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H. Pylori Infection
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| Counselor,
A large number of reports have been produced on HP
and its pathogenetic potential. In fact, although peptic ulcer disease
is the most studied disease related to HP infection, this bacterium is
seemingly involved in the pathogenesis of several extragastric
diseases, such as mucosa-associated lymphoid tissue lymphomas
(MALTomas), coronaritis, gastroesophageal reflux disease, iron
deficiency anemia, skin disease, and rheumatological conditions.
A strong association has been reported between HP
infection and gastric lymphoma and adenocarcinoma of the body and
antrum of the stomach. Currently, whether HP eradication can decrease
the risk of cancer remains unknown.
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Mortality/Morbidity:
The mortality rate related
to HP infection is not precisely known, but it seems to be minimal
(i.e.: approximately 2-
4% of all infected people). Mortality is due to the complications of
the infection, such as gastric ulcer perforation or MALTomas of the GI
tract. Otherwise, the morbidity of HP infection can be very high.
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Age:
HP infection may be
acquired at any age. According to some epidemiologic studies, this
infection is acquired most frequently during childhood. Children and
females have a higher incidence of reinfection (5-8%) than adult males.
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History/Physical:
No significant differences in the presence and
frequency of symptoms, such as nausea, vomiting, pain, heartburn, or
diarrhea, occur in patients who are infected with HP and patients who
are not. No specific clinical signs have been described in patients
with HP infection.
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Lab Studies:
HP fecal antigen test: It has been reported to be
very specific (98%) and sensitive (94%). The results are positive in
the initial stages of infection and can be used to detect eradication
after treatment.
Carbon 13 urea breath test: The carbon 13 urea
breath test (UBT) is based on the detection of the products created
when urea is split by the organism.
Problems include false-negative results due to
intake of antibiotics, bismuth, histamine 2 (H2) blockers, or proton
pump inhibitors.
HP serology: The serology test has a high
(>90%) specificity and sensitivity. It is useful for detecting a
newly infected patient, but it is not a good test for follow-up.
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Imaging Studies:
Imaging studies are not helpful in the diagnosis
of HP infection. Otherwise, they may be useful in patients with
complicated disease (e.g.: ulcer disease, gastric cancer, MALToma).
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Other Tests:
An esophagogastroduodenoscopy (EGD) is often
necessary in patients with symptoms of peptic ulcer disease in order to
view the condition of the mucosal lining of the stomach and duodenum
and to obtain biopsy specimens from the gastric antrum. An echography
associated with an EGD is mandatory in patients with biopsy results
that are positive for gastric MALTomas in order to allow a more precise
staging of the disease. Peptic ulcer disease and gastric cancer may
manifest with the same symptoms, and the only way to differentiate them
is to view the lesion and perform a histologic examination on biopsy
specimens.
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Staging:
Although a staging system for the HP infection
does not exist, some steps of the disease are well described. The first
step is chronic gastritis, followed after a time by the second step,
atrophic gastritis. The third step is intestinal metaplasia, which may
evolve into dysplasia. The last step in this process is gastric
adenocarcinoma. As reported above, ultrasound and EGD should be
considered in patients with gastric MALTomas in order to allow a more
precise staging of the disease.
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Treatment:
Only treat patients who have a test result
positive for HP infection. Carefully educate patients regarding the
importance of completing the prescription and about the potential
adverse effects of the medication. Importantly, consider possible
antibiotic resistance when selecting the treatment regimen.
Administer triple therapies for 10-14 days. The
treatment regimens are omeprazole, amoxicillin, and clarithromycin
(OAC) for 10 days; bismuth subsalicylate, metronidazole, and
tetracycline (BMT) for 14 days; and lansoprazole, amoxicillin, and
clarithromycin (LAC), which has been approved for either 10 or 14 days
of treatment. Macrolide resistance in patients with HP infection is an
important problem. An emerging and increasing problem in many Western
countries is the fact that some HP strains in children are resistant to
the antibiotic clarithromycin. The causes are not known.
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Deterrence/Prevention:
Risk is increased for
patients who have an HP infection and whose first-degree relatives have
a history of gastric cancer, even if they are asymptomatic. Also,
persons emigrating from geographic areas with a high incidence of
gastric cancer have an increased risk. Consider any patient with
precancerous lesions of the stomach (i.e.: intestinal metaplasia) for
treatment of HP.
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Complications:
Gastric adenocarcinoma is
the most severe consequence of an HP infection. Gastric MALToma may be
treated with HP eradication therapy and has a better prognosis than
gastric adenocarcinoma. HP infection is associated with squamous cell
esophageal cancer. HP may play an important role in idiopathic
thrombocytopenic purpura.
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Prognosis:
Prognosis is usually
excellent, even in patients with complications such as gastric MALToma.
However, the prognosis becomes poor for patients who develop squamous
cell esophageal cancer or gastric carcinoma.
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Medical/Legal Concerns:
Consider performing an EGD before prescribing a
treatment for peptic ulcer disease. Peptic ulcer disease and gastric
cancer may manifest with the same symptoms, and a correct diagnosis is
mandatory to avoid legal claims. Also consider that in a small number
of cases (2%), peptic ulcer disease and gastric carcinoma, even
ulcerated, may coexist.
Another problematic area is when HP infection
occurs during pregnancy. In this case delay the treatment until after
delivery because of the adverse teratogenous effects of some drugs used
in the therapeutic protocols for HP eradication. In addition, delaying
a new pregnancy for at least 1 month after the end of treatment may be
advisable.
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