Gastritis guideline recommendation

• Testing for H. pylori infection is indicated in patients with active peptic ulcer disease, a past history of documented peptic ulcer or gastric MALT lymphoma.

• The test-and-treat strategy for H. pylori infection is a proven management strategy for patients with uninvestigated dyspepsia who are under the age of 55 yr and have no “alarm features” (bleeding, anemia, early satiety, unexplained weight loss, progressive dysphagia, odynophagia, recurrent vomiting, family history of gastrointestinal cancer, previous esophagogastric malignancy).

• Active peptic ulcer disease (gastric or duodenal ulcer)

• Confirmed history of peptic ulcer disease (not previously treated for H. pylori)

• Gastric MALT lymphoma (low grade)

• After endoscopic resection of early gastric cancer

• Uninvestigated dyspepsia (depending upon H. pylori prevalence)

• Nonulcer dyspepsia

• Gastroesophageal reflux disease

• Persons using nonsteroidal antiinflammatory drugs (NSAIDs)

• Unexplained iron deficiency anemia

• Populations at higher risk for gastric cancer

• • Excellent sensitivity (>95%) and specificity (95%)

• Expensive and requires infrastructure and trained personnel
• Detection improved by use of special stains- e.g. the Warhin-Starry silver stain, or the cheaper giemsa staning protocol

• Inexpensive and provides rapid results
• Excellent specificity (99%) and very good sensitivity (98%) in properly selected patients

• Sensitivity significantly reduced in the post-treatment setting

• Excellent specificity
• Allows determination of antibiotic sensitivities

• Expensive, difficult to perform, and not widely available
• Poor sensitivity if adequate transport media are not available
• Experience/ expertise required

• Excellent sensitivity and specificity
• Allows determination of antibiotic sensitivities

• Methodology not standardized across laboratories and not widely available
• Considered experimental

• Inexpensive and widely available
• Very good NPV
• Sensitivity (85-92%) and specificity (70-83%)

• PPV dependent upon background H. pylori prevalence
• Not recommended after H. pylori therapy
• Less accurate and does not identify infection

• Identifies active H. pylori infection
• Excellent PPV and NPV regardless of H. pylori prevalence
• Useful before and after H. pylori therapy
• Sensitivity (95%) and specificity (96%

• Reimbursement and availability remain inconsistent

• Identifies active H. pylori infection
• Excellent positive and negative predictive values regardless of H. pylori prevalence
• Useful before and after H. pylori therapy
• Sensitivity (95%) and specificity (94%)

• Polyclonal test less well validated than the urea breath test (UBT) in the post-treatment setting
• Monoclonal test appears reliable before and after antibiotic therapy
• Unpleasantness associated with collecting stool

PPI = proton pump inhibitor; PPV = positive predictive value; NPV = negative predictive value; UBT = urea breath test.

• In the United States, the recommended primary therapies for H. pylori infection include: a PPI, clarithromycin, and amoxicillin, or metronidazole (clarithromycin-based triple therapy) for 14 days or a PPI or H2RA, bismuth, metronidazole, and tetracycline (bismuth quadruple therapy) for 10–14 days.

• Sequential therapy consisting of a PPI and amoxicillin for 5 days followed by a PPI, clarithromycin, and tinidazole for an additional 5 days may provide an alternative to clarithromycin-based triple or bismuth quadruple therapy but requires validation within the United States before it can be recommended as a first-line therapy.

clarithromycin 500 mg b.i.d., amoxicillin 1,000 mg b.i.d.

metronidazole 500 mg b.i.d.

250 mg p.o. q.i.d., tetracycline 500 mg p.o. q.i.d.,

ranitidine 150 mg p.o. b.i.d. or standard dose

PPI q.d. to b.i.d.

*Standard dosages for PPIs are as follows:

lansoprazole 30 mg p.o., omeprazole 20 mg p.o., pantoprazole 40 mg p.o., rabeprazole 20 mg p.o., esomeprazole 40 mg p.o.

Note: the above recommended treatments are not all FDA approved. The FDA approved regimens are as follows:

1. Bismuth 525 mg q.i.d. + metronidazole 250 mg q.i.d. + tetracycline 500 mg q.i.d. × 2 wk + H2RA as directed × 4 wk.

2. Lansoprazole 30 mg b.i.d. + clarithromycin 500 mg b.i.d. + amoxicillin 1 g b.i.d. × 10 days.

3. Omeprazole 20 mg b.i.d. + clarithromycin 500 mg b.i.d. + amoxicillin 1 g b.i.d. × 10 days.

4. esomeprazole 40 mg q.d. + clarithromycin 500 mg b.i.d. + amoxicillin 1 g b.i.d. × 10 days.

5. Rabeprazole 20 mg b.i.d. + clarithromycin 500 mg b.i.d. + amoxicillin 1 g b.i.d. × 7 days.

PPI q.d. tetracycline, Pepto Bismol, metronidazole q.i.d.

PPI, amoxicillin 1 g b.i.d., levofloxacin 500 mg q.d.

PPI = proton pump inhibitor; q.d. = daily; q.i.d. = four times daily; b.i.d. = twice daily.