A 38-year-old woman comes to the office for follow-up 6 weeks after completing triple-drug therapy for Helicobacter pylori infection. Eight weeks ago, she had an esophagogastroduodenoscopy showing a non-bleeding duodenal ulcer with a positive antral biopsy for H pylori. The patient reports improvement of her epigastric discomfort but still feels bloated. She has had no melena or vomiting. The patient is taking daily over-the-counter esomeprazole. She does not use tobacco, alcohol, or illicit drugs.
Her vital signs are stable. The abdomen is soft and nontender. Rectal examination shows guaiac-negative brown stool.
Urea breath test for H pylori is positive.
Which of the following is the best next step in managing this patient?

Question

A 38-year-old woman comes to the office for follow-up 6 weeks after completing triple-drug therapy for Helicobacter pylori infection.  Eight weeks ago, she had an esophagogastroduodenoscopy showing a non-bleeding duodenal ulcer with a positive antral biopsy for H pylori.  The patient reports improvement of her epigastric discomfort but still feels bloated.  She has had no melena or vomiting.  The patient is taking daily over-the-counter esomeprazole.  She does not use tobacco, alcohol, or illicit drugs.
Her vital signs are stable.  The abdomen is soft and nontender.  Rectal examination shows guaiac-negative brown stool.
Urea breath test for H pylori is positive.
Which of the following is the best next step in managing this patient?

Quizplus · Accepted Answer

11ec193a_981b_d0cb_853d_cd7a70ae5a7f_MD0002_00 Initial treatment for Helicobacter pylori includes standard triple therapy with a proton pump inhibitor (PPI), amoxicillin, and clarithromycin for 10-14 days. This regimen is usually preferred in patients without previous macrolide use or for those in areas with low macrolide resistance. Metronidazole can be substituted for amoxicillin in patients with penicillin allergy. Patients in areas with high macrolide or metronidazole resistance should receive quadruple therapy with a PPI, bismuth, metronidazole, and tetracycline (or doxycycline) for 10-14 days. Up to 20% of patients can fail one of the above regimens. Testing to confirm H pylori eradication (>4 weeks after initial therapy) can be considered in all patients but is recommended for persistent symptoms after initial treatment, or in the setting of H pylori-associated ulcer, gastric MALToma, or early gastric cancer that was resected. Eradication tests include the urea breath test (88%-95% sensitive, 95%-100% specific), fecal antigen test, or repeat upper endoscopy. H pylori serology does not discriminate between active and past infection. PPIs can decrease the sensitivity of the stool antigen and urea breath tests so these medications should generally be withheld for 2 weeks prior to testing. This patient's positive urea breath test in the setting of continued PPI use is highly suggestive of active infection and initial treatment failure; therefore, further testing is not necessary (Choices C, D, and E). Patients who fail initial treatment require an alternate regimen with either a different triple therapy or quadruple therapy (Choice B). Educational objective: Up to 20% of patients can fail standard initial therapy for Helicobacter pylori infection. Patients with persistent symptoms should undergo eradication testing (eg, urea breath test, fecal antigen test, or repeat upper endoscopy) and be treated with an alternate regimen (different triple therapy or quadruple therapy) if positive. __________ References: Primary and secondary treatment for Helicobacter pylori in the United States. (http://www.ncbi.nlm.nih.gov/pubmed/15976737) American College of Gastroenterology guideline on the management of Helicobacter pylori infection. (http://www.ncbi.nlm.nih.gov/pubmed/17608775)

A 38-Year-Old Woman Comes to the Office for Follow-Up 6