About gall stones

What is H. pylori?
Helicobacter pylori (H. pylori) is a spiral-shaped bacterium that is
found in the gastric mucous layer or adherent to the epithelial
lining of the stomach. H. pylori causes more than 90% of duodenal
ulcers and up to 80% of gastric ulcers. Before 1982, when this
bacterium was discovered, spicy food, acid, stress, and lifestyle
were considered the major causes of ulcers. The majority of patients
were given long-term medications, such as H2 blockers, and more
recently, proton pump inhibitors, without a chance for permanent
cure. These medications relieve ulcer-related symptoms, heal gastric
mucosal inflammation, and may heal the ulcer, but they do NOT treat
the infection. When acid suppression is removed, the majority of
ulcers, particularly those caused by H. pylori, recur. Since we now
know that most ulcers are caused by H. pylori, appropriate antibiotic
regimens can successfully eradicate the infection in most patients,

with complete resolution of mucosal inflammation and a minimal chance
for recurrence of ulcers.
How common is H. pylori infection?
Approximately two-thirds of the world’s population is infected with
H. pylori. In the United States, H. pylori is more prevalent among
older adults, African Americans, Hispanics, and lower socioeconomic
groups.
What illnesses does H. pylori cause?
Most persons who are infected with H. pylori never suffer any
symptoms related to the infection; however, H. pylori causes chronic
active, chronic persistent, and atrophic gastritis in adults and
children. Infection with H. pylori also causes duodenal and gastric
ulcers. Infected persons have a 2- to 6-fold increased risk of
developing gastric cancer and mucosal-associated-lymphoid-type (MALT)
lymphoma compared with their uninfected counterparts. The role of H.
pylori in non-ulcer dyspepsia remains unclear.
What are the symptoms of ulcers?
Approximately 25 million Americans suffer from peptic ulcer disease
at some point in their lifetime. Each year there are 500,000 to
850,000 new cases of peptic ulcer disease and more than one million
ulcer-related hospitalizations. The most common ulcer symptom is
gnawing or burning pain in the epigastrium. This pain typically
occurs when the stomach is empty, between meals and in the early
morning hours, but it can also occur at other times. It may last from
minutes to hours and may be relieved by eating or by taking antacids.
Less common ulcer symptoms include nausea, vomiting, and loss of
appetite. Bleeding can also occur; prolonged bleeding may cause
anemia leading to weakness and fatigue. If bleeding is heavy,
hematemesis, hematochezia, or melena may occur.
Who should be tested and treated for H. pylori ?
Persons with active gastric or duodenal ulcers or documented history
of ulcers should be tested for H. pylori, and if found to be
infected, they should be treated. To date, there has been no
conclusive evidence that treatment of H. pylori infection in patients
with non-ulcer dyspepsia is warranted. Testing for and treatment of
H. pylori infection are recommended following resection of early
gastric cancer and for low-grade gastric MALT lymphoma. Retesting
after treatment may be prudent for patients with bleeding or
otherwise complicated peptic ulcer disease. Treatment recommendations
for children have not been formulated. Pediatric patients who require
extensive diagnostic work-ups for abdominal symptoms should be
evaluated by a specialist.
How is H. pylori infection diagnosed?
Several methods may be used to diagnose H. pylori infection.
Serological tests that measure specific H. pylori IgG antibodies can
determine if a person has been infected. The sensitivity and
specificity of these assays range from 80% to 95% depending upon the
assay used. Another diagnostic method is the breath test. In this
test, the patient is given either 13C- or 14C-labeled urea to drink.
H. pylori metabolizes the urea rapidly, and the labeled carbon is
absorbed. This labeled carbon can then be measured as CO2 in the
patient’s expired breath to determine whether H. pylori is present.
The sensitivity and specificity of the breath test ranges from 94% to
98%. Upper esophagogastroduodenal endoscopy is considered the
reference method of diagnosis. During endoscopy, biopsy specimens of
the stomach and duodenum are obtained and the diagnosis of H. pylori
can be made by several methods: The biopsy urease test - a
colorimetric test based on the ability of H. pylori to produce
urease; it provides rapid testing at the time of biopsy. Histologic
identification of organisms - considered the gold standard of
diagnostic tests. Culture of biopsy specimens for H. pylori, which
requires an experienced laboratory and is necessary when
antimicrobial susceptibility testing is desired.
What are the treatment regimens used for H. pylori eradication?
Therapy for H. pylori infection consists of 10 days to 2 weeks of one
or two effective antibiotics, such as amoxicillin, tetracycline (not
to be used for children <12 yrs.), metronidazole, or clarithromycin,
plus either ranitidine bismuth citrate, bismuth subsalicylate, or a
proton pump inhibitor. Acid suppression by the H2 blocker or proton
pump inhibitor in conjunction with the antibiotics helps alleviate
ulcer-related symptoms (i.e., abdominal pain, nausea), helps heal
gastric mucosal inflammation, and may enhance efficacy of the
antibiotics against H. pylori at the gastric mucosal surface.
Currently, eight H. pylori treatment regimens are approved by the
Food and Drug Administration (FDA) (Table 1); however, several other
combinations have been used successfully. Antibiotic resistance and
patient noncompliance are the two major reasons for treatment
failure. Eradication rates of the eight FDA-approved regimens range
from 61% to 94% depending on the regimen used. Overall, triple
therapy regimens have shown better eradication rates than dual
therapy. Longer length of treatment (14 days versus 10 days) results
in better eradication rates.
FDA-Approved Treatment Options
FDA-approved treatment options
Omeprazole 40 mg QD + clarithromycin 500 mg TID x 2 wks, then
omeprazole 20 mg QD x 2 wks
-OR-
Ranitidine bismuth citrate (RBC) 400 mg BID + clarithromycin 500 mg
TID x 2 wks, then RBC 400 mg BID x 2 wks
-OR-
Bismuth subsalicylate (Pepto Bismol®) 525 mg QID + metronidazole 250
mg QID + tetracycline 500 mg QID* x 2 wks + H2 receptor antagonist
therapy as directed x 4 wks
-OR-
Lansoprazole 30 mg BID + amoxicillin 1 g BID + clarithromycin 500 mg
TID x 10 days
-OR-
Lansoprazole 30 mg TID + amoxicillin 1 g TID x 2 wks**
-OR-
Rantidine bismuth citrate 400 mg BID + clarithromycin 500 mg BID x 2
wks, then RBC 400 mg BID x 2 wks
-OR-
Omeprazole 20 mg BID + clarithromycin 500 mg BID + amoxicillin 1 g
BID x 10 days
-OR-
Lansoprazole 30 mg BID + clarithromycin 500 mg BID + amoxicillin 1 g
BID x 10 days
*Although not FDA approved, amoxicillin has been substituted for
tetracycline for patients for whom tetracycline is not recommended.
**This dual therapy regimen has restrictive labeling. It is indicated
for patients who are either allergic or intolerant to clarithromycin
or for infections with known or suspected resistance to
clarithromycin.
Are there any long-term consequences of H. pylori infection?
Recent studies have shown an association between long-term infection
with H. pylori and the development of gastric cancer. Gastric cancer
is the second most common cancer worldwide; it is most common in
countries such as Colombia and China, where H. pylori infects over
half the population in early childhood. In the United States, where
H. pylori is less common in young people, gastric cancer rates have
decreased since the 1930s.
How do people get infected with H. pylori?
It is not known how H. pylori is transmitted or why some patients
become symptomatic while others do not. The bacteria are most likely
spread from person to person through fecal-oral or oral-oral routes.
Possible environmental reservoirs include contaminated water sources.
Iatrogenic spread through contaminated endoscopes has been documented
but can be prevented by proper cleaning of equipment.
What can people do to prevent H. pylori infection?
Since the source of H. pylori is not yet known, recommendations for
avoiding infection have not been made. In general, it is always wise
for persons to wash hands thoroughly, to eat food that has been
properly prepared, and to drink water from a safe, clean source.
What is the Centers for Disease Control and Prevention (CDC) doing to
prevent H. pylori infection?
CDC, with partners in other government agencies, academic
institutions, and industry, is conducting a national education
campaign to inform health care providers and consumers of the link
between H. pylori and stomach and duodenal ulcers. CDC is also
working with partners to study routes of transmission and possible
prevention measures, and to establish an antimicrobial resistance
surveillance system to monitor the changes in resistance among H.
pylori strains in the United States.
How can I get more information about H. pylori?
1. NIH Consensus Development Conference. Helicobacter pylori in
peptic ulcer disease. JAMA 272:65-69, 1994.
2. Soll, AH. Medical treatment of peptic ulcer disease. Practice
guidelines. [Review]. JAMA 275:622-629, 1996. [published erratum
appears in JAMA 1996 May 1;275:1314].
3. Hunt, RH. Helicobacter pylori: from theory to practice.
Proceedings of a symposium. Am J Med 1996; 100 (5A) supplement.
4. The American Gastroenterological Association, American Digestive
Health Foundation, 7910 Woodmont Avenue, 7th floor, Bethesda, MD
20814, (301) 654-2055 telephone, (301) 654-5920 fax.
5. The National Digestive Diseases Information Clearinghouse,
National Institute of Diabetes and Digestive and Kidney Diseases,
National Institutes of Health, 2 Information Way, Bethesda, MD 20892-
3570, (301) 654-3810 telephone.
6. Hunt RH, Thompson ABR. Canadian Helicobacter pylori Consensus
Conference. Can J. Gastroenterol 1998, 12(1):31-41.
7. European Helicobacter pylori Study Group. Current European
concepts in the management of H. pylori information. The Maastricht
Consensus. Gut 1997; 41, 8-13.
For further information, contact:
Health Communications Activity
Division of Bacterial and Mycotic Diseases
National Center for Infectious Diseases
Centers for Disease Control and Prevention
1600 Clifton Road, MS-A49
Atlanta, GA 30333
1-888-MY-ULCER (1-888-698-5237)