A 52-year-old man comes to the emergency department after 1 day of melena and 2 episodes of coffee-ground emesis. Over the past several months he has had episodic epigastric discomfort, especially several hours after a meal and at night. The patient has had no dysphagia, back pain, or weight loss, and has not used aspirin or nonsteroidal anti-inflammatory drugs. Chronic medical problems include hypertension and hypercholesterolemia. He does not use tobacco, alcohol, or illicit drugs.
Blood pressure is 126/70 mm Hg, and pulse is 86/min with no orthostatic changes. The abdomen is soft and nontender, and rectal examination reveals occult blood-positive black stool.
Laboratory results are as follows:
Intravenous proton pump inhibitor therapy is started. Upper gastrointestinal endoscopy shows a 2-cm duodenal ulcer with a visible vessel at the base. Endoscopic treatment is performed; the patient has no recurrent hematemesis, and his hemoglobin level remains stable. Gastric mucosal biopsies are negative for Helicobacter pylori.
Which of the following is the most appropriate next step regarding evaluation and treatment for H pylori infection in this patient?

Question

A 52-year-old man comes to the emergency department after 1 day of melena and 2 episodes of coffee-ground emesis.  Over the past several months he has had episodic epigastric discomfort, especially several hours after a meal and at night.  The patient has had no dysphagia, back pain, or weight loss, and has not used aspirin or nonsteroidal anti-inflammatory drugs.  Chronic medical problems include hypertension and hypercholesterolemia.  He does not use tobacco, alcohol, or illicit drugs.
Blood pressure is 126/70 mm Hg, and pulse is 86/min with no orthostatic changes.  The abdomen is soft and nontender, and rectal examination reveals occult blood-positive black stool.
Laboratory results are as follows:
 Intravenous proton pump inhibitor therapy is started.  Upper gastrointestinal endoscopy shows a 2-cm duodenal ulcer with a visible vessel at the base.  Endoscopic treatment is performed; the patient has no recurrent hematemesis, and his hemoglobin level remains stable.  Gastric mucosal biopsies are negative for Helicobacter pylori.
Which of the following is the most appropriate next step regarding evaluation and treatment for H pylori infection in this patient?

Quizplus · Accepted Answer

Peptic ulcers are most commonly due to Helicobacter pylori infection or nonsteroidal anti-inflammatory drug use. All patients with bleeding peptic ulcer disease should be tested for H pylori with biopsy during endoscopy; those with evidence of infection require treatment. However, false-negative results for H pylori can occur due to gastrointestinal bleeding or commonly used medications (eg, proton pump inhibitors [PPI], bismuth, antibiotics). As a result, H pylori infection remains likely despite a negative biopsy during endoscopy. Therefore, a second test for H pylori is needed to confidently exclude the infection (Choice B). The urea breath test and stool antigen test are highly sensitive and specific for active H pylori infection. Testing can be performed on an outpatient basis after the patient can safely stop PPI therapy for 1-2 weeks. Serology is less effective for diagnosis as it cannot differentiate between active and prior infection. (Choice A) Current guidelines recommend confirmation of infection before initiating treatment, especially in countries with a relatively low prevalence of H pylori (eg, developed countries). (Choices D and E) Repeating the endoscopy immediately may be indicated if the patient develops uncontrolled bleeding; however, it is unlikely to yield different biopsy results, especially given that a PPI has already been initiated. Repeat testing for H pylori can be performed less invasively with a urea breath test or stool antigen test. Repeat endoscopy after 4-6 weeks is typically performed for bleeding gastric ulcers (particularly if symptoms persist or there is high concern for malignancy). It is not routinely recommended for follow-up of duodenal ulcers as the malignancy risk is low. Educational objective: Patients with acute gastrointestinal hemorrhage due to peptic ulcer should undergo endoscopic sampling for Helicobacter pylori. However, false-negative results can occur due to active gastrointestinal bleeding or certain medications (eg, proton pump inhibitors, bismuth, antibiotics). Therefore, a negative biopsy should be confirmed by a second test (urea breath or stool antigen) after the patient can safely stop the proton pump inhibitor for 1-2 weeks. __________ References: Helicobacter pylori infection: diagnostic strategies in primary diagnosis and after therapy. (http://www.ncbi.nlm.nih.gov/pubmed/26391269)

A 52-Year-Old Man Comes to the Emergency Department After 1