Diagnostic tests for H. pylori
The diagnostic tests for H. pylori can be divided into those that require endoscopy, and those that do not.
Endoscopic techniques include histological analysis, rapid urease testing, cultures, and polymerase chain reactions (PCR).
Non-endoscopic tests include antibody testing, the urea breath-test and fecal antigen testing.
Histology is considered the gold standard of diagnosis, as it has excellent sensitivity and specificity; however, it is expensive, and requires specialized equipment and trained personnel, thus limiting its value.
Rapid urease testing is inexpensive and provides rapid results; it also has excellent specificity and a very good sensitivity in properly selected patients. However, the sensitivity is significantly reduced in the post-treatment setting.
Of the non-endoscopic tests, antibody testing is inexpensive, widely available, and has a very good negative predictive value.
Note that the exact diagnostic test used should be selected on a patient by patient basis
Proton Pump Inhibitor Therapy
Long-term anti-ulcer therapy is generally indicated (e.g. daily proton pump inhibitors - PPI) in patients with idiopathic (i.e. non-H. pylori, non-NSAID) ulcers, and in patients with ulcers who are required to continue NSAID therapy.
In addition, long term daily PPI therapy is also recommended in patients who require low-dose aspirin for secondary prevention of cardiac events, so as to minimize the risk of rebleeding of the ulcer.
H. pylori eradication therapy
In the United States, the recommended primary therapies for H. pylori infection include a proton pump inhibitor (PPI), clarithromycin, and amoxicillin or metronidazole (i.e. clarithromycin-based triple therapy) for 14 days; or a PPI or H2 receptor antagonist (H2RA), bismuth, metronidazole, and tetracycline (bismuth quadruple therapy) for 10-14 days.
The first course of therapy offers the greatest chance of eradicating H. pylori infection.
Subsequent treatments, particularly if the same antibiotics are used, or if the patient has been previously exposed to any antibiotics contained in the treatment regimen, are less likely to become successful.
Therefore, it is important to only use treatment regimens for which there is evidence of proven effectiveness
When to transfuse platelets?
According to current guidelines, platelet transfusion should be offered to patients who are actively bleeding, and who have a platelet count of less than 50 x 10^9/litre.
Platelet transfusion should not be offered to patients who are not actively bleeding, and are hemodynamically stable.
It is not recommended to use adrenalin/epinephrin as monotherapy in the endoscopic treatment of non-variceal bleeding.
Recommended methods include:
• a mechanical method (e.g. clips), with or without adrenaline
• thermal coagulation, with adrenaline
• fibrin or thrombin, with adrenaline
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