Gastritis guideline recommendation

Gastritis Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Gastritis from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

Physical Examination

Diagnostic tests

Endoscopic tests
Nonendoscopic tests

X Ray

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Gastritis guideline recommendation On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Gastritis guideline recommendation

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Gastritis guideline recommendation

CDC on Gastritis guideline recommendation

Gastritis guideline recommendation in the news

Blogs on Gastritis guideline recommendation

Directions to Hospitals Treating Gastritis

Risk calculators and risk factors for Gastritis guideline recommendation

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:  Aravind Reddy Kothagadi M.B.B.S[2]

## Overview

[edit | edit source]

American collage of gastroenterology guidelines for the management of H. pylori gastritis.

## ACG recommendations

[edit | edit source]

The following are the American College of Gastroenterology guidelines for H. pylori gastritis.[1]

### Diagnosis

[edit | edit source]

Recommendations

* 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).

Indications for Diagnosis and Treatment of H.pylori Infection

Established

* 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)

Controversial

* Nonulcer dyspepsia

* Gastroesophageal reflux disease

* Persons using nonsteroidal antiinflammatory drugs (NSAIDs)

* Unexplained iron deficiency anemia

* Populations at higher risk for gastric cancer

### Diagnostic Testing for H.pylori Infection

[edit | edit source]

* Testing for H. pylori should only be performed if the clinician plans to offer treatment for positive results.
* Deciding which test to use in which situation relies heavily upon whether a patient requires evaluation with upper endoscopy and an understanding of the strengths, weaknesses, and costs of the individual tests.

Endoscopic testing  | Advantages  | Disadvantages

|
|

*1. Histology |

*     * 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

*2. Rapid urease testing |

* 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

*3. Culture |

* 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

*4. Polymerase chain reaction (PCR) |

* Excellent sensitivity and specificity
* Allows determination of antibiotic sensitivities

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

Nonendoscopic testing  | Advantages  | Disadvantages
1\. ELISA serology (quantitative and qualitative) |

* 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

*2. Urea breath tests (13C and 14C) |

* 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

*3. Fecal antigen test |

* 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

*The sensitivity of all endoscopic and nonendoscopic tests that identify active H. pylori infection is reduced by the recent use of PPIs, bismuth, or antibiotics

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

For more information on endoscopic diagnostic studies please click here

For more information on nonendoscopic diagnostic studies please click here

### Treatment of H.pylori Infection

[edit | edit source]

Primary Treatment of H.pylori Infection

* 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.

First-Line Regimens for Helicobacter pylori Eradication

Regimen  | Duration  | Eradication Rates  | Comments
Standard dose PPI b.i.d. (esomeprazole is q.d.),

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

| 10–14  | 70–85%  | Consider in non-penicillin allergic patients who have not previously received a macrolide
Standard dose PPI b.i.d., clarithromycin 500 mg b.i.d.

metronidazole 500 mg b.i.d.

| 10–14  | 70–85%  | Consider in penicillin allergic patients who have not previously received a macrolide or are unable to tolerate bismuth quadruple therapy
Bismuth subsalicylate 525 mg p.o. q.i.d. metronidazole

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.

| 10–14  | 75–90%  | Consider in penicillin allergic patients
PPI \+ amoxicillin 1 g b.i.d. followed by:  | 5  | >90%  | Requires validation in North America
PPI, clarithromycin 500 mg, tinidazole 500 mg b.i.d.  | 5  |  |
PPI = proton pump inhibitor; pcn = penicillin; p.o. = orally; q.d. = daily; b.i.d. = twice daily; t.i.d. = three times daily; q.i.d. = four times daily.

*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.

#### Salvage Therapy for Persistent H.pylori Infection

[edit | edit source]

* In patients with persistent H. pylori infection, every effort should be made to avoid antibiotics that have been previously taken by the patient.
* Bismuth-based quadruple therapy for 7-14 days is an accepted salvage therapy.
* Levofloxacin-based triple therapy for 10 days is another option in patients with persistent infection, which requires validation in the United States.

Recommendations

Regimen  | Duration  | Eradication Rates  | Comments
Bismuth quadruple therapy

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

| 7  | 68% (95% CI 62–74%)  | Accessible, cheap but high pill count and frequent mild side effects
Levofloxacin triple therapy

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

| 10  | 10 87% (95% CI 82–92%)  | Requires validation in North America
For recommendations regarding rifabutin and furazolidone, please refer to the text.

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

## References

[edit | edit source]

1. ↑ https://gi.org/guideline/management-of-helicobacter-pylori-infection/ (2007) Accessed on January 23, 2017