Ambulatory Report – Abd Pain, H.Pylori Testing, and Scoping – 7.13.16

Thanks to Chloe Chiccariello for presenting a case of a 22yo male from Nicaragua p/w epigastric pain, and subjective weight loss and melena.  Chloe was an amazing PCP and followed up the next day and thus far his CBC/BMP/LFT/Lipase/HIV were all completely normal.  Still waiting for that H.pylori though…and EGD?! (keep us updated Chloe!)
  • Testing for H.pylori
    • Preferred testing in low prevalence populations = Stool Ag or Urea Breath Test
    • Stool Antigen Assay – Sen 94%, Spec 86-92%
      • False negatives when on bismuth (15% of the time) or PPI (25% of the time)
    • Urea Breath Test (UBT) – Sen 88-95%, Spec 95-100% (uncommon false-positives)
      • False negatives seen when on antisecretory therapy, bismuth, Abx, GI bleed
    • Serum IgG Serology – Sen 90-100%, Spec 76-96%
      • PPV depends on prevalence, NOT recommended in places where prevalence is low
        • when Prev is 20% —> a positive result only represents active infection 50% of the time
  • Confirming Eradication of H.pylori
    • Should confirm eradication in the following settings:
      • Any patient with H.pylori-associated ulcer or H.pylori-assoc MALT lymphoma
      • Persistent dyspeptic sx despite tx
      • Individuals who’ve undergone resection of early gastric cancer
    • Preferred Tests – UBT (4 wks after treatment)
      • Stool Ag can also be used (no sooner than 4-6 wks after tx)
  • When should I scope them? (complements of Justin Sewell @ ZSFG)
    • Red Flags in Dyspepsia —> straight to EGD
      • >55yo with new onset dyspepsia, FHx upper GI cancer, unintended wt loss, GI bleed, progressive dysphagia, odynophagia, unexplained Fe def anemia, persistent vomiting, palpable mass or LAD, jaundice
      • FF22729A-9B13-401F-B451-872735DB3E72
  • PPI’s aren’t benign!
    • Ask yourself – What am I treating with this PPI?
    • Risks of PPIs = inc risk of C. Diff, hypoMag, possible risk of pneumonia, hip fracture, atrophic gastritis, B12 and iron malabsorption
    • No accepted guideline for when to stop a PPI, but consider stopping it if:
      • Pts with GERD/Dyspepsia have been asymptomatic for 3 months
      • Pts treated for acute duodenal/gastric ulcers for 4-8 weeks
      • Pts after they’ve been treated for H.pylori
    • They may relapse after treatment
  • Pearls to Assess Unintended Weight Loss = clothing fitting different? notching your belt buckle tighter? wallet biopsy (look at their driver’s license to see if they are thinner)

Evernote Link: https://www.evernote.com/l/ADWjiXQJh_tHOboWP9eFTYrKvkkK0ZSWJqA

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