A 47-year-old female patient attends her GP with a one week history of nausea, upper abdominal
discomfort and acid reflux. Four weeks earlier she had completed a Helicobacter pylori (H. pylori)
eradication therapy, consisting of omeprazole, amoxicillin and clarithromycin. What is the most
appropriate next step in the management of this patient?
A. Re-test for H. pylori using a carbon-13 urea breath test [63%]
B. Refer the patient for an upper GI endoscopy [17%]
C. Re-test for H. pylori using a stool antigen test [8%]
D. Commence second-line treatment for H. pylori with omeprazole, amoxicillin and
doxycycline [1%]
E. Commence second-line treatment for H. pylori with omeprazole, amoxicillin and
metronidazole [8%]
Incorrect. Correct answer is A
63% answered correctly
Explanation:
The presentation of this patient suggests an inadequate response with her initial H. pylori
eradication regime. Expert opinion recommends re-testing for H. pylori before second-line treatment
is considered to confirm eradication as there are serious side effects associated with antibiotics, e.g.
Clostridium difficile infection, and antibiotic resistance is increasing.
According to the British Infection Association1, the carbon-13 urea breath test is the most accurate
method of re-testing for H. pylori. This should be performed 4 weeks after the eradication therapy
since antibiotics and proton pump inhibitors (PPIs) can suppress the bacteria causing a false
negative result.
A PPI, amoxicillin and clarithromycin or a PPI, amoxicillin and metronidazole is typically used first-
line in H. pylori eradication. Second-line treatment will use a PPI, amoxicillin and either
clarithromycin or metronidazole whichever was not used for first-line treatment.
In patients who have an inadequate response to second-line treatment, patients should be referred
for upper GI endoscopy.
1.
https://www.gov.uk/government/uploads/system/uploads/attachmentdata/file/346305/Helicobacterguidanceupda
Helicobacter pylori: tests
Urea breath test
patients consume a drink containing carbon isotope 13 (13C) enriched urea
urea is broken down by H. pylori urease
after 30 mins patient exhale into a glass tube
mass spectrometry analysis calculates the amount of 13C CO2
should not be performed within 4 weeks of treatment with an antibacterial or within 2 weeks of
an antisecretory drug (e.g. a proton pump inhibitor)
sensitivity 95-98%, specificity 97-98%
may be used to check for H. pylori eradication
Rapid urease test (e.g. CLO test)
biopsy sample is mixed with urea and pH indicator
colour change if H pylori urease activity
sensitivity 90-95%, specificity 95-98%
Serum antibody
remains positive after eradication
sensitivity 85%, specificity 80%
Culture of gastric biopsy
provide information on antibiotic sensitivity
sensitivity 70%, specificity 100%
Gastric biopsy
histological evaluation alone, no culture
sensitivity 95-99%, specificity 95-99%
Stool antigen test
sensitivity 90%, specificity 95%
Time spent:162 sec QID:8027
Subject:
Gastroenterology
