Helicobacter pylori

Background

• H. pylori is a gram negative bacteria that causes gastritis, peptic ulcer disease, and gastric adenocarcinoma.

Clinical Features

• Epigastric abdominal pain
• Gastroesophageal Reflux Disease

Differential Diagnosis

Epigastric Pain

• Gastroesophageal reflux disease (GERD)
• Peptic ulcer disease with or without perforation
  • Zollinger-Ellison syndrome
• Gastritis
• Pancreatitis
• Gallbladder disease
  • Acute cholecystitis
  • Cholangitis
  • Symptomatic cholelithiasis
  • Acalculous cholecystitis
• Myocardial Ischemia
• Splenic Infarctionenlargement/rupture/aneurysm
• Pericarditis/Myocarditis
• Aortic dissection
• Hepatitis
• Pyelonephritis
• Pneumonia
• Pyogenic liver abscess
• Fitz-Hugh-Curtis Syndrome
• Hepatomegaly due to CHF
• Bowel obstruction
• SMA syndrome
• Pulmonary embolism
• Bezoar
• Ingested foreign body

Evaluation

• Non-invasive Testing
  • Urea Breath Testing
  • Serology - ELISA
  • Stool Antigen Assay
• Invasive Testing - Endoscopy

Management

• Though feasible in the ED, antibiotic therapy is typically not offered
• Beware of other causes of abdominal pain despite positive testing

Triple Therapy

• PPI plus clarithromycin 500mg twice daily, and amoxicillin 1000mg twice daily for 10-14 days
• If penicillin allergic: PPI plus clarithromycin 500mg twice daily, metronidazole 500mg twice daily for 10-14 days
• Concomitant therapy adds metronidazole 500 mg BID to triple therapy for 10-14 days

Bismuth Quadruple Therapy

• May have highest eradication rates as compared to classical triple therapy or concomitant therapy
• Bismuth quadruple therapy for 10 days:
  • Bismuth subsalicylate 300 mg QID
  • Lansoprazole 30 mg BID
  • Tetracycline 500 mg QID
  • Metronidazole 500 mg TID

Disposition

• Discharge with GI outpatient follow-up

See Also

• Peptic Ulcer Disease
• Gastroesophageal Reflux Disease