Gastritis, dyspepsia, and peptic ulcer disease are common causes of abdominal pain that may be caused by Helicobacter pylori infection. When people with peptic ulcers have H. pylori infections, antibiotic treatment can help speed the initial healing of some ulcers and may prevent ulcers from returning. Testing for H. pylori infection is uncommon in EDs in the United States despite abdominal pain being one of the most common complaints in ED visits.
Test & Treat
In general, a “test and treat” strategy is recommended for patients with uninvestigated dyspepsia who do not have “red flags” for cancer. Successful identification of infection in the ED and initiation of antibiotic treatment may reduce future risk of gastritis, gastric lymphoma, and gastric cancer. This approach may also be cost-effective by reducing future healthcare costs and symptom severity.
In my opinion, there are a few reasons why testing and treating for H. pylori infection should not be performed in ED patients who have uninvestigated dyspepsia and do not have red flags for more serious disease. First, testing can occur at the bedside with almost real-time results. Second, a positive test leads to an immediate change in how patients are managed. Third, treatment of H. pylori infection may have beneficial downstream effects on healthcare utilization. These include decreases in:
• Long-term proton pump inhibitor use.
• Inappropriate use of endoscopy.
• Future doctor visits.
In our ED at George Washington University, the prevalence of H. pylori infection is roughly 25% in symptomatic patients. Using a test and treat approach, we have anecdotally observed a high degree of physician and patient satisfaction.
How to Test
Testing can occur via blood antibodies, endoscopic tissue samples, stool antigen, or urea breath test (UBT). In our ED, we have tested for about 2 years using a 13C UBT for symptomatic patients. 13C is a non-radioactive, less common isotope of carbon that can be detected in the exhaled carbon dioxide of patients infected with H. pylori. We have found that the 13C UBT is an easy modality to use in the ED setting for several reasons. The test is non-invasive, patients tolerate it well, inexperienced medical personnel can administer the test, and the results are available within about 10 minutes. All patients who test positive and are treated with antibiotics should be retested 4 weeks after completion of antibiotics to confirm eradication.
Pitfalls of Testing
The downside of an ED test and treat strategy is that physicians must be careful about prematurely closing a differential diagnosis, thus missing a more serious illness, such as acute cholecystitis or pancreatitis. Patients with red flags need to be encouraged to follow-up with a gastroenterologist for a definitive test to rule out a more serious
cause of pain.
Readings & Resources (click to view)
Ford AC, Moayyedi P, Jarbol DE, Logan RF, Delaney BC. Meta-analysis: Helicobacter pylori ‘test and treat’ compared with empirical acid suppression for managing dyspepsia. Aliment Pharmacol Ther. 2008;28:534-544.
Ford AC, Moayyedi P. Current guidelines for dyspepsia management. Dig Dis. 2008;26:225-230.
Asaka M, Kato M, Graham DY. Prevention of gastric cancer by Helicobacter pylori eradication. Intern Med. 2010;49:633-636.
Mason JM, Raghunath AS, Hungin AP, Jackson W. Helicobacter pylori eradication in long-term proton pump inhibitor users is highly cost-effective: economic analysis of the HELPUP trial. Aliment Pharmacol Ther. 2008;28:1297-1303.
Meltzer AC, Pierce R, Cummings DA, et al. Rapid (13)C urea breath test to identify Helicobacter pylori infection in emergency department patients with upper abdominal pain. West J Emerg Med. 2013;14:278-282.