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home - Stomach - Peptic Ulcer Disease - Helicobacter Pylori Investigation And Treatment Written by Dr Sebastian Zeki
Knowledge

Knows the range of organic and non-organic causes of dyspepsia. Be
aware of current BSG and NICE guidelines for selecting patients for
investigation. Know the significance of alarm symptoms
Understands the relevance of Helicobacter pylori infection and how it
can be detected and treated.
Recognise the adverse effect of nonsteroidal anti-inflammatory drugs
Understands the physiology of gastric acid secretion, mucosal
protection and gastroduodenal motility and know how drugs can
modify these
Knows the complications of ulcer disease, the principles of surgery
that may be required and be aware of post-operative sequelae

Skills
Makes a thorough clinical assessment, perform appropriate
investigations and be familiar with how medical treatments are used.
Show awareness of how to recognise and manage complications

Behaviours
Can explain the steps taken towards making a diagnosis and
planning treatment clearly and comprehensibly

Also....

Knowledge
Knows the causes of upper gastrointestinal bleeding and its
presentation
Understands the circulatory disturbance associated with blood loss
and the pathophysiology underlying the clinical manifestations of
hypovolaemic shock
Knows the principles of assessing hypovolaemia and of restoring the
circulation. Be able to identify and correct coagulopathy
Knows the principles of using the various risk stratification tools SCE 1
Knows how endoscopic techniques are used to control bleeding CbD, DOPS, SCE 1
Understands how oesophageal and gastric varices develop and the
endoscopic and pharmacological methods that are used to control
blood loss

Skills
Can make an accurate clinical assessment, and stratify the risk. Know
the principles of fluid resuscitation and arrange endoscopy
Is aware of methods to secure haemostasis, recognise signs of rebleeding and liaise with other disciplines (such as interventional
radiology or surgery

Behaviours
Assesses and treats patients who have bleeding with appropriate
degree of urgency.

Also...
Knowledge


Understands why part or all of the patient’s stomach is removed and
the altered post-surgical anatomy

Understands the problems of a gastro-enterostomy and a Roux-en-y
anastomosis

Has awareness of dumping syndromes
Knows the various surgical operations performed for obesity (bariatric
surgery) and their complications

Skills
Can give nutritional advice and choose the appropriate method by
which an enteral feeding tube is inserted into the small bowel

Can initiate the use of pancreatic enzyme therapy
Has ability to recognise and treat early and late dumping syndrome
Behaviours
Able to help the patient carers friends and family understand how
the patient can be encouraged to gain weight

Works closely with dieticians and surgical colleagues

Helicobacter Pylori Investigation And Treatment

Approaches for Treatment Failure:Either use alternate treatment regimen or quadruple therapy with bismuth for 14 days.Check compliance if fail two attempts at treatment.Use rescue therapy before doing endoscopic MC&S. Indications for testing:Active PUD/past history of documented PUD.Gastric MALT lymphoma.Dyspepsia in < 55yrs + no "alarm features".Prior to NSAID treatment esp in those taking NSAIDs continuously for weeks, months, or years.In patients with idiopathic thrombocytopenic purpura.In patients with otherwise unexplained iron deficiency anemia. Test Sensitivity and specificity Invasive tests:Rapid urease test (67 and 93%)Histology (70 and 90%)Culture (45 and 95%). Noninvasive tests (13)C urea breath test 93 and 92 %Stool antigen test 87 and 70 % Serology 88 and 69 % Endoscopic Testing types:Biopsy urease testing - this is the usual endoscopic test.Rapid urease testing - can get result within 1 hour. Histology- This needs several biopsies be taken from both the antrum and body of the stomach.Brush cytology Sensitivity 98 % and specificity 96 % but hardly ever used.Bacterial culture and sensitivity testing -metronidazole resistance is 85% in tropical countries, 50 % in some European countries. Noninvasive testingUrea breath testing is based upon the hydrolysis of urea by H. pylori to produce CO2 and ammonia.Labeled carbon isotope given by mouth; H. pylori liberates tagged CO2, detectable in breath samples.False -ves for urea breath testing occur in the same patients as rapid urease test.To reduce false -ve results, suggest stopping antibiotics for at least 4 weeks and to come off PPIs for at least 2 weeks.As concerns serology IgG is useful but IgM is not.Treatment should be based upon positive serology if there is a high pretest probability.Confirm a negative serology result with a second non-serologic test.Negative tests are helpful to exclude infection if the pretest probability is low.Serology allows the determination of IgG titers of paired sera from the acute and convalescent (3-6 months) phase to confirm eradication of the infection (titre declines by 50%).For the 13C bicarbonate assay one blood specimen is taken before and the second 60mins after ingestion of a 13C-urea rich meal.The 13C bicarbonate is hardly ever used.Stool antigen assay is assocaited with up to a 20 % false -ve rate when performed 4-6 weeks after eradication therapy.A novel rapid polyclonal H. pylori stool antigen test that can be performed during a clinic visit is available.Sensitivity and specificity of newer stool antigen testing is 76 and 98 %, respectively.A monoclonal stool antigen test has sensitivity was 94 % and specificity was 97 %.Polymerase chain reaction is not practical for the routine diagnosis of H. pylori.PCR is useful in detecting the organism when ordinary culture is difficult, as with testing stool or drinking water.PCR can be performed in gastric tissues.Salivary assays can be used, but aren’t. Those in whom eradication should be confirmed:Any patient with an H. pylori-associated ulcer.Individuals with persistent dyspeptic symptoms despite the test-and-treat strategy.Those with H. pylori-associated MALT lymphoma.Individuals who have undergone resection of early gastric cancer Urea Ammonia Urease Alkaline pHgives colour change 1-24 hours False negative (so do second test- )Recent GI bleedingUse of PPIsH2 antagonistsAntibiotics,Bismuth-containing compounds. Increase sensitivity by sampling from antrum and fundus Treatment Investigation and Treatment of Helicobacter pylori Suggested Treatment Regimes:PPI, amoxycillin, clari bd for 7-14 d.PPI amoxicillin, metronidazole for 14 d.Bismuth, metronidazole, tetracycline and PPI.PPI, levofloxacin, amoxycillin 14d.PPI, rifabutin, amoxycillin 14 d.PPI + amoxycillin. H pylori eradication confirmationUBT at 4 weeks is best test. Stool antigen testing is alternative, but less accurate (4-6 weeks post-eradication).Antibiotics and bismuth should be discontinued for at least 4 weeks and PPIs at least one week if possible prior to testing one to confirm H. pylori cure. Special case testing:Asymptomatic patients and family — Usually not tested for H. pylori infectionLong-term PPI therapy — Testing and treatment for H. pylori is not recommended solely for the prevention of atrophic gastritis in patients on long-term PPI therapy.Functional dyspepsia — Issues related to H. pylori testing in functional dyspepsia are presented separately. Sens and spec- 95% and 90%, respectively Superior to agar gel tests at one hour. Problems with Histology:-Patchy H. pylori distribution-Interobserver variability.-Reduced sensitivity if on PPI-Special stains such as Giemsa or specific immune stains improve diagnostic accuracy The incidence of primary macrolide resistance is 4 to 12%.If have refractory H. pylori, then get culture in a few drops of saline. Written by Dr Sebastian Zeki

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