Unknown #115
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Unknown #115

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    Unknown #115 Unknown #115 Presentation Transcript

    • Unknown #115
    • Case Presentation
      • A 59-year-old man has a 3-month history of epigastric discomfort and nausea without weight loss, melena, or vomiting. Over-the-counter H2-receptor antagonists have been ineffective. The patient is otherwise healthy and takes no other medications.
      • Physical examination reveals mild epigastric tenderness to palpation. Upper endoscopy shows a 1-cm duodenal ulcer, and antral biopsy specimens demonstrate chronic gastritis and Helicobacter pylori infection
    • Question
      • Which of the following is the most appropriate therapy for this patient?
      • A) proton pump inhibitor for 2 months
      • B) An H2-receptor antagonist for 2 months
      • C) A proton pump inhibitor and amoxicillin for 2 weeks
      • D) A proton pump inhibitor, amoxicillin, and clarithromycin for 2 weeks
      • E) A proton pump inhibitor, amoxicillin, and clarithromycin for 2 months
    • Answer
    • Answer
      • Which of the following is the most appropriate therapy for this patient?
      • A) proton pump inhibitor for 2 months
      • B) An H2-receptor antagonist for 2 months
      • C) A proton pump inhibitor and amoxicillin for 2 weeks
      • D) A proton pump inhibitor, amoxicillin, and clarithromycin for 2 weeks
      • E) A proton pump inhibitor, amoxicillin, and clarithromycin for 2 months
    • Helicobacter Pylori Infection
      • Estimated 30-40% of the U.S. population infected with H. Pylori
      • Associated with upper GI conditions including chronic gastritis, peptic ulcer disease, and gastric malignancy
    • ACG guidelines for diagnosis and testing
      • Should be performed only if clinicians are planning to offer treatment with a positive diagnosis
      • Active PUD, documented hx PUD, or gastric MALT lymphoma
    • “ Test-and-treat” strategy for certain patients:
      • Uninvestigated dyspepsia less than 55 y.o. and without “alarm” symptoms
        • Bleeding
        • Anemia
        • Early satiety
        • Unexplained weight loss
        • Progressive dysphagia
        • Odynophagia
        • Recurrent vomitting
        • Family hx of GI cancer
        • Previous esophagogastric malignancy
    •  
    • Initial diagnostic workup
      • Serum serology
      • Stool antigen (if patient is not actively bleeding, taking PPIs or bismuth)
      • Reserve endoscopic biopsy for those who are requiring diagnostic biopsy, or are having follow up endoscopy for gastric ulcer or suspected MALT lymphoma
    • Treatment of H. Pylori
      • Recommended therapy in the U.S.
        • PPI + clarithromycin + amoxicillin or metronidazole for 14 days
        • PPI or H2 blocker + bismuth + metronidazole + tetracycline for 10-14 days
    • Follow up for eradication
      • Urea breath test at least 4 weeks after therapy
      • Stool antigen testing 6 weeks after therapy, more widely available but not as accurate.
      • Chey, William et. al. “American College of Gastroenterology Guideline on the Management of Helicobacter pylori infection” American Journal of Gastroenterology . 2007; 102: 1808-1825.