Think you know everything about peptic ulcer disease? Find out here, with concepts, cases, and sample questions based on the author's recent attendance at the Internal Medicine Board Review at the Cleveland Clinic Foundation.
Histopathology of Helicobacter pylori infection in a gastric foveolar pit. Licensed under Creative Commons Attribution-Share Alike 3.0 via Wikimedia Commons.
Second in a 5-part Series
Back in 1982, Drs Barry Marshall and Robin Warren tried to tell the world that a bacterium could cause ulcers, gastritis, and cancer. Hardly anyone took them seriously. Fortunately, the prevailing skepticism gave way and these gentlemen and scholars won a Nobel Prize, and that settled the issue once and for all.
I recently attended an Internal Medicine Board Review,1 and although I am not recertifying this year, I received some valuable guidance. Among other things I found that did not know enough about Helicobacter pylori.
Is it worth spending time on a single bacterium? When that bacterium’s resume includes inflammation, atrophic gastritis, iron deficiency, B12 deficiency, gastric/duodenal ulcers, gastric cancer, and MALTomas, I think it is. Let’s look at some clinical questions, background, and points about H. pylori that might help you improve your approach to test questions and to patient care.
- How has the landscape for managing peptic ulcer disease changed?
- When do you look for H. pylori as a pathogen?
Question 12: A 65-year-old woman presents with a chief complaint of “gnawing” epigastric pain and a hemoglobin level of 10.9 g/dL. You are asked to choose her most significant risk factor for ulcer disease from among a nonselective NSAID, age, an H. pylori infection, a COX-2 inhibitor, and cardioprotective aspirin.
Answer:H. pylori infection
Most physicians are tempted to answer a nonselective NSAID. NSAIDs are causative in about one-fourth of folks with ulcer disease. In fact: H. pylori is the most common cause of ulcers, tipping the scales at 3 out of 4, especially in the case of duodenal ulcers. Age isn’t a bad answer. The propensity for ulcers does increase with age, but only because 2 other major risk factors are more prevalent in aging adults: H. pylori and NSAID use.
Question 22: A 39-year-old complains of epigastric discomfort that worsens after eating. What is the best diagnostic approach? An 8-week trial of a proton pump inhibitor (PPI), upper GI endoscopy, breath testing for H. pylori, empiric antibiotic treatment for H. pylori, or a gastric emptying study.
Answer: Breath testing
Because we are concentrating on the importance of H. pylori, the answer is a breath test followed, if positive, by treatment. Always make sure that alarm symptoms-hematemesis, melena, anemia, weight loss, nausea, and vomiting-are absent. Their presence leads to endoscopy. Diagnosis and management of H. pylori is a more fruitful approach than a PPI trial.
Question 33: A 45-year-old man undergoes endoscopy for dyspepsia and nausea and receives a diagnosis of H. pylori infection and a duodenal ulcer. He completes 14 days of triple therapy. He is better but still is not back to baseline. What do you do next? Perform a breath test, repeat endoscopy, do an H. pylori antibody test, get a CT scan of the abdomen, or order an ultrasound of the abdomen.
Answer: Do the H. pylori breath test
Let’s unpack the rationale. After therapy, eradication of H. pylori should be demonstrated. If treatment fails, it is appropriate to retreat. But 2 choices are offered for eradication testing, the breath test and antibodies. Also, another test is available that is not in the choices, the fecal antigen test. Antibodies will be positive for 1 to 3 years after successful eradication. They will not be helpful in this instance. Two tests are accurate-the fecal antigen test (not an antibody) and the breath test, which is the correct answer. Because both the antigen test and the breath test work in this instance, only 1 was offered as a choice.
The landscape for H. pylori has changed significantly. Do not stumble on recertification! Review the concepts and realize how important this pathogen is to recognize and treat to ensure eradication.
Editor’s note: This article is the second in a 5-part series on preparation for recertification exams and gaining clinical knowledge from the questions that are asked. The first article covered questions about headache, corneal ulcer, and laparoscopic surgery with asthma (link below). Upcoming articles will look at cardiac stress tests, kidney disease, and hypertension.
Fall 2014: exam dates are October 8, 14, 30, and 31; to take the exam, enrollment in the ABIM Maintenance of Certification must have been completed by August 1; a seat must be scheduled between May 1 and August 15.
Spring 2015: exam dates are April 14, 15, and 17, 2015; to take the exam, enrollment in the ABIM Maintenance of Certification must have been completed by February 14, 2015; a seat must be scheduled between December 1, 2014 and February 28, 2015.
Fall 2015: exam dates are October 2, 13, 16, and 26, 2015; to take the exam, enrollment in the ABIM Maintenance of Certification must have been completed by August 1, 2015; a seat must be scheduled between May 1, 2015 and August 15, 2015.
1. Stoller JK, Nielsen C, Buccola J, Brateanu A, eds. The Cleveland Clinic Foundation Intensive Review of Internal Medicine. 6th ed. Philadelphia: Wolters Kluwer; 2014.
2. Stoller JK, Nielsen C, Buccola J, Brateanu A, eds. The Cleveland Clinic Foundation Intensive Review of Internal Medicine. 6th ed. Philadelphia: Wolters Kluwer; 2014:317.
3. Stoller JK, Nielsen C, Buccola J, Brateanu A, eds. The Cleveland Clinic Foundation Intensive Review of Internal Medicine. 6th ed. Philadelphia: Wolters Kluwer; 2014:326-327.