H PYLORI NEGATIVE ULCER Paul Nacier MD Fellow American College of Physicians Fellow American...
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Transcript of H PYLORI NEGATIVE ULCER Paul Nacier MD Fellow American College of Physicians Fellow American...
H PYLORI NEGATIVE ULCER
Paul Nacier MD
Fellow American College of Physicians
Fellow American Gastroenterology Association
AMA Member
AMHE Member
Chief of Endoscopy KJMC, Brooklyn, NY
H PYLORI NEGATIVE ULCER
Introduction
H PYLORI NEGATIVE ULCER
Introduction Until 1983, most peptic ulcers were
considered “idiopathic”
H PYLORI NEGATIVE ULCER
Introduction Until 1983, most peptic ulcers were
considered “idiopathic” “Ulcer disease is an infectious
disease” as proven by Warren and Marshall
H PYLORI NEGATIVE ULCER
Introduction Until 1983, most peptic ulcers were
considered “idiopathic” “Ulcer disease is an infectious
disease” as proven by Warren and Marshall
The pendulum is swinging: increase incidence of H Pylori negative ulcer.
H PYLORI NEGATIVE ULCER
Incidence
H PYLORI NEGATIVE ULCER
Incidence The frequency is not exactly known
but it is rising as the treatment or eradication of H Pylori is more successful.
H PYLORI NEGATIVE ULCER
Causes
H PYLORI NEGATIVE ULCER
Causes The more common are false
negative H Pylori results such as
H PYLORI NEGATIVE ULCER
Causes The more common are false
negative H Pylori results such asTesting while on proton pump inhibitor, or recently on Bismuth or antibiotic
H PYLORI NEGATIVE ULCER
Causes The more common are false
negative H Pylori results such asTesting while on proton pump inhibitor, or recently on Bismuth or antibiotic
Sampling error from biopsy site
H PYLORI NEGATIVE ULCER
Causes The more common are false negative H
Pylori results such asTesting while on proton pump inhibitor, or recently on Bismuth or antibiotic
Sampling error from biopsy siteBiopsy from a “burn out” atrophic body gastritis with H pylori serology positive and lower serum pepsinogen I level
H PYLORI NEGATIVE ULCER
Causes The more common are false
negative H Pylori results such asH Pylori biopsy negative, but histological evidence of past infection or recently treated infection
False negative by CHLO test in upper GI bleeding.
H PYLORI NEGATIVE ULCER
Causes And other more common causes are
H PYLORI NEGATIVE ULCER
Causes And other more common causes are
NSAID’s prescribed or OTC or surreptitious.
H PYLORI NEGATIVE ULCER
Causes The less common are
H PYLORI NEGATIVE ULCER
Causes The less common are
Chron’s disease and other granulomatous conditions
H PYLORI NEGATIVE ULCER
Causes The less common are
Chron’s disease and other granulomatous conditions
Sarcoidosis
H PYLORI NEGATIVE ULCER
Causes The less common are
Chron’s disease and other granulomatous conditions
SarcoidosisIschemia
H PYLORI NEGATIVE ULCER
Causes The less common are
Chron’s disease and other granulomatous conditions
SarcoidosisIschemiaBile reflux
H PYLORI NEGATIVE ULCER
Causes The less common are
Chron’s disease and other granulomatous conditions
SarcoidosisIschemiaBile refluxZE syndrome
H PYLORI NEGATIVE ULCER
Causes The less common are
Chron’s disease and other granulomatous conditions
SarcoidosisIschemiaBile refluxZE syndromePenetrating carcinoma of the pancreas
H PYLORI NEGATIVE ULCER
Causes The less common are
Mastocytosis
H PYLORI NEGATIVE ULCER
Causes The less common are
MastocytosisHelicobacter Helmani
H PYLORI NEGATIVE ULCER
Causes The less common are
MastocytosisHelicobacter HelmaniIsolated H Pylori duodenal colonization (older age, diseases of the duodenal mucosa) which needs second look gastroscopy with duodenal biopsy or HPSA stools or urea breath test.
H PYLORI NEGATIVE ULCER
Causes Idiopathic
H PYLORI NEGATIVE ULCER
Causes Idiopathic
They are exceedingly rare. It has been noted a higher gastrin level and peak acid output, and a rapid gastric emptying of solid and liquid resulting in a higher exposure of the duodenum to acid, causing mucosal ulceration. (Ke Mccoll, Gut 1993,34,762-8)
H PYLORI NEGATIVE ULCER
Clinical Implications and Complications
H PYLORI NEGATIVE ULCER
Clinical Implications and Complications H Pylori negative ulcers can be
refractory. “They lack the beneficial effect of H Pylori infection on antisecretory therapy” (James Freston, Alimentary Pharmacology Therapy, vol. 15, issue 2, pages 2-5). More long term therapy
H PYLORI NEGATIVE ULCER
Clinical Implications and Complications Recurrent ulcers, obstruction and
perforation. In a 12 month period: 2.5% of recurrence in patients treated for H Pylori compare to 13.4% in H Pylori negative cases
H PYLORI NEGATIVE ULCER
Clinical Implications and Complications More probability of rectal bleeding:
16% of patients admitted for UGI bleeding could be
H Pylori negative. (Lawrence Ct, Gastro 128, 2005, 1845-52)
H PYLORI NEGATIVE ULCER
Clinical Implications and Complications In some parts of the world with an
incidence of 90% positivity for H Pylori, therapy for ulcer is based on “empirical treatment and eradication without testing”. Such an approach could be subject to change.
H PYLORI NEGATIVE ULCER
Management
H PYLORI NEGATIVE ULCER
Management Review causes
H PYLORI NEGATIVE ULCER
Management Review causes Long term therapy
H PYLORI NEGATIVE ULCER
Management Review causes Long term therapy HPSA, C13 UBT test
H PYLORI NEGATIVE ULCER
Management Review causes Long term therapy HPSA, C13 UBT test Second look gastroscopy and
duodenal biopsy
AMHE37th Annual Convention - Montebello, Quebec
Wednesday July 28, 2010