Brought to you by the HFHT Choosing Wisely Committee...
Get to Know OTN's eConsult Model
January 16, 2018
Access is an important buzzword in health care today and as we all experience, access to specialist consultations is becoming increasingly difficult. OTN eConsult is being rolled out across the province and is a useful tool in allowing referring providers (family physician or other) to ask a specialist a clinical question about their patient and receive advice quickly and securely… in less than 3 days on average.

The HFHT Choosing Wisely Committee knows how efficient and effective eConsult can be, and wants you to see its benefits too! Check out our new series, Referring Wisely (coming to your inbox every month or so), to see examples of REAL eConsults provided to HFHT physicians in as little as an hour after referral.
The following is a recent eConsult submitted to Dr. Ted Xenodemetropoulos, gastroenterologist at McMaster:

  • 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?

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.

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)

  • Dr. John Marshall
  • Dr. Barry Lumb
  • Dr. Ted Xenodemetropoulos
  • Dr. Smita Halder
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