Ulcer Symptoms and Helicobacter pylori

Frederick R. Jelovsek MD

Before 1982, we used to think that ulcers were caused by spicy food, acid, stress and the "Type A" personality. Then a bacterium called Helicobacter pylori was discovered. Now we know that up to 80% of stomach ulcers and 90% of duodenal ulcers are caused by the bacterium, H. pylori.

As a result, ulcers are often cured now by medical therapy rather than surgical therapy.

The Center for Disease Control and Prevention now puts out a fact sheet for health care providers to make sure the message is out that this is often a curable problem. From this July 1998 Fact Sheet and the H. pylori web site that is maintained by the CDC, we can learn the answers to several questions about ulcer disease and the H. pylori infection.

What are the symptoms of ulcers?

The most frequent symptom noted with ulcers is a gnawing, burning pain in the mid stomach area just below the rib cage. Its onset is usually gradual over weeks or months rather than an acute beginning. The pain typically occurs when the stomach is empty between meals and in early morning hours. It can last from minutes to hours and is relieved by eating or taking antacids.

Less frequently occurring are symptoms such as nausea, vomiting, and loss of appetite. Bleeding from the ulcer may result in black, tar-like stools, vomiting of blood or even coughing up of blood.

Should I be tested for H. pylori?

Anyone who has been diagnosed with an ulcer or who has had a history of ulcers should be tested. Also, people who have a history of gastric (stomach) cancer or a mucosal-associated-lymphoid-type (MALT) lymphoma should also be tested. H pylori is strongly associated with these latter two malignancies.

It is not currently clear whether persons with just stomach upset (dyspepsia) that do not have ulcers should be tested. Remember that over 2/3's of the world's population is infected with H.pylori and most do not have any symptoms or ulcers from it.

How is H. pylori infection diagnosed?

There are several methods currently available to diagnose H. pylori infection. There are antibody tests that can determine if a person has ever been exposed to the bacteria. They pick up about 80% of all people who have been or were infected. If the test is negative, it only misses about 5% of people who actually have been infected.

There also is a breath test in which patients are given radioisotope labelled liquids to drink and the H. pylori metabolizes the labelled compounds which can then be measured in a person's breath. These tests are more accurate than the antibody tests.

The gold standard diagnostic test is is at time of upper esophagogastroduodenal endoscopy (EGD) in which an endoscope is put into the stomach to look for ulcers and take a biopsy. The biopsy is then examined either by a urease test, a microscopic look at the tissue or a bacterial culture of the tissue.

What are the long term consequences of H. pylori infection?

Other than ulcer disease and its complications, gastric cancer is the biggest risk of long term infection. In places like Columbia and China where over half the population is infected in early childhood, there is a high incidence of gastric cancer. In the U.S., H. pylori is is less common in young people and the incidence of gastric cancer has been decreasing since the 1930's.

How would I have been infected with H. pylori?

It is not known how H. pylori is transmitted or why some people become symptomatic while others do not. It is thought most likely to be spread from person to person through the food or water supply.

What are the treatment regimens used to cure H. pylori?

There are several different treatment regimens used.

FDA-approved treatment options for H. pylori (1998)

Medication	Dose
Treatment
omeprazole (Prilosec®)	40 mg each day for two weeks
clarithromycin (Biaxin®)	500 mg three times a day for 2 weeks THEN
omeprazole (Prilosec®)	20 mg each day for 2 weeks
Treatment
ranitidine bismuth citrate (RBC) (Zantac®)	400 mg twice a day for 4 weeks
clarithromycin (Biaxin®)	500 mg three times a day for 2 weeks
Treatment
bismuth subsalicylate (Pepto Bismol®)	525 mg four times a day for 2 weeks
metronidazole (Flagyl®)	250 mg four times a day for 2 weeks
tetracycline	500 mg four times a day for 2 weeks
any H2; receptor antagonist	therapy as directed for 4 weeks
Treatment
lansoprazole (Prevacid®)	30 mg twice a day for 10 days
amoxicillin (Amoxil®)	1 gram twice a day for 10 days
clarithromycin (Biaxin®)	500 mg three times a day for 10 days
Treatment
lansoprazole (Prevacid®)	30 mg three times a day for 2 weeks
amoxicillin (Amoxil®)	1 gram three times a say for 2 weeks

Treatment
ranitidine bismuth citrate (RBC)(Zantac®)	400 mg twice a day for 4 weeks
clarithromycin (Biaxin®)	500 mg twice a day for 2 weeks
Treatment
omperazole (Prilosec®)	20 mg twice a day for 10 days
clarithromycin (Biaxin®)	500 mg twice a day for 10 days
amoxicillin (Amoxil®)	1 gram twice a day for 10 days
Treatment
lansoprazole (Prevacid®)	30 mg twice a day for 10 days
clarithromycin (Biaxin®)	500 mg twice a day for 10 days
amoxicillin (Amoxil®)	1 gram twice a day for 10 days