Leaky

Gastrointestinal System


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

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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.

Adrenaline monotherapy

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

References

  1. LAINE L, JENSEN DM. Management of patients with ulcer bleeding. Am J Gastroenterol [online] 2012 Mar, 107(3):345-60; quiz 361 [viewed 08 June 2014] Available from: doi:10.1038/ajg.2011.480
  2. National Institute for Health and Clinical Excellence (NICE). Acute upper gastrointestinal bleeding: management. London (UK): National Institute for Health and Clinical Excellence (NICE); 2012 Jun. 23 p. (Clinical guideline; no. 141).
  3. University of Texas at Austin, School of Nursing Family Nurse Practitioner Program. Recommendations in primary care for the most efficacious and cost effective pharmacologic treatment for Helicobacter pylori in non-pregnant adults. Austin (TX): University of Texas at Austin, School of Nursing; 2013 May. 17 p.
  4. CHEY WD, WONG BC, PRACTICE PARAMETERS COMMITTEE OF THE AMERICAN COLLEGE OF GASTROENTEROLOGY. American College of Gastroenterology guideline on the management of Helicobacter pylori infection. Am J Gastroenterol [online] 2007 Aug, 102(8):1808-25 [viewed 08 June 2014] Available from: doi:10.1111/j.1572-0241.2007.01393.x
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