The following is a recent eConsult submitted to Dr. Ted Xenodemetropoulos, gastroenterologist at McMaster:
REFERRAL:
- 55 year old male with persistent GI symptoms located in the epigastrium
- +ve H pylori serology 2015, given HpPAC
- seen and scoped 2016, given HpPAC again and again epigastric Sx persist
- had +ve C14 breath test 2016
- so we have no eradication of H pylori
- he is also allergic to sulfa
Question:
Does he need a longer treatment duration or an alternate HP regimen? Can H pylori develop resistance as per other bacteria?
RESPONSE:
Thank you for the consultation. Treatment (and retreatment) with the HPAC for the conventional 7 day course of treatment is not recommended first line therapy for HP, as the eradication rates are poor (largely related to clarithromycin resistance). I would recommend a 14 day course of quadruple therapy (bismuth, tetracycline, metronidazole and a PPI) in accordance to the Toronto Consensus Guidelines (which I have attached for your reference). Once treatment is complete, I would arrange for C14 urea breath testing (ideally at least 4 weeks following treatment, with no antibiotics/PPI/bismuth treatment during that time) to confirm successful eradication. Second and other treatment are also discussed in the guidelines, and should be individualized to the patient's particular set of clinical circumstances (ie. allergies, etc.).
Please let me know if you have any additional questions or concerns related to this case.
OTHER APPROPRIATE eCONSULT REFERRALS:
Dr. Xenodemetropoulos has the following suggestions as to what would be an appropriate eConsult:
There are an infinite variety of topics (simple to complex) that would be well suited to eConsult. Questions that I have dealt with relate to management facets of Celiac disease and NASH, as examples. I think that areas amenable to primary-care directed initial management in this area include generic topics such as:
- Heartburn
- Non-cardiac chest pain
- Undifferentiated diarrhea
- Undifferentiated constipation
- Undifferentiated liver enzyme abnormalities
- NAFLD/NASH assessment and management
- Functional gastrointestinal disorders (ex. functional dyspepsia, IBS)
GI SPECIALISTS IN OUR AREA ACCEPTING eCONSULTS:
- Dr. John Marshall
- Dr. Barry Lumb
- Dr. Ted Xenodemetropoulos
- Dr. Smita Halder
