Sandbox pud

# Overview
Eradication of Helicobacter pylori with antimicrobial agents is indicated for patients with gastric or duodenal peptic ulceration who are colonized with Helicobacter pylori and patients with MALT lymphoma.  Eradication therapy should also be considered for patients with immune thrombocytopenic purpura who are H. pylori positive or patients who have undergone resection for early-stage gastric cancer.  The use of antibiotics is discouraged in asymptomatic carriers.

# Medical Therapy

## Diagnostic testing
The American Journal of Gastroenterology guidelines recommend that endoscopy should be performed to rule out peptic ulcer disease, esophagogastric malignancy, and other rare upper gastrointestinal tract disease in the following settings:
- Dyspeptic patients more than 55 years old OR
- Dyspeptic patients with alarm features
- Bleeding
- Anemia
- Early satiety
- Unexplained weight loss (> 10% body weight)
- Progressive dysphagia
- Odynophagia
- Persistent vomiting
- A family history of gastrointestinal cancer
- Previous esophagogastric malignancy
- Previous documented peptic ulcer, lymphadenopathy, or an abdominal mass
In patients aged 55 years or younger with no alarm features, two management options may be considered:
- Test-and-treat strategy using a validated noninvasive test (urea breathing test or stool antigen test) for H. pylori and a trial of acid suppression if eradication is successful but symptoms do not resolve  preferable in populations with a moderate to high prevalence of H. pylori infection ( 10%)
- Empiric trial of acid suppression with a proton pump inhibitor for 48 weeks  preferable in low prevalence situations
Repeat endoscopy is not recommended once a firm diagnosis of functional dyspepsia has been established, unless new symptoms or alarm features develop.  Testing to prove H. pylori eradication is most accurate if performed 4 weeks after the completion of therapy.

## Treatment strategies
- The use of high-dose (twice a day) proton pump inhibitor (PPI) increases the efficacy of triple therapy.
- In areas of low clarithromycin resistance, clarithromycin-containing treatments (PCA or PCM) are recommended for first-line empirical treatment.  Bismuth-containing quadruple treatment is also an alternative.
- In areas of high clarithromycin resistance, bismuth-containing quadruple treatment is recommended for first-line empirical treatment.  If this regimen is not available, sequential treatment is recommended.
- Extending the duration of triple treatment from 7 to 1014 days improves the eradication success rate and may be considered.
- After failure of a PPI-clarithromycin containing therapy, either a bismuth-containing quadruple treatment or levofloxacin-containing triple therapy (PLA) is recommended.
- After failure of second-line treatment, treatment should be guided by antimicrobial susceptibility testing whenever possible.
- The urea breath test or a laboratory based validated monoclonal stool test are both recommended as non-invasive tests for determining the success of eradication treatment.

# Eradication Therapy for Helicobacter pylori Infection

## First-line therapies
- Triple therapy (PCA or PCM regimen)
Proton pump inhibitor (standard dose twice daily) for 714 days AND
Clarithromycin (500 mg twice daily) for 714 days AND
Amoxicillin (1 g twice daily) for 714 days OR Metronidazole (250 mg four times daily) for 714 days
- Proton pump inhibitor (standard dose twice daily) for 714 days AND
- Clarithromycin (500 mg twice daily) for 714 days AND
- Amoxicillin (1 g twice daily) for 714 days OR Metronidazole (250 mg four times daily) for 714 days
- Quadruple therapy
Proton pump inhibitor (standard dose twice daily) for 1014 days AND
Metronidazole (250 mg four times daily) for 1014 days AND
Tetracycline (500 mg four times daily) for 1014 days AND
Bismuth (dose depends on preparation) for 1014 days
- Proton pump inhibitor (standard dose twice daily) for 1014 days AND
- Metronidazole (250 mg four times daily) for 1014 days AND
- Tetracycline (500 mg four times daily) for 1014 days AND
- Bismuth (dose depends on preparation) for 1014 days
- Sequential therapy
Proton pump inhibitor (standard dose twice daily) for 5 days AND
Amoxicillin (1 g twice times daily) for 5 daysFOLLOWED BY
Proton pump inhibitor (standard dose twice daily) for another 5 days AND
Clarithromycin (500 mg twice daily) for another 5 days AND
Tinidazole (500 mg twice daily) for another 5 days
- Proton pump inhibitor (standard dose twice daily) for 5 days AND
- Amoxicillin (1 g twice times daily) for 5 daysFOLLOWED BY
- Proton pump inhibitor (standard dose twice daily) for another 5 days AND
- Clarithromycin (500 mg twice daily) for another 5 days AND
- Tinidazole (500 mg twice daily) for another 5 days

## Second-line therapies
- Triple therapy (PLA regimen)
Proton pump inhibitor (standard dose twice daily) for 10 days AND
Levofloxacin (500 mg twice daily) for 10 days AND
Amoxicillin (1 g twice daily) for 10 days
- Proton pump inhibitor (standard dose twice daily) for 10 days AND
- Levofloxacin (500 mg twice daily) for 10 days AND
- Amoxicillin (1 g twice daily) for 10 days
- Triple therapy (PMA regimen)
Proton pump inhibitor (standard dose twice daily) for 714 days AND
Metronidazole (250 mg four times daily) for 714 days AND
Amoxicillin (1 g twice daily) for 714 days
- Proton pump inhibitor (standard dose twice daily) for 714 days AND
- Metronidazole (250 mg four times daily) for 714 days AND
- Amoxicillin (1 g twice daily) for 714 days
- Triple therapy (PRA regimen)
Proton pump inhibitor (standard dose twice daily) for 10 days AND
Rifabutin (150300 mg/day) for 10 days AND
Amoxicillin (1 g twice daily) for 10 days
- Proton pump inhibitor (standard dose twice daily) for 10 days AND
- Rifabutin (150300 mg/day) for 10 days AND
- Amoxicillin (1 g twice daily) for 10 days

# Algorithm for the Approach to Dyspepsia

# Contraindicated Medications
Bleeding peptic ulcer is considered an absolute contraindication to the use of the following medications:
- Ketorolac tromethamine
- Mefenamic acid
- Ticlopidine
- Prasugrel
- Reserpine
- Streptokinase
- Vorapaxar

# Guidelines and Resources
- American College of Gastroenterology (ACG)  Guidelines for the management of dyspepsia.
- American Society for Gastrointestinal Endoscopy (ASGE)  The role of endoscopy in dyspepsia.
- American Society for Gastrointestinal Endoscopy (ASGE)  The role of endoscopy in gastroduodenal obstruction and gastroparesis.
- American College of Cardiology Foundation/American College of Gastroenterology/American Heart Association (ACCF/ACG/AHA)  Reducing the gastrointestinal risks of antiplatelet therapy and NSAID use.
- The European Helicobacter Study Group (EHSG)  Management of Helicobacter pylori infection.