A 46-year-old female comes with a two-week history of intermittent epigastric abdominal pain and nausea. The pain gets better after a light meal or a cup of milk. The symptoms often occur at night. She has never had these symptoms before. She is currently not taking any medications. Endoscopy reveals a small duodenal ulcer in the bulbar area. The serology test for Helicobacter pylori is positive. You decide to manage the patient with triple drug therapy. Which of the following is the most appropriate next step to confirm the eradication of H. pylori infection in this patient?

Question

A 46-year-old female comes with a two-week history of intermittent epigastric abdominal pain and nausea.  The pain gets better after a light meal or a cup of milk.  The symptoms often occur at night.  She has never had these symptoms before.  She is currently not taking any medications.  Endoscopy reveals a small duodenal ulcer in the bulbar area.  The serology test for Helicobacter pylori is positive.  You decide to manage the patient with triple drug therapy.  Which of the following is the most appropriate next step to confirm the eradication of H. pylori infection in this patient?

Quizplus · Accepted Answer

Explanation: Temporary improvement of epigastric pain after a small meal is typical of duodenal ulcers, whereas pain exacerbation after meals tends to occur with gastric ulcers. Worsening symptoms at night is also frequent with duodenal ulcers. H. pylori infection is highly associated with duodenal ulcers, with at least 70% of patients being infected. The combination of proton pump inhibitor omeprazole, clarithromycin, and amoxicillin is the commonly used triple therapy. Confirmation of H. pylori eradication is recommended for patients with a duodenal ulcer. Either a urea breath test or fecal antigen test can be performed to confirm eradication, but neither should be performed until 4 weeks after the completion of therapy. The fecal antigen test is more readily available but may be less accurate than the urea breath test. Intake of antibiotics or bismuth can result in false-negative test results for both the urea breath and fecal antigen tests. Eradication should also be confirmed in patients with persistent dyspepsia, MALT lymphoma, or who have had resection of early gastric cancer. (Choice A) H. pylori serology tests evaluate for the presence of antibodies. However, H. pylori antibodies may be present after the infection has been eradicated and therefore they should not be used to assess for eradication for at least a year. (Choice B) Surveillance endoscopy is generally indicated to confirm the healing of gastric ulcers, which have high risk for malignancy. The risk of malignancy is extremely low with duodenal ulcers and no surveillance endoscopy is needed. Even so, endoscopy would not directly confirm H. pylori eradication. (Choice C) H. pylori bacteria is not typically present in the bloodstream of infected patients, and therefore blood culture should not be used to evaluate for eradication. (Choice D) Urea breath testing can be used at least 4 weeks after the completion of therapy. 1 week is too soon and may result in a false positive test. Educational objective: Confirmation of H. pylori eradication is recommended for patients with ulcers or ongoing dyspepsia. Either urea breath or fecal antigen testing can be used after 4 weeks to confirm H. pylori eradication. H. pylori serology should not be used since it may remain positive a year or more after eradication. References: A rapid lateral flow stool antigen immunoassay and (14)C-urea breath test for the diagnosis and eradication of Helicobacter pylori infection in children. (http://www.ncbi.nlm.nih.gov/pubmed/18722071) Accuracy of a new monoclonal stool antigen test in post-eradication assessment of Helicobacter pylori infection: comparison with the polyclonal stool antigen test and urea breath test. (http://www.ncbi.nlm.nih.gov/pubmed/16023902)

A 46-Year-Old Female Comes with a Two-Week History of Intermittent