topic
0
0
Questions
3
0
0
Evidence
5
0
0
Videos
1
Snapshot
  • A 54-year-old man presents to his primary care physician for an annual checkup. He reports having intermittent epigastric discomfort. He reports that the symptoms often improve after eating and that he has some bloating after big meals. He denies any fevers, chills, nausea or vomiting. He also denies having any blood in his stools. His physical exam is unremarkable. A urea breath test is arranged and the results are positive. He is started on triple therapy for eradication of the infection.
Introduction
  • Classification
    • Helicobacter pylori 
      • gram-negative, spiral-shaped (comma-shaped), catalase-positive, urease-positive, oxidase-positive rod with motile flagella 
      • transmission
        • oral to oral
        • fecal to oral
      • causes chronic gastritis, which can lead to
        • peptic ulcer disease, particularly in the duodenum
        • mucosa-associated lymphoid tissue (MALT) lymphoma
        • gastric adenocarcinoma
  • Epidemiology
    • incidence
      • very common
    • demographics
      • infections are often acquired during childhood
    • risk factors
      • smoking
      • nonsteroidal anti-inflammatory drug (NSAID) use
  • Pathogenesis
    • the bacteria produces urease, which produces ammonia and results in an alkaline environment
      • the ammonia allows the bacteria to survive in the acidic gastric environment
    • the bacteria colonize the antrum of the stomach
    • mucosal inflammation leads to atrophy
    • hypochloridia causes ↑ gastrin
    • ↑ gastrin from G cells in the stomach and duodenum
      • ↑ gastric acid secretion and growth of gastric mucosa
  • Prognosis
    • very good prognosis with treatment
    • recurrence may occur
Presentation
  • Symptoms
    • dyspepsia
      • belching
      • postprandial bloating
      • heartburn
    • epigastric pain
      • may cause nighttime awakening
      • relief with food or antacids
    • fullness
Studies
  • Labs
    • urea breath test
      • administer 13C urea
        • test for ammonia + 13C-CO2 exhaled
      • may have false negatives when patients are exposed to H. pylori treatments such as proton pump inhibitors, histamine-2 (H2) blockers, bismuth, and antibiotics that either reduce bacterial load or are anti-secretory, reducing the amount of urea produced
      • most accurate testing
    • stool antigen test
  • Endoscopy with gastric biopsy
    • histology with silver stain or immunohistochemical staining
      • H. pylori infection
      • inflammation
      • intestinal metaplasia
      • atrophy
  • Making the diagnosis
    • based on clinical presentation and noninvasive tests such as urea breath test or stool antigen test
    • endoscopy can also be used to diagnose
Differential
  • Peptic ulcer disease from other causes
    • distinguishing factors
      • associated with NSAIDs use
      • may also have Zollinger-Ellison syndrome
Treatment
  • Management approach
    • eradication therapy is beneficial for patients with peptic ulcer disease, chronic gastritis,
  • Medical
    • triple therapy
      • indications
        • no history of previous macrolide exposure
        • no local resistance of H. pylori clarithromycin resistance
      • drugs
        • proton pump inhibitor
        • clarithromycin
        • amoxicillin or metronidazole
    • quadruple therapy
      • indication
        • history of macrolide exposure or penicillin allergy
      • drugs
        • proton pump inhibitor
        • bismuth subcitrate
        • metronidazole
        • tetracycline
Complications
  • Malignancies
    • gastric adenocarcinoma
    • MALT lymphoma
  • Iron deficiency anemia
  • Immune thrombocytopenia
 

Please rate topic.

Average 5.0 of 5 Ratings

Thank you for rating! Please vote below and help us build the most advanced adaptive learning platform in medicine

The complexity of this topic is appropriate for?
How important is this topic for board examinations?
How important is this topic for clinical practice?
Questions (3)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
Calculator

(M1.MC.75) A 45-year-old woman has a history of mild epigastric pain, which seems to have gotten worse over the last month. Her pain is most severe several hours after a meal and is somewhat relieved with over-the-counter antacids. The patient denies abnormal tastes in her mouth or radiating pain. She does not take any other over-the-counter medications. She denies bleeding, anemia, or unexplained weight loss, and denies a family history of gastrointestinal malignancy. Which of the following is the best next step in the management of this patient? Review Topic

QID: 106736
1

Urease breath test

42%

(47/112)

2

Empiric proton pump inhibitor therapy

13%

(15/112)

3

Upper endoscopy with biopsy of gastric mucosa

35%

(39/112)

4

Esophageal pH monitoring

4%

(5/112)

5

Barium swallow

2%

(2/112)

M1

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(M1.MC.31) A 40-year-old man presents to clinic three weeks after undergoing a total hip replacement. He complains of chronic nausea, epigastric pain and occasional melena, and notes that he has been taking celecoxib for pain control since his surgery. An esophagogastroduodenoscopy is performed, and a biopsy is taken of an erythematous area of the antrum of the stomach (Figure A). What treatment is recommended in this patient? Review Topic

QID: 101152
FIGURES:
1

Sulfasalazine and corticosteroid therapy

0%

(0/24)

2

Gluten free diet

0%

(0/24)

3

Omeprazole, clarithromycin and amoxicillin

83%

(20/24)

4

Intramuscular intrinsic factor injection

0%

(0/24)

5

Discontinue celecoxib

12%

(3/24)

M1

Select Answer to see Preferred Response

PREFERRED RESPONSE 3
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
ARTICLES (5)
VIDEOS (1)
Topic COMMENTS (11)
Private Note