Dyspepsia and H. Pylori

H. pylori is very common in patients from developing nations. Therefore, it is often diagnosed when investigating refugee patients with dyspepsia. Refugee patients often complain of symptoms of dyspepsia (postprandial fullness, early satiety, epigastric pain/burning), but different cultures might use various terms and expressions to refer to these symptoms, such as “heat” or “noise” in the abdomen. It is often difficult to differentiate between constipation symptoms and dyspepsia in some refugee patients.

Parasites such as hookworms, strongyloides, Giardia lamblia and Dientamoeba fragilis can sometimes cause dyspepsia symptoms and should be considered in refugee patients with persistent upper GI symptoms.

The “alarm features” for dyspepsia that warrant endoscopy are the same in refugee patients as for the rest of the population: onset at age ≥60, weight loss, anemia, iron deficiency, dysphagia, vomiting, palpable mass or lymphadenopathy, and family history of upper gastrointestinal cancer.

 

DIAGNOSIS

Unless there is a clear indication for endoscopy, we first test all refugee patients with dyspepsia for H. pylori and treat if positive. Either a stool antigen test or a urea breath test (UBT) can be used as first-line non-invasive diagnostic tests for H. pylori in refugee patients. In the case of the stool antigen test, since patients will already be collecting a stool sample, it is reasonable to also order a stool Ova & Parasites and Protozoal Screen (PCR) in order to rule out parasites as a potential etiology.

While we often test adults who present with any GI complaint for H. pylori, testing in children should only be considered in patients with clear symptoms suggesting peptic ulcer disease or with refractory unexplained iron deficiency anemia. This is because H. pylori infections in children without PUD rarely give rise to symptoms, and testing is thus not recommended in children with functional abdominal pain disorders (Jones et al., 2017).

When ordering an H. pylori stool antigen test or UBT, patients should be told to avoid the following medications prior to collecting the sample / performing the UBT (these are general rules only and physicians should always follow their local laboratory guidelines):​

  • Proton pump inhibitors: 14 days for stool test (can sometimes be shorter for UBT)
  • Antibiotics: 28 days
  • Bismuth preparations (Peptol Bismol): 14 days
  • Histamine H2 Receptor Antagonists and Antacids: 1 day (mainly for UBT)

 

TREATMENT

Due to increasing resistance, quadruple therapy is now widely recommended as first-line treatment for H. pylori (unless local guidelines still recommend triple therapy). Because it is less complicated than the other first-line regimen (Bismuth Quadruple regimen), we prefer the CLAMET Quadruple regimen in refugee patients*:​

For 14 days:

  • PPI (1 tablet standard dose) twice daily
  • Amoxicillin (1 g) twice daily
  • Clarithromycin (500 mg) twice daily
  • Metronidazole (500 mg) twice daily
* We recommend prescribing H. pylori regimens in blister packs to improve adherence.

 

TEST-OF-CURE

We recommend performing a test-of-cure only in patients who are still symptomatic after treatment. In these cases, a repeat stool antigen test should be done >4 weeks after completion of treatment. H. pylori is becoming more and more resistant (especially to clarithromycin) and often requires a second (Bismuth Quadruple regimen) or third  (Levofloxacin-based regimen) regimen before being eradicated.

 

>> For more information on the treatment of H. pylori, refer to The Toronto Consensus for the Treatment of Helicobacter pylori Infection in Adults.

>> If H. pylori or GI parasites are not identified as the cause of the patient’s dyspepsia or if eradicating the infection does not resolve his/her symptoms, refer to the American College of Gastroenterology (ACG) and the Canadian Association of Gastroenterology (CAG) 2017 joint guidelines on dyspepsia for more evidence-based recommendations.