This document discusses Helicobacter pylori (H. pylori), including its epidemiology, complications, diagnosis, and treatment. Some key points:
- H. pylori was first discovered in 1982 and linked to peptic ulcer disease and gastric cancer. It is acquired primarily in childhood and transmitted within families.
- Asia has a high prevalence of around 58%. Risk factors include poor hygiene and high population density.
- Complications include gastric cancer, ulcers, gastric MALT lymphoma, and intestinal metaplasia.
- Diagnosis involves tests like the urea breath test, stool antigen test, and endoscopy. Treatment guidelines recommend testing dyspepsia, ulcer,
Helicobacter Pylori Infection: Management in 2020ChernHaoChong
1) Helicobacter pylori infection is common and testing should be done for patients with dyspepsia, peptic ulcer history, or family history of gastric cancer.
2) The urea breath test is the best tool to detect active H. pylori infection.
3) Patients who test positive for H. pylori antibodies should undergo a urea breath test to confirm active infection before treatment.
This document discusses irritable bowel syndrome (IBS) and summarizes a case study of a 32-year-old female patient, Ms. Lee, experiencing IBS symptoms. It covers the evolving diagnostic criteria for IBS, potential treatments including lifestyle modifications, medications, probiotics, and the relationship between small intestinal bacterial overgrowth (SIBO) and IBS. Hydrogen breath testing is presented as a non-invasive way to diagnose SIBO, though it has limitations. The antibiotic rifaximin is introduced as a treatment option for patients who test positive for SIBO.
Speaker Reuben Wong gave an update on irritable bowel syndrome (IBS). He discussed that IBS is a functional gastrointestinal disorder defined by Rome criteria as abdominal pain associated with changes in bowel habits. IBS has multiple contributing factors including genetics, infections, stress, diet, gut sensitivity, and microbiota imbalance. While there is no cure, treatment approaches aim to manage symptoms and target specific factors, with options including dietary modification, probiotics, psychological interventions, and new pharmacologic therapies tailored to IBS subtypes and severity of symptoms.
This talk discusses GI/liver side effects of commonly used drugs and provides guidance on advising patients and monitoring or preventing adverse effects. It covers factors that may contribute to side effects like drug interactions and underlying diseases. Specific drugs discussed include statins, NSAIDs, aspirin, and ketoconazole. The speaker emphasizes advising patients on medication use and seeking medical help if unwell, considering individual risk factors when prescribing or recommending prophylaxis, and consulting specialists if serious adverse effects occur.
1. The document discusses updated guidelines for screening of GI cancers, including colorectal, stomach, and pancreatic cancers.
2. For colorectal cancer screening, average risk adults aged 50-75 should be screened with stool tests every 2 years or colonoscopy every 10 years. Surveillance intervals for colon polyps have been adjusted to be less frequent in most cases.
3. For stomach cancer screening, guidelines agree routine screening is not recommended but may be considered for high risk populations. If gastric intestinal metaplasia is found, H. pylori testing and treatment is recommended, without routine endoscopic surveillance.
4. For pancreatic cancer, guidelines recommend against routine screening for asymptomatic adults as there is no
Common liver Disease in Primary Care SettingChernHaoChong
- The document discusses common liver problems encountered in primary care, including abnormal liver function tests, abnormal findings on liver ultrasound, and viral hepatitis serology interpretations.
- Studies show that only a small percentage of abnormal liver function tests are actually due to liver disease, while the majority are caused by cancer, cardiovascular disease, or respiratory disease.
- Non-alcoholic fatty liver disease is increasingly common in Asia, with genetic factors playing a stronger role. Screening and management of metabolic complications is important when NAFLD/NASH is identified.
- Assessment for significant liver fibrosis or cirrhosis is important for high-risk NAFLD/NASH patients, while lifestyle modifications remain the first-line
1. The document discusses various gastrointestinal disorders that can present with non-gastrointestinal symptoms, including GERD, asthma, chronic cough, chest pain, ENT symptoms, and others.
2. It provides an overview of approaches to evaluating these atypical presentations, including pH monitoring, impedance monitoring, treatment with PPIs, and considering other potential etiologies.
3. Surgical intervention may be considered for refractory cases, though response is variable depending on the specific disorder and symptoms. Overall, the document aims to help clinicians avoid pitfalls in diagnosing and managing GI disorders that present atypically.
Helicobacter Pylori Infection: Management in 2020ChernHaoChong
1) Helicobacter pylori infection is common and testing should be done for patients with dyspepsia, peptic ulcer history, or family history of gastric cancer.
2) The urea breath test is the best tool to detect active H. pylori infection.
3) Patients who test positive for H. pylori antibodies should undergo a urea breath test to confirm active infection before treatment.
This document discusses irritable bowel syndrome (IBS) and summarizes a case study of a 32-year-old female patient, Ms. Lee, experiencing IBS symptoms. It covers the evolving diagnostic criteria for IBS, potential treatments including lifestyle modifications, medications, probiotics, and the relationship between small intestinal bacterial overgrowth (SIBO) and IBS. Hydrogen breath testing is presented as a non-invasive way to diagnose SIBO, though it has limitations. The antibiotic rifaximin is introduced as a treatment option for patients who test positive for SIBO.
Speaker Reuben Wong gave an update on irritable bowel syndrome (IBS). He discussed that IBS is a functional gastrointestinal disorder defined by Rome criteria as abdominal pain associated with changes in bowel habits. IBS has multiple contributing factors including genetics, infections, stress, diet, gut sensitivity, and microbiota imbalance. While there is no cure, treatment approaches aim to manage symptoms and target specific factors, with options including dietary modification, probiotics, psychological interventions, and new pharmacologic therapies tailored to IBS subtypes and severity of symptoms.
This talk discusses GI/liver side effects of commonly used drugs and provides guidance on advising patients and monitoring or preventing adverse effects. It covers factors that may contribute to side effects like drug interactions and underlying diseases. Specific drugs discussed include statins, NSAIDs, aspirin, and ketoconazole. The speaker emphasizes advising patients on medication use and seeking medical help if unwell, considering individual risk factors when prescribing or recommending prophylaxis, and consulting specialists if serious adverse effects occur.
1. The document discusses updated guidelines for screening of GI cancers, including colorectal, stomach, and pancreatic cancers.
2. For colorectal cancer screening, average risk adults aged 50-75 should be screened with stool tests every 2 years or colonoscopy every 10 years. Surveillance intervals for colon polyps have been adjusted to be less frequent in most cases.
3. For stomach cancer screening, guidelines agree routine screening is not recommended but may be considered for high risk populations. If gastric intestinal metaplasia is found, H. pylori testing and treatment is recommended, without routine endoscopic surveillance.
4. For pancreatic cancer, guidelines recommend against routine screening for asymptomatic adults as there is no
Common liver Disease in Primary Care SettingChernHaoChong
- The document discusses common liver problems encountered in primary care, including abnormal liver function tests, abnormal findings on liver ultrasound, and viral hepatitis serology interpretations.
- Studies show that only a small percentage of abnormal liver function tests are actually due to liver disease, while the majority are caused by cancer, cardiovascular disease, or respiratory disease.
- Non-alcoholic fatty liver disease is increasingly common in Asia, with genetic factors playing a stronger role. Screening and management of metabolic complications is important when NAFLD/NASH is identified.
- Assessment for significant liver fibrosis or cirrhosis is important for high-risk NAFLD/NASH patients, while lifestyle modifications remain the first-line
1. The document discusses various gastrointestinal disorders that can present with non-gastrointestinal symptoms, including GERD, asthma, chronic cough, chest pain, ENT symptoms, and others.
2. It provides an overview of approaches to evaluating these atypical presentations, including pH monitoring, impedance monitoring, treatment with PPIs, and considering other potential etiologies.
3. Surgical intervention may be considered for refractory cases, though response is variable depending on the specific disorder and symptoms. Overall, the document aims to help clinicians avoid pitfalls in diagnosing and managing GI disorders that present atypically.
The document discusses GI and liver problems commonly seen in elderly patients and how management may differ. Physiologic declines with aging can impact the GI tract indirectly by increasing other medical issues. Common GI problems include swallowing difficulties, constipation, weight loss, and anemia. Liver disease progression may be faster in elderly due to reduced regenerative ability and increased susceptibility to injury from medications. Careful evaluation and treatment of underlying conditions is important when managing GI and liver issues in elderly patients.
This document discusses four clinical cases involving gallstones and bile duct issues.
Case 1 involves a 40-year-old woman with acute gallstone pancreatitis who underwent medical treatment and may require surgery if symptoms recur. Case 2 is a 53-year-old woman with vague upper abdominal symptoms who was managed medically with follow up. Case 3 is a 67-year-old woman with jaundice, weight loss, and elevated tumor marker found to have a hilar mass requiring further investigation and management. Case 4 is a 41-year-old woman with acute gallstone pancreatitis and CBD stones seen on ultrasound who requires further evaluation and treatment.
This document provides information on dyspepsia, including its definition, causes, investigations, and management guidelines. It begins by defining dyspepsia and outlining its prevalence in the UK population. It then discusses the common and rare causes of dyspepsia and how to investigate patients. The document reviews guidelines from NICE on investigating and managing dyspepsia. It provides examples of case histories and questions to help apply the guidelines. Key points are emphasized, such as addressing lifestyle factors, empirically treating dyspepsia, and referring patients with red flag symptoms urgently for endoscopy.
gutCARE IBS Talk on 20/5/2020.
In this talk, we update Singapore local epidemiology about increasing trend of IBS locally since 1998. There is also challenges in diagnosing IBS confidently in primary care due to patient presentation and symptoms.
We also update audience about latest diagnostic criteria for IBS.
New treatment for IBS, relationship between Small intestine bacterial overgrowth and IBS and the role of hydrogen breath testing in managing IBS.
We hope you enjoy the slides.
Dyspepsia is one of the most common symptoms in the adult population, and affects 20-40% of adults annually. We present an evidence based approach to this common topic, incorporating the latest guidelines.
This document summarizes the results of a study on the effectiveness of the drug itopride in treating functional dyspepsia. The study found that:
- Itopride was significantly more effective than placebo in improving symptom severity scores and response rates based on patients' global assessments of efficacy.
- A higher dose of itopride (100mg and 200mg) was more effective than a lower dose (50mg) or placebo in improving response rates.
- Quality of life scores improved more for patients taking itopride than placebo, though differences between itopride doses were not significant.
The study provides evidence that itopride is effective in treating functional dyspepsia compared to placebo
IBS is a functional bowel disorder characterized by abdominal pain and altered bowel habits. It affects 5-10% of people in North America, predominantly women aged 20-39. The causes involve genetics, gut motility issues, hypersensitivity, and the brain-gut axis. Treatment focuses on symptom relief through diet, exercise, fiber, probiotics, antispasmodics, antidepressants, and 5-HT agonists/antagonists. Managing IBS can be challenging due to recurrent, resistant symptoms.
Ulcerative Colitis: Applying Guidelines in PracticeDevi Seal
This presentation developed was by David Rubin, MD, Millie Long, MD, MPH, and Anita Afzali, MD, MPH, for a CME activity titled, Ulcerative Colitis: Applying Guidelines in Practice
This document summarizes guidelines for the diagnosis, surveillance, and management of Barrett's esophagus. It defines Barrett's esophagus as the replacement of the normal squamous epithelial lining of the esophagus with metaplastic columnar epithelium. Surveillance aims to detect early cancers but has not been proven to reduce mortality in randomized trials. Management involves surveillance of non-dysplastic Barrett's and treatment of dysplastic areas, with options including ablation, endoscopic resection, or surgery depending on the stage. Guidelines recommend a multidisciplinary team approach and further research is still needed.
- Irritable bowel syndrome (IBS) has a worldwide prevalence of 7-11% and prevalence in North America is around 7-15%.
- IBS is associated with decreased quality of life and over $20 billion in annual direct and indirect costs in the US. Diagnosis is based on Rome criteria which involves recurrent abdominal pain associated with changes in stool frequency or form.
- The pathophysiology of IBS involves visceral hypersensitivity, abnormal motility, low-grade inflammation, alteration of gut microflora, food sensitivity, and psychosocial factors. Treatment involves diet modification, antispasmodics, antidepressants, and psychosocial therapies.
This case report describes a 66-year-old obese woman admitted to the hospital for abdominal pain, nausea, vomiting and acute diverticulitis with a suspected colorectal bladder fistula. Over her 8 day hospital stay she received IV antibiotics and underwent diagnostic testing confirming diverticulitis and a colovaginal fistula. Her medical history included multiple conditions related to her obesity. She was seen by a dietitian who provided nutrition counseling and advanced her diet from clear liquids to regular foods before discharge.
Gastroenterology for the internist. The Clinics 2019Manuel Chumacero
This document summarizes key points about proton pump inhibitors (PPIs):
1) PPIs are among the most commonly prescribed medications but have been associated with potential adverse effects in observational studies.
2) While evidence for adverse effects is weak, there is also insufficient evidence to dismiss the risks.
3) PPIs are often prescribed inappropriately or at higher than recommended doses.
4) Physicians should carefully consider the indication for PPIs and ensure appropriate dosing before prescribing, and regularly review whether continued PPI therapy is needed.
1. Gastroparesis is a condition characterized by delayed gastric emptying without mechanical obstruction, often accompanied by nausea, vomiting, early satiety, and abdominal pain.
2. It can be diagnosed by demonstrating delayed gastric emptying on scintigraphy using a standardized meal, as well as evaluating symptoms.
3. The diagnosis requires ruling out other potential causes and confirming that symptoms are consistent with delayed gastric emptying. Interpreting mild delays cautiously is important to avoid misdiagnosing functional dyspepsia as gastroparesis.
Cremon C. Functional Digestive disease. Not simply IBS. ASMaD 2013Gianfranco Tammaro
This document discusses functional gastrointestinal disorders (FGIDs) such as irritable bowel syndrome (IBS) and functional dyspepsia. Over 40% of the general population experiences digestive symptoms, many of which are functional in nature. FGIDs involve variable combinations of chronic or recurrent gastrointestinal symptoms that cannot be fully explained by structural or biochemical abnormalities. IBS, functional dyspepsia, and chronic constipation together account for over 90% of all FGIDs. The Rome criteria provide a positive diagnostic approach for FGIDs rather than an exclusion-based diagnosis. It is challenging for general practitioners and gastroenterologists to manage FGIDs given their high prevalence and significant impact on quality of life and healthcare costs.
This document presents a case study of a 31-year-old female patient complaining of worsening heartburn impairing her quality of life for the past year. A trial of PPI therapy provided marked improvement in her symptoms. Two months later, her symptoms recurred, and an endoscopy showed a small hiatal hernia with no signs of reflux and positive H. pylori infection. Ambulatory pH monitoring showed pathological acid reflux. She was treated for H. pylori and maintained on PPI therapy, but complained of increased nocturnal heartburn on step-down therapy. The document discusses various treatment approaches and indications for surgery based on the patient's case.
- The patient, a 48-year-old housewife, presented with nausea, vomiting, loss of appetite, and 7 kg weight loss in the past month with a history of similar symptoms one month ago.
- She was diagnosed with dyspepsia and is being treated with soft food, IV fluids, and omeprazole to eliminate her symptoms while undergoing endoscopy to determine the cause of her dyspepsia.
- The goals are to relieve her current symptoms, identify the cause of her dyspepsia, and prevent future recurrent symptoms and complications through treatment and lifestyle changes.
Point-of-Care Ultrasound Diagnosis an Asset for IBD PatientsJason Jaramillo
An MD practicing at the Maimonides Medical Center in New York, Dr. Jason Jaramillo is part of a community private practice. Jason Jaramillo, MD, provides patient-centered ultrasound diagnostics through the handheld, bedside, Point-of-Care Ultrasound (POCUS) approach.
As reported in Gastroenterology & Endoscopy News, a 2021 University of Calgary study revealed the effectiveness of bedside POCUS in delivering meaningful, efficient care to inflammatory bowel disease (IBD) patients. The impetus was the COVID-19 pandemic and a need to restrict IBD patients’ routine endoscopy access, as well as hospitalization and visits to the emergency department.
Calgary physicians developed a centralized bedside intestinal ultrasound protocol that enabled them to accurately and objectively measure IBD progress in patients. Of the 72 patients evaluated as part of the study, more than 84 percent underwent intestinal ultrasound, sigmoidoscopy, or a combination of the two techniques, which led to detection of active inflammation and significant management changes.
Physicians referred a half dozen of these patents to colorectal surgery for complicated disease resection, and three new IBD diagnoses were made as well. With POCUS diagnosis in place, not a single IBD visited the ER across the duration of the study. In addition, 80 percent of patients avoided acute care in-hospital endoscopy. These results point to POCUS as a significant asset to gastroenterologists seeking to minimize patient time in ER and clinical settings.
The document discusses gastric sensorimotor disorders and their management. It provides an overview of gastric anatomy and functions, common symptoms of sensorimotor disorders, and the prevalence of specific disorders like functional dyspepsia and gastroparesis. It then outlines a logical, step-wise diagnostic algorithm and emphasizes using test results to guide treatment. Finally, it presents three clinical cases and asks which next step would be most appropriate for each.
This document summarizes recent advances in the diagnosis and treatment of gastroesophageal reflux disease (GERD). It discusses new diagnostic tests such as the Bravo capsule and multichannel intraluminal impedance that allow for improved detection of acid and non-acid reflux. It also reviews therapeutic advances for GERD including new drugs that target transient lower esophageal sphincter relaxations, combination therapies, and endoscopic procedures like Stretta and Enteryx that aim to strengthen the lower esophageal sphincter. Finally, it discusses ongoing issues around Barrett's esophagus screening and surveillance.
GIT Kurdistan Board J club Functional heart burn16.Shaikhani.
- The patient has heartburn that does not respond to PPI therapy and has a normal endoscopy. Based on these findings, the most likely diagnosis is functional heartburn (FH). FH is diagnosed when there are typical reflux symptoms but normal acid exposure and no correlation between symptoms and reflux events.
- FH affects both men and women and is associated with visceral hypersensitivity, esophageal dysmotility, and traits seen in other functional gastrointestinal disorders. Diagnosis involves ruling out underlying reflux disease or motility issues through endoscopy, pH testing, and motility studies.
- FH has a benign clinical course but can impact quality of life. Treatment focuses on reassurance and lifestyle changes rather than acid
The document discusses GI and liver problems commonly seen in elderly patients and how management may differ. Physiologic declines with aging can impact the GI tract indirectly by increasing other medical issues. Common GI problems include swallowing difficulties, constipation, weight loss, and anemia. Liver disease progression may be faster in elderly due to reduced regenerative ability and increased susceptibility to injury from medications. Careful evaluation and treatment of underlying conditions is important when managing GI and liver issues in elderly patients.
This document discusses four clinical cases involving gallstones and bile duct issues.
Case 1 involves a 40-year-old woman with acute gallstone pancreatitis who underwent medical treatment and may require surgery if symptoms recur. Case 2 is a 53-year-old woman with vague upper abdominal symptoms who was managed medically with follow up. Case 3 is a 67-year-old woman with jaundice, weight loss, and elevated tumor marker found to have a hilar mass requiring further investigation and management. Case 4 is a 41-year-old woman with acute gallstone pancreatitis and CBD stones seen on ultrasound who requires further evaluation and treatment.
This document provides information on dyspepsia, including its definition, causes, investigations, and management guidelines. It begins by defining dyspepsia and outlining its prevalence in the UK population. It then discusses the common and rare causes of dyspepsia and how to investigate patients. The document reviews guidelines from NICE on investigating and managing dyspepsia. It provides examples of case histories and questions to help apply the guidelines. Key points are emphasized, such as addressing lifestyle factors, empirically treating dyspepsia, and referring patients with red flag symptoms urgently for endoscopy.
gutCARE IBS Talk on 20/5/2020.
In this talk, we update Singapore local epidemiology about increasing trend of IBS locally since 1998. There is also challenges in diagnosing IBS confidently in primary care due to patient presentation and symptoms.
We also update audience about latest diagnostic criteria for IBS.
New treatment for IBS, relationship between Small intestine bacterial overgrowth and IBS and the role of hydrogen breath testing in managing IBS.
We hope you enjoy the slides.
Dyspepsia is one of the most common symptoms in the adult population, and affects 20-40% of adults annually. We present an evidence based approach to this common topic, incorporating the latest guidelines.
This document summarizes the results of a study on the effectiveness of the drug itopride in treating functional dyspepsia. The study found that:
- Itopride was significantly more effective than placebo in improving symptom severity scores and response rates based on patients' global assessments of efficacy.
- A higher dose of itopride (100mg and 200mg) was more effective than a lower dose (50mg) or placebo in improving response rates.
- Quality of life scores improved more for patients taking itopride than placebo, though differences between itopride doses were not significant.
The study provides evidence that itopride is effective in treating functional dyspepsia compared to placebo
IBS is a functional bowel disorder characterized by abdominal pain and altered bowel habits. It affects 5-10% of people in North America, predominantly women aged 20-39. The causes involve genetics, gut motility issues, hypersensitivity, and the brain-gut axis. Treatment focuses on symptom relief through diet, exercise, fiber, probiotics, antispasmodics, antidepressants, and 5-HT agonists/antagonists. Managing IBS can be challenging due to recurrent, resistant symptoms.
Ulcerative Colitis: Applying Guidelines in PracticeDevi Seal
This presentation developed was by David Rubin, MD, Millie Long, MD, MPH, and Anita Afzali, MD, MPH, for a CME activity titled, Ulcerative Colitis: Applying Guidelines in Practice
This document summarizes guidelines for the diagnosis, surveillance, and management of Barrett's esophagus. It defines Barrett's esophagus as the replacement of the normal squamous epithelial lining of the esophagus with metaplastic columnar epithelium. Surveillance aims to detect early cancers but has not been proven to reduce mortality in randomized trials. Management involves surveillance of non-dysplastic Barrett's and treatment of dysplastic areas, with options including ablation, endoscopic resection, or surgery depending on the stage. Guidelines recommend a multidisciplinary team approach and further research is still needed.
- Irritable bowel syndrome (IBS) has a worldwide prevalence of 7-11% and prevalence in North America is around 7-15%.
- IBS is associated with decreased quality of life and over $20 billion in annual direct and indirect costs in the US. Diagnosis is based on Rome criteria which involves recurrent abdominal pain associated with changes in stool frequency or form.
- The pathophysiology of IBS involves visceral hypersensitivity, abnormal motility, low-grade inflammation, alteration of gut microflora, food sensitivity, and psychosocial factors. Treatment involves diet modification, antispasmodics, antidepressants, and psychosocial therapies.
This case report describes a 66-year-old obese woman admitted to the hospital for abdominal pain, nausea, vomiting and acute diverticulitis with a suspected colorectal bladder fistula. Over her 8 day hospital stay she received IV antibiotics and underwent diagnostic testing confirming diverticulitis and a colovaginal fistula. Her medical history included multiple conditions related to her obesity. She was seen by a dietitian who provided nutrition counseling and advanced her diet from clear liquids to regular foods before discharge.
Gastroenterology for the internist. The Clinics 2019Manuel Chumacero
This document summarizes key points about proton pump inhibitors (PPIs):
1) PPIs are among the most commonly prescribed medications but have been associated with potential adverse effects in observational studies.
2) While evidence for adverse effects is weak, there is also insufficient evidence to dismiss the risks.
3) PPIs are often prescribed inappropriately or at higher than recommended doses.
4) Physicians should carefully consider the indication for PPIs and ensure appropriate dosing before prescribing, and regularly review whether continued PPI therapy is needed.
1. Gastroparesis is a condition characterized by delayed gastric emptying without mechanical obstruction, often accompanied by nausea, vomiting, early satiety, and abdominal pain.
2. It can be diagnosed by demonstrating delayed gastric emptying on scintigraphy using a standardized meal, as well as evaluating symptoms.
3. The diagnosis requires ruling out other potential causes and confirming that symptoms are consistent with delayed gastric emptying. Interpreting mild delays cautiously is important to avoid misdiagnosing functional dyspepsia as gastroparesis.
Cremon C. Functional Digestive disease. Not simply IBS. ASMaD 2013Gianfranco Tammaro
This document discusses functional gastrointestinal disorders (FGIDs) such as irritable bowel syndrome (IBS) and functional dyspepsia. Over 40% of the general population experiences digestive symptoms, many of which are functional in nature. FGIDs involve variable combinations of chronic or recurrent gastrointestinal symptoms that cannot be fully explained by structural or biochemical abnormalities. IBS, functional dyspepsia, and chronic constipation together account for over 90% of all FGIDs. The Rome criteria provide a positive diagnostic approach for FGIDs rather than an exclusion-based diagnosis. It is challenging for general practitioners and gastroenterologists to manage FGIDs given their high prevalence and significant impact on quality of life and healthcare costs.
This document presents a case study of a 31-year-old female patient complaining of worsening heartburn impairing her quality of life for the past year. A trial of PPI therapy provided marked improvement in her symptoms. Two months later, her symptoms recurred, and an endoscopy showed a small hiatal hernia with no signs of reflux and positive H. pylori infection. Ambulatory pH monitoring showed pathological acid reflux. She was treated for H. pylori and maintained on PPI therapy, but complained of increased nocturnal heartburn on step-down therapy. The document discusses various treatment approaches and indications for surgery based on the patient's case.
- The patient, a 48-year-old housewife, presented with nausea, vomiting, loss of appetite, and 7 kg weight loss in the past month with a history of similar symptoms one month ago.
- She was diagnosed with dyspepsia and is being treated with soft food, IV fluids, and omeprazole to eliminate her symptoms while undergoing endoscopy to determine the cause of her dyspepsia.
- The goals are to relieve her current symptoms, identify the cause of her dyspepsia, and prevent future recurrent symptoms and complications through treatment and lifestyle changes.
Point-of-Care Ultrasound Diagnosis an Asset for IBD PatientsJason Jaramillo
An MD practicing at the Maimonides Medical Center in New York, Dr. Jason Jaramillo is part of a community private practice. Jason Jaramillo, MD, provides patient-centered ultrasound diagnostics through the handheld, bedside, Point-of-Care Ultrasound (POCUS) approach.
As reported in Gastroenterology & Endoscopy News, a 2021 University of Calgary study revealed the effectiveness of bedside POCUS in delivering meaningful, efficient care to inflammatory bowel disease (IBD) patients. The impetus was the COVID-19 pandemic and a need to restrict IBD patients’ routine endoscopy access, as well as hospitalization and visits to the emergency department.
Calgary physicians developed a centralized bedside intestinal ultrasound protocol that enabled them to accurately and objectively measure IBD progress in patients. Of the 72 patients evaluated as part of the study, more than 84 percent underwent intestinal ultrasound, sigmoidoscopy, or a combination of the two techniques, which led to detection of active inflammation and significant management changes.
Physicians referred a half dozen of these patents to colorectal surgery for complicated disease resection, and three new IBD diagnoses were made as well. With POCUS diagnosis in place, not a single IBD visited the ER across the duration of the study. In addition, 80 percent of patients avoided acute care in-hospital endoscopy. These results point to POCUS as a significant asset to gastroenterologists seeking to minimize patient time in ER and clinical settings.
The document discusses gastric sensorimotor disorders and their management. It provides an overview of gastric anatomy and functions, common symptoms of sensorimotor disorders, and the prevalence of specific disorders like functional dyspepsia and gastroparesis. It then outlines a logical, step-wise diagnostic algorithm and emphasizes using test results to guide treatment. Finally, it presents three clinical cases and asks which next step would be most appropriate for each.
This document summarizes recent advances in the diagnosis and treatment of gastroesophageal reflux disease (GERD). It discusses new diagnostic tests such as the Bravo capsule and multichannel intraluminal impedance that allow for improved detection of acid and non-acid reflux. It also reviews therapeutic advances for GERD including new drugs that target transient lower esophageal sphincter relaxations, combination therapies, and endoscopic procedures like Stretta and Enteryx that aim to strengthen the lower esophageal sphincter. Finally, it discusses ongoing issues around Barrett's esophagus screening and surveillance.
GIT Kurdistan Board J club Functional heart burn16.Shaikhani.
- The patient has heartburn that does not respond to PPI therapy and has a normal endoscopy. Based on these findings, the most likely diagnosis is functional heartburn (FH). FH is diagnosed when there are typical reflux symptoms but normal acid exposure and no correlation between symptoms and reflux events.
- FH affects both men and women and is associated with visceral hypersensitivity, esophageal dysmotility, and traits seen in other functional gastrointestinal disorders. Diagnosis involves ruling out underlying reflux disease or motility issues through endoscopy, pH testing, and motility studies.
- FH has a benign clinical course but can impact quality of life. Treatment focuses on reassurance and lifestyle changes rather than acid
Approach to Uninvestigated Dyspepsia.pptxAshishSatyal2
This document discusses the approach to uninvestigated dyspepsia. It recommends taking a thorough history and physical examination. Initial management strategies include prompt endoscopy, testing and treating for H. pylori infection, or empirical antisecretory drug therapy. The preferred initial approach depends on the patient's age, risk factors, and prevalence of H. pylori infection in the population. Additional testing may be considered if symptoms remain refractory.
Need a response to the following Therapy guidelines for H. .docxdohertyjoetta
Need a response to the following:
Therapy guidelines for H. Pylori Treatment
H. Pylori remains to be one of the most common chronic bacterial infection affecting humans. Research shows that H. Pylori is normally acquired during childhood, with most victims being those who are socially disadvantaged and people who have migrated to North America (Chey et al., 2017). Although currently, there are no new drugs that have been developed, treatment primarily depends on a mixture of antibiotics and anti-secretory agents. H. Pylori treatment regimens are such as triple therapy, sequential therapy, quadruple treatment, and levofloxacin-based triple therapy (De Francesco et al., 2017). In selecting the best treatment regimen, it’s important to consider previous antibiotic exposure, the rate of eradication, and regional antibiotic-resistance patterns as these can affect the successful treatment of the condition (Myran & Zarbock, 2018). Additionally, it can be noted that for a treatment to be effective and successful, then host factors such as allergies and patient adherence need to be considered (Fashner & Gitu, 2015).
Recent treatment guidelines have recommended quadruple therapy, which consists of PPI and three antibiotics (metronidazole, clarithromycin, and amoxicillin), which are to be administered concurrently (Chey et al., 2017). According to Shiotani et al. (2017), the rationale for this treatment option is that it’s not evidence-based but “hope-based” because gastroenterologists do believe that the infection would be susceptible to metronidazole or clarithromycin.
Patient compliance is a key factor that would determine treatment success. To minimize cases of side effects, clinicians should talk to their patients to adhere to their treatment plans and also instruct their patients on the right time to take their doses in relation to their meal (Li et al., 2019). Patients should be informed that they should avoid taking alcohol with metronidazole, avoid cheese, soy beans, and soy sauce taken with furazolidone (Li et al., 2019). Finally, it’s important to advice the patient to maintain personal hygiene by taking clean water and avoid ingesting contaminated food.
The original work is below in case you needed:
GI Case Study:
Chief complaint:
“I have recurrent H. Pylori infection”.
HPI:
M.C. a 46-year-old Hispanic female presents to the GI clinic for complaint of recurrent H. Pylori infection. She was treated about 2 ½ months ago with H. Pylori triple therapy and failed treatment. She has PMH of dyspepsia, and GERD. She also indicates that she has noticed that her symptoms of dyspepsia are worsening for past 2 months. She has associated her symptoms with nausea, upset stomach with all foods. Denies associated symptoms of hematochezia, melena, hemoptysis, abdominal pain, fever, chills, pain or any other symptoms.
PMH:
H. Pylori infection gastritis
Diabetes Mellitus, type 2
Surgeries:
None
Allergies
:
NKDA
.
This document discusses Helicobacter pylori (H. pylori), the most common bacterial infection worldwide. It causes chronic gastritis and is linked to peptic ulcers, gastric cancer, and lymphoma. Infection rates are higher and acquired earlier in developing countries due to socioeconomic factors. H. pylori is transmitted person-to-person through fecal-oral or oral-oral routes. Treatment requires antibiotic therapy, with clarithromycin-based regimens avoided if there are risk factors for resistance. Eradication should be confirmed with follow-up testing, and culture-guided treatment used for patients who fail multiple regimens.
Dyspepsia, or indigestion, is a common condition affecting 20-30% of the world's population. It includes symptoms like epigastric pain, burning, fullness, and early satiety. While most cases are functional, endoscopy is recommended for patients over age 40, those with red flag symptoms, or a family history of GI cancer to check for potential organic causes like ulcers or cancer. Studies show clinically significant findings in over 90% of dyspeptic patients undergoing endoscopy, including gastritis, ulcers, and rare cases of cancer. Long term PPI use for uninvestigated dyspepsia can increase risks of malabsorption and infections. Thus, thorough evaluation is
Helicobacter pylori is a gram-negative, spiral-shaped bacterium that infects the stomachs of approximately half of the world's population. It is the primary cause of peptic ulcers and is associated with chronic gastritis and gastric cancer. In Pakistan, a study found the prevalence of H. pylori infection to be 74.4%, with risk factors including presence of household animals and larger family size. H. pylori infection is usually treated with a combination of proton pump inhibitors, antibiotics, and bismuth to achieve eradication rates as high as 93%.
Acid peptic disease /dental courses /certified fixed orthodontic courses by I...Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
00919248678078
The document discusses the history and discovery of Helicobacter pylori and its role in peptic ulcer disease. It describes how in the 1980s, Drs. Barry Marshall and Robin Warren discovered that H. pylori infection was a major cause of peptic ulcers, overturning decades of belief. Their discovery was initially met with resistance from the medical community but was later recognized with the 2005 Nobel Prize in Physiology or Medicine. The document also discusses the epidemiology, diagnosis, treatment and antibiotic resistance of H. pylori infection.
This document discusses Helicobacter pylori infection. It begins with a summary of the discovery of H. pylori, including Giulio Bizzozero's initial description in 1892 and Robin Warren and Barry Marshall's cultivation of H. pylori in 1982. It then covers the epidemiology of H. pylori infection, indications for treatment, methods for diagnosing infection, treatments for infection, and the role of H. pylori eradication in preventing gastric cancer. Key points include that over 50% of the world's population is infected with H. pylori and treatment aims to cure ulcers and reduce cancer risk. Diagnosis involves non-invasive tests like serology or breath tests
This document provides guidelines from the American Society for Gastrointestinal Endoscopy on the role of endoscopy in evaluating patients with dyspepsia. It recommends that patients over 50 years old or those exhibiting alarm features should undergo endoscopic evaluation, while those under 50 without alarm features can be initially treated with noninvasive H. pylori testing and treatment if positive or a short course of PPIs. For patients who do not respond to or have recurring symptoms after these initial approaches, endoscopy is recommended to exclude structural diseases. The guidelines aim to optimize the use of endoscopy for diagnosing conditions like peptic ulcer disease or malignancy while avoiding unnecessary endoscopies.
This document presents a case study of a 31-year-old female patient complaining of worsening heartburn impairing her quality of life for the past year. A trial of PPI therapy provided marked improvement in her symptoms. Two months later, her symptoms recurred, and an endoscopy showed a small hiatal hernia with no signs of reflux and positive H. pylori infection. Ambulatory pH monitoring showed pathological acid reflux. She was treated for H. pylori and maintained on PPI therapy, but complained of increased nocturnal heartburn on step-down therapy. The document discusses various treatment approaches and indications for surgery.
Regional Antibiotic Resistance Of Helicobacter PyloriMelissa Dudas
This document discusses Helicobacter pylori (H. pylori), a bacterial pathogen that can cause peptic ulcers and is responsible for most stomach cancers. It begins by providing background on the history of understanding H. pylori's role in ulcers. It was originally thought that stress and diet caused ulcers, but in 1982 Robin Warren and Barry Marshall discovered the connection between H. pylori and ulcers. The document then discusses how H. pylori can cause ulcers if left untreated in the stomach or duodenum. It also notes that H. pylori infection is very common, affecting over half of the world's population.
This document provides an overview of Helicobacter pylori infections. It discusses that H. pylori is the most common bacterial infection worldwide, affecting 70-90% of populations in developing countries. While most infections are asymptomatic, H. pylori can cause peptic ulcer disease in 10% of individuals and gastric cancer in 1%. The document outlines the microbiology of H. pylori, describing it as a gram-negative, microaerophilic spiral bacterium. It also discusses the pathogenesis of H. pylori infections and indications for testing. Treatment guidelines and various testing methods like invasive biopsy-based testing and non-invasive breath and stool antigen tests are also summarized.
Helicobacter pylori associated Peptic ulcer diseaseS M Ali Hasan
Helicobacter pylori is a common cause of peptic ulcer disease. It infects about half of the global population and transmission occurs through person-to-person contact or from infected instruments. Only 10-15% of infected individuals develop ulcers or other diseases. In Bangladesh, H. pylori infection rates are very high, ranging from 67-92% in studies. Treatment involves antibiotic regimens but resistance is a problem, with high rates of resistance to clarithromycin, metronidazole, and levofloxacin seen in Bangladesh. Management of peptic ulcers involves testing and treating H. pylori, endoscopic treatment for bleeding ulcers, and maintenance therapy to prevent
This document summarizes guidelines for the diagnosis and management of gastroesophageal reflux disease (GERD) from the 2013 American College of Gastroenterology. Some of the key points include:
- PPIs are generally safe and effective for treating GERD symptoms but may be associated with rare adverse events like C. difficile infection.
- Screening for Barrett's esophagus should only be done in high-risk patients based on severity and duration of GERD symptoms.
- pH testing on or off PPIs can help diagnose GERD but impedance testing is preferred to detect non-acid reflux as well.
- Weight loss, head of bed elevation, and avoiding
H. pylori is a common human pathogen that causes peptic ulcer disease and gastric cancer by infecting the stomach and causing inflammation. It is transmitted through poor sanitation and hygiene. Over time, the inflammation can lead to cell damage in the stomach lining and increase cancer risk. Treating H. pylori infections with antibiotics can eliminate gastric cancer risk by eradicating the bacteria. The risk level depends on how much damage has already occurred, so follow up after treatment may be needed to check cancer risk in areas where it is more common.
Postpartum Meningitis by Enterococcus Faecalis Secondary to Neuraxial AnesthesiaAnonIshanvi
This study evaluated the efficacy and safety of fecal microbiota transplantation (FMT) for 12 patients with diarrhea-predominant irritable bowel syndrome (IBS-D). Baseline symptoms and scores were assessed using IBS severity scores, Birmingham IBS symptom scores, and quality of life questionnaires. Patients underwent FMT and were followed up at 1, 3, and 6 months. Scores showed significant improvement from baseline to 3 months after FMT, including reduced IBS severity scores and Birmingham scores. FMT was found to provide significant symptom relief for IBS-D over 6 months with no serious adverse events reported.
Travel Clinic Cardiff: Health Advice for International TravelersNX Healthcare
Travel Clinic Cardiff offers comprehensive travel health services, including vaccinations, travel advice, and preventive care for international travelers. Our expert team ensures you are well-prepared and protected for your journey, providing personalized consultations tailored to your destination. Conveniently located in Cardiff, we help you travel with confidence and peace of mind. Visit us: www.nxhealthcare.co.uk
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
Are you looking for a long-lasting solution to your missing tooth?
Dental implants are the most common type of method for replacing the missing tooth. Unlike dentures or bridges, implants are surgically placed in the jawbone. In layman’s terms, a dental implant is similar to the natural root of the tooth. It offers a stable foundation for the artificial tooth giving it the look, feel, and function similar to the natural tooth.
Nano-gold for Cancer Therapy chemistry investigatory projectSIVAVINAYAKPK
chemistry investigatory project
The development of nanogold-based cancer therapy could revolutionize oncology by providing a more targeted, less invasive treatment option. This project contributes to the growing body of research aimed at harnessing nanotechnology for medical applications, paving the way for future clinical trials and potential commercial applications.
Cancer remains one of the leading causes of death worldwide, prompting the need for innovative treatment methods. Nanotechnology offers promising new approaches, including the use of gold nanoparticles (nanogold) for targeted cancer therapy. Nanogold particles possess unique physical and chemical properties that make them suitable for drug delivery, imaging, and photothermal therapy.
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
STUDIES IN SUPPORT OF SPECIAL POPULATIONS: GERIATRICS E7shruti jagirdar
Unit 4: MRA 103T Regulatory affairs
This guideline is directed principally toward new Molecular Entities that are
likely to have significant use in the elderly, either because the disease intended
to be treated is characteristically a disease of aging ( e.g., Alzheimer's disease) or
because the population to be treated is known to include substantial numbers of
geriatric patients (e.g., hypertension).
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
Osvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdfOsvaldo Bernardo Muchanga
GASTROINTESTINAL INFECTIONS AND GASTRITIS
Osvaldo Bernardo Muchanga
Gastrointestinal Infections
GASTROINTESTINAL INFECTIONS result from the ingestion of pathogens that cause infections at the level of this tract, generally being transmitted by food, water and hands contaminated by microorganisms such as E. coli, Salmonella, Shigella, Vibrio cholerae, Campylobacter, Staphylococcus, Rotavirus among others that are generally contained in feces, thus configuring a FECAL-ORAL type of transmission.
Among the factors that lead to the occurrence of gastrointestinal infections are the hygienic and sanitary deficiencies that characterize our markets and other places where raw or cooked food is sold, poor environmental sanitation in communities, deficiencies in water treatment (or in the process of its plumbing), risky hygienic-sanitary habits (not washing hands after major and/or minor needs), among others.
These are generally consequences (signs and symptoms) resulting from gastrointestinal infections: diarrhea, vomiting, fever and malaise, among others.
The treatment consists of replacing lost liquids and electrolytes (drinking drinking water and other recommended liquids, including consumption of juicy fruits such as papayas, apples, pears, among others that contain water in their composition).
To prevent this, it is necessary to promote health education, improve the hygienic-sanitary conditions of markets and communities in general as a way of promoting, preserving and prolonging PUBLIC HEALTH.
Gastritis and Gastric Health
Gastric Health is one of the most relevant concerns in human health, with gastrointestinal infections being among the main illnesses that affect humans.
Among gastric problems, we have GASTRITIS AND GASTRIC ULCERS as the main public health problems. Gastritis and gastric ulcers normally result from inflammation and corrosion of the walls of the stomach (gastric mucosa) and are generally associated (caused) by the bacterium Helicobacter pylor, which, according to the literature, this bacterium settles on these walls (of the stomach) and starts to release urease that ends up altering the normal pH of the stomach (acid), which leads to inflammation and corrosion of the mucous membranes and consequent gastritis or ulcers, respectively.
In addition to bacterial infections, gastritis and gastric ulcers are associated with several factors, with emphasis on prolonged fasting, chemical substances including drugs, alcohol, foods with strong seasonings including chilli, which ends up causing inflammation of the stomach walls and/or corrosion. of the same, resulting in the appearance of wounds and consequent gastritis or ulcers, respectively.
Among patients with gastritis and/or ulcers, one of the dilemmas is associated with the foods to consume in order to minimize the sensation of pain and discomfort.
Breast cancer: Post menopausal endocrine therapyDr. Sumit KUMAR
Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
Staging involves determining the size of the tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The American Joint Committee on Cancer (AJCC) staging system is commonly used. Accurate staging is critical as it guides treatment decisions.
Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
DECLARATION OF HELSINKI - History and principlesanaghabharat01
This SlideShare presentation provides a comprehensive overview of the Declaration of Helsinki, a foundational document outlining ethical guidelines for conducting medical research involving human subjects.
Know the difference between Endodontics and Orthodontics.Gokuldas Hospital
Your smile is beautiful.
Let’s be honest. Maintaining that beautiful smile is not an easy task. It is more than brushing and flossing. Sometimes, you might encounter dental issues that need special dental care. These issues can range anywhere from misalignment of the jaw to pain in the root of teeth.
2. Main objectives
• Epidemiology and Pathophysiology
• Risk factors
• Complication of HP infection
• Specialized diagnostic tests
• Treatment
• Common scenarios in clinical practice
2
3. Introduction
• Barry Mashall and Robin Warren first came across a recurrent gastric /duodenal
ulcer patient in 1982. First published Helicobacter Pylori infection in THE LANCET
1984
• 1985, Marshall drank a broth contained H Pylori bacteria , he did a pre and post
scope showing normal stomach later infected with H Pylori with new gastritis.
This was published in Medical Journal of Australia in 1985.
• Marshall and Robin were awarded Nobel Prize in physiology or medicine in 2005.
3
4. GLOBAL EPIDEMIOLOGY OF HP INFECTION
Zamani, M, Ebrahimtabar, F, Zamani, V, et al. Systematic review with
meta‐analysis: the worldwide prevalence of Helicobacter
pylori infection. Aliment Pharmacol Ther. 2018; 47: 868– 876.
Asia HP Prevalence : 58%
Risk factors: Poor household hygiene, high density population, bed
sharing in childhood, lack of running water
5. Complications of HP infection
5
1) Gastric Adenocarcinoma
2) Bleeding gastric and duodenal ulcer
3) Gastric MALT(mucosa-associated lymphoid tissue)
Lymphoma
4) Gastric Intestinal Metaplasia Changes
5) a/w squamous cell oesophageal cancer
6) a/w idiopathic thrombocytopenia purpura due to anti – CagA
ab cross react with platelet antigens
6. Intestinal Metaplasia - Clinical
Implications
Pangastritis (85%): HP infection
of stomach body causing
suppression of parietal cells and
acid production, leading to
atrophic changes and intestinal
metaplasia, increase risk of
stomach cancer
Antral-type gastritis ( 15%) :
decrease somatostatin and
increase gastrin secretion,
causing increase acid secretion,
increase risk of stomach and
duodenal ulcer.
8. Which Patients to Survey
8
AGA 2019 advised against routine use of endoscopic surveillance for patient with
gastric IM
Pool prevalence of GIM in 897,371 patients is 4.8%
3,5,10 years cumulative gastric cancer incidence : 0.4%, 1.1% , 1.6%
Patient with Gastric IM with specifically higher risk of gastric cancer include those:
> 45 Years old
1) Family history of gastric cancer
2) Extensive IM
3) Incomplete IM
Conditional, Very
Low Evidence
9. Common Clinical Scenarios
9
1) When Should I Test Patient for Helicobacter Pylori
infection for patient?
2) A Patient with history of dyspepsia found to have HP
positive, now his family came to ask about HP testing,
they are asymptomatic, should I do the test for them?
3) A Patient was seen in my clinic for reflux disease,
should I do HP testing for patient?
4) There are many HP treatment in guideline with different
durations, which one should I choose?
5) My Patient failed first line therapy, what should I do?
10. 1)When Should I Test Patient for Helicobacter
Pylori infection for patient?
Indication Evidence
Current/Past hx of peptic ulcer disease 1A
Uninvestigated Dyspepsia 1A
Reflux Symptoms 1C
Gastric MALT Lymphoma 1B
Family hx of gastric cancer 1B
Idiopathic thrombocytopenia 1B
Family hx of peptic ulcer disease 1B
Consider in family members residing in same
household as patients with proven HP infection
1B
El-Serag HB, Kao JY, Kanwal F, et al. Houston
Consensus Conference on Testing for Helicobacter
pylori Infection in the United States. Clin Gastroenterol
Hepatol. 2018;16(7):992-1002.e6.
11. 11
1)When Should I Test Patient for Helicobacter
Pylori infection for patient with dyspepsia?
• Uninvestigated dyspepsia may have underlying H pylori related
peptic ulcer disease, estimated NNT 8 to achieve 1 symptomatic
response.
• Test and treat strategy has been proposed in American college
of gastroenterology, Canadian and Kyoto guidelines
• HP eradication may not resolve the clinical problem, but
successful eradication will reduce significantly long term risk of
peptic ulcer or gastric cancer
Mass Eradication of Helicobacter pylorito Prevent Gastric
Cancer: Theoretical and Practical Considerations.Lee YC,
Chiang TH, Liou JM, Chen HH, Wu MS, Graham DY
Gut Liver. 2016 Jan; 10(1):12-26.
12. Common Clinical Scenarios
12
1) When Should I Test Patient for Helicobacter Pylori
infection for patient?
2) A Patient with history of dyspepsia found to have HP
positive, now his family came to ask about HP testing,
they are asymptomatic, should I do the test for them?
3) A Patient was seen in my clinic for reflux disease,
should I do HP testing for patient?
4) Is Helicobacter Pylori re-infection common?
5) There are many HP treatment in guideline with different
durations, which one should I choose?
6) My Patient failed first line therapy, what should I do?
13. 13
A Patient with history of dyspepsia found to
have HP positive, now his family came to ask
about HP testing, they are asymptomatic,
should I do the test for them?
• 1st degree relatives of those with symptomatic H pylori disease
are usually raised in the same environment as the affected
patient
• H pylori is primarily acquired in childhood and transmitted within
famiies, 1st degree relatives are at increase risk of similar
disease outcome, leading to recommendation of test and treat
strategy.
• This is particularly important in countries with higher gastric
cancer prevalence, such as Japan, Korea, China and Taiwan.
Increased prevalence of precancerous changes in relatives of
gastric cancer patients: critical role of H. pylori.El-Omar EM,
Oien K, Murray LS, El-Nujumi A, Wirz A, Gillen D, Williams C,
Fullarton G, McColl KE
Gastroenterology. 2000 Jan; 118(1):22-30.
14. Common Clinical Scenarios
14
1) When Should I Test Patient for Helicobacter Pylori
infection for patient?
2) A Patient with history of dyspepsia found to have HP
positive, now his family came to ask about HP testing,
they are asymptomatic, should I do the test for them?
3) A Patient was seen in my clinic for reflux disease,
should I do HP testing for patient?
4) There are many HP treatment in guideline with different
durations, which one should I choose?
5) My Patient failed first line therapy, what should I do?
15. 15
A Patient was seen in my clinic for reflux
disease, should I do HP testing for patient?
• GERD is typically a manifestation of robust acid secretion and
abnormal oesophagogastric antireflux barrier.
• High acid output sometimes can be associated with antral type
HP gastritis.
• Unfortunately, Studies shows that treatment of HP in patient
with GERD does not alter the symptoms.
• Thus test is only recommended if patient has concomitant
dyspeptic symptoms, or those who are high risk of HP related
disease.
Raghunath A, Hungin AP, Wooff D, et al. Prevalence
of Helicobacter pylori in patients with gastro-oesophageal
reflux disease: systematic review. BMJ 2003;326:737
Moayyedi P, Bardhan C, Young L, et al. Helicobacter
pylori eradication does not exacerbate reflux symptoms in
gastroesophageal reflux disease. Gastroenterology 2001
16. Approach to Dyspepsia
16
Alarm features? NSAIDS?
> 40, history of GERD?
YES No
OGD to look for
1) Peptic Ulcer
2) Gastric Cancer
3) Barrett’s oesophagus
Non invasive test for HP
infection ( stop PPI 2 weeks)
- UBT
- Stool Antigen Test
- HP serology
Treat if positive, confirm
eradication 4-6 weeks later w
UBT
Trial of PPI x 2-4 weeks
Symptoms persistent
Treat based on findings
17. Helicobacter Pylori Tests
17
Test Advantages Disadvantages
Serology Accesible, least expensive Does not differentiate
current/past infection, cannot
confirm eradication
Stool Antigen test High negative/positive PPV
Use for confirmation
eradication/active infection
Stool sample required,
discontinuation of abx, PPI
Urea Breath Test High negative/positive PPV
Use for confirmation
eradication/active infection
Need resources/trained
personnel
Discontinuation of abx, PPI
Endoscopic
Culture Specificity, test for abx sn Not widely available, variable
sensitivity
Histology Good sn/sp
Provides information such as
intestinal metaplasia, atrophic
gastritis
Requires endoscopy, higher
cost, inter observer variability
Rapid Urease based tests Good sn/sp, rapid,
inexpensive
Requires discontinuation of
antibiotics, PPI.
18. Treatment of Helicobacter Pylori infections
18
Special considerations:
1) Antibiotics previously used by patient
2) Drug allergy
3) Antibiotic Resistance Rate
4) Local guidelines
19. H Pylori Antibiotic resistance in
ASEAN
19
Asian Pac J Cancer May 2018
Antibiotic
resistance profile
China 2019
Clarithromycin 31%
Metronidazole 78%
Levofloxacin 56%
Amoxicillin 9%
Tetrcycline 15%
20. Common Clinical Scenarios
20
1) When Should I Test Patient for Helicobacter Pylori
infection for patient?
2) A Patient with history of dyspepsia found to have HP
positive, now his family came to ask about HP testing,
they are asymptomatic, should I do the test for them?
3) A Patient was seen in my clinic for reflux disease,
should I do HP testing for patient?
4) There are many HP treatment in guideline with different
durations, which one should I choose?
5) My Patient failed first line therapy, what should I do?
21. Treatment Strategies
21
First LIne Duration Eradication
No Penicillin
allergy
1) Amoxicillin 1g BD, Clarithromycin 500mg BD, PPI
BD
2) Amoxicillin 1g BD, Clarithromycin 500mg BD, PPI
BD, Metronidazole 400mg TDS
3) Bismuth subcitrate 240mg BD/subsalicylate 525mg
QDS, metronidazole 400mg TDS, Tetracycline 500
QDS, PPI BD
4) Amoxicillin 1g BD, clarithromycin 500mg BD,
Bismuth and PPI BD
10-14D 70-85%
70-85%
75-90%
Singapore Data Amoxicillin 1g BD, Clarithromycin 500mg BD, PPI BD 7 Days
10 Days
14 Days
76.9%
88.3%
92%
Penicillin Allergy Bismuth subcitrate 240mg BD/subsalicylate 525mg
QDS, metronidazole 400mg TDS, Tetracycline 500 QDS,
PPI BD
14D 75-90%
Helicobacter Pylori Treatment Strategies
in Singapore. Ang TL 2019 Dec
23. Vonoprazan
23
First in class Potassium Competitive Acid Blocker
Provides greater acid suppression compared to
conventional PPI
Useful in GERD, Peptic Ulcer Disease and
Helicobacter Pylori Eradication
27. 3rd and 4th Line therapy
27
Consider Referral for endoscopic evaluation and culture
Options : High Dose Dual Therapy – Rabeprazole 20mg QDS, Amoxicillin 750mg QDS
Medicine (Baltimore). Xue et Al 2019 Feb
28. Rifabutin containing Therapy
28
Antibiotic commonly used for tuberculosis and mycobacterium avium
complex
Not widely available, need special approval to prescribed for HP treatment
Rifabutin-Based Triple Therapy (RHB-105) for Helicobacter pylori Eradication. 2020 May
5]. Graham et al. Ann Intern Med.
Rifabutin-based High-Dose Proton-Pump Inhibitor and Amoxicillin Triple Regimen as the
Rescue Treatment for Helicobacter Pylori. Hyun et al 2014
Regime Eradication
ERADICARE Hp2 2020 Rifabutin 150mg OD/Amoxicillin
1g TDS/Omeprazole 40mg TDS
83.8%
Vs Amoxicillin 1g
TDS/Omeprazole 40mg TDS 14
days
57.7%
Hyun et al Helicobacter 2014 Lansoprazole 30mg
BD+Amoxicillin 1g TDS +Rifabutin
150mg BD
78.1%
Lansoprazole 60mg BD,
Amoxicillin 1g TDS+Rifabutin
150mg BD
96.3%
29. Helicobacter Pylori Treatment
29
Triple Therapy Quad Therapy
High Dose
Dual/Levofloxacin
containing agent
Non Penicillin
Allergy
Quad
Therapy
Levofloxacin
Containing
Therapy
Rifabutin
Containing
Therapy
Penicillin
Allergy
Consider Gastric Biopsy for
Culture and Sensitivity
Use high dose PPI
Consider role of
Vonoprazan
30. Other Practical Scenarios
30
1) Can I use Serology to look for active HP infection?
Serology Testing not suitable to detect active HP infection, it measures
exposure.
A confirmatory UBT test should be done for patient if serology positive
2) How long Should antibiotic and PPI be stopped before UBT?
4 weeks
3) My Patient concerns he may have gastric pain once PPI stopped upon
treatment completion while waiting for UBT 4 weeks later, are there any
medication he can take without affecting the result?
- Yes , H2 blockers and antacids may be utilized without affecting accuracy
of UBT
4) My Patient asked if he can get HP reinfection again in future
- Based on studies, the reinfection rate ranges from 1.7%-3.3%
- Risk of reinfection – younger age, infection of close contacts, dental plaque
and low income
Once successful eradication, we recommend against further HP testing
unless patient develop new symptoms/recurrent symptoms years later.
31. Summary
31
1) Helicobacter Pylori Infection is common, patient with
recurrent/persistent dyspepsia, history of peptic ulcer disease, family of
gastric cancer should be tested for Helicobacter Pylori Infection
2) Urea Breath Test is the best tool to look for active Helicobacter pylori
infection
3) Patient with HP Serology positive should be referred for UBT
confirmation prior to treatment
4) Eventhough local clarithromycin resistance rate reported as 17%, our
local triple therapy regime 14 days sensitivity still achieve > 90%
eradication rate, thus still consider being used as first line treatment
5) Bismuth based quad therapy is the first line treatment for patients
with penicillin allergy
6) Consider to refer when :
- Red Flags
- Failure to response to first line therapy
- Persistent Symptoms
- High risk for gastric cancer