Helicobacter Pylori

Helicobacter Pylori in Adults

Infection with Helicobacter Pylori varies within the population and is falling in prevalence , recent studies have suggested less than 15% of the European population have infection but the prevalence is higher in people born outside Europe and also increases with age. At least 1 In 5 of patients with Helicobacter infection have ulcers.

Helicobacter pylori infection is present in 95% of patients with duodenal ulcers and in 75% of those with gastric ulcers. Effective H.pylori eradication will prevent the recurrence of duodenal and gastric ulcers in more than 85% of patients and removes a risk factor for gastric cancer. However up to 64% of patients with non-ulcer dyspepsia will have persistent symptoms after treatment for helicobacter.

H.pylori eradication is more effective than long-term acid lowering therapy in reducing both the relapse rate and the complication rate of peptic ulcer disease. H.pylori eradication therapy is also of value in the treatment of a minority of patients (approximately 5%) with functional dyspepsia.

The faecal antigen test we are using picks up 95% of Helicobacter infections and a positive result has an over 95% chance of being a true result. Unlike serology there is little chance of false negative or false positive results.

Test and Treat Strategy

This strategy involves performing a non-invasive test, eradicating the infection in all those testing positive and providing symptomatic treatment for those who test negative. Non-invasive Helicobacter pylori testing is as effective as endoscopy in determining the management of uncomplicated dyspepsia. Consequently neither endoscopy nor barium studies are required in the initial management of patients with uncomplicated dyspepsia. In contrast, prompt referral to a hospital specialist is indicated for patients with dyspepsia accompanied by alarm features. Most of these patients will need urgent endoscopy and should be referred using SCI Gateway.

In the absence of alarm symptoms, current practice is to treat empirically or ‘test and treat’ all patients with suspected GORD or peptic ulcer disease.

When to test for Helicobacter

• Patients with uncomplicated dyspepsia unresponsive to lifestyle change, antacids, single course of PPI for 1 month and without alarm symptoms.
• Patients with a past history of gastric ulcer or duodenal ulcer (DU) who have not previously been treated for helicobacter- if on long term treatment that you are considering stopping.
• In patients taking NSAIDs Eradication of HP can help prevent peptic ulcers in patients requiring NSAIDs, but will not remove all risk.

Do not test for Helicobacter in

• Gastro-Oesophageal Reflux Disease
• Children with functional dyspepsia

Helicobacter Testing
DO NOT perform stool antigen test within at least 2 weeks of taking Proton pump inhibitors or 4 weeks of antibiotics, as these drugs suppress bacteria and may lead to false negatives

• Please make sure the patient does not have acute diarrhoea. Helicobacter is not implicated as a cause of acute gastroenteritis and the sample may be diluted and give a false negative result.
• Send us a grape-sized sample of stool in a standard blue top container. Please ask the patient or carer to write the date and time of sample collection on the container.
• The test can be requested on any of the current microbiology forms by writing in the ‘test requested’ section. For those who have Order Comms (ICE), please tick the standard box.
• For practical reasons, we are unable to do stool antigen and other bacteriology tests on the same sample. If the Microscopy culture and sensitivity or C.diff toxin boxes are ticked on the form as well as requesting helicobacter, the result may be that the stool antigen test is not done.
• Please could the sample arrive at the laboratory within a day of collection i.e. avoid taking samples on Friday afternoons.
• The results will be back within a week.

When to retest for Helicobacter after eradication therapy

Patients with persistent symptoms over age 55 should be considered for referral for endoscopy.

The absence of symptoms 8 weeks after eradication therapy is strong evidence that eradication has been successful. Confirmation of H.pylori eradication in patients who are asymptomatic at 8 weeks is unnecessary unless there has been bleeding or perforation of a peptic ulcer or where there are relevant ongoing risk factors e.g. anti-coagulant or NSAID therapy. When indicated, the H.pylori stool antigen test is best deferred for 8 weeks after the conclusion of eradication therapy

Patients under 55 with persistent symptoms should be considered for test of eradication of Helicobacter for:

• If compliance poor
• Family history of cancer
• Patients with complicated peptic ulcer
• Patients with MALTOMA – (A rare lymphoma of the mucosa associated lymphoid tissue – all these patients will be under the care of a gastroenterologist or surgeon)
• Patients requiring aspirin in whom a PPI is not going to be co-prescribed
• Patients with severe recurrent symptoms, particularly if not typical of GORD

Wait at least 8 weeks after eradication therapy before retesting for Helicobacter.

Ensure that patient has not been taking antibiotics or PPI as outlined above to avoid false negative results.

The faecal antigen test is nearly as good as the urea breath test in detecting failure of eradication therapy. A negative test does not always indicate that a patient is free of infection If there are still severe symptoms and a negative faecal antigen test of cure sample advice should be sought from a gastroenterologist.

Treatment

The combination of TWO antibiotics together with a PPI given for at least ONE WEEK is required to ensure H.pylori eradication rates >85%. Please see the formulary for current guidance on H.pylori treatment.

Acid lowering drug therapy enhances the efficacy of H.pylori eradication therapy and can usually be discontinued after ONE WEEK unless there is a complicating factor such as gastric ulcer, perforated ulcer, bleeding ulcer, NSAID therapy, troublesome reflux symptoms or ongoing symptoms.

Please also consider the following:

• If patient has had a recent course of antibiotic, that antibiotic should not be used in the eradication regime (amoxicillin, clarithromycin, metronidazole, or oxytetracycline are options).
• Blind anti-H.pylori therapy without prior confirmation of H.pylori status is only appropriate in patients with documented ulcer disease
• Up to 30% of patients will experience diarrhoea with H.pylori eradication therapy. Patients should be warned of this adverse effect and advised to complete the therapy. Serious side effects are rare
• Patients should avoid alcohol during metronidazole therapy because of the possibility of Antabuse-like effects
• PPIs should be used with caution in the elderly. There may be an association between PPI use and Clostridium difficile infection and osteoporosis. Careful consideration should be made to the risk benefit ratio.
• H.pylori eradication therapy interacts with warfarin and may cause disturbances in INR control
• See the guidance on drug interactions with hormonal contraceptives on the Faculty of Sexual and Reproductive Health website for details of the latest advice.

If first line treatment fails, move to second line. If eradication failure occurs, never repeat the same treatment course. Patients who fail second line therapy should be referred for specialist advice.