A 48-year-old woman presents to the emergency department complaining of occasional sharp epigastric pain for the past month and an episode of hematemesis this past week. The patient reported 6 months ago having a similar pain and received a 4-week course of esomeprazole which relieved her discomfort. She reports feeling nauseated this past week and has noted “coffee ground” emesis mixed with food content and saliva when she vomited. She denies fever, chills, chest pain, palpitations, cough, wheezing, hematuria, hematochezia, and melena. She denies being on any other medications including non-steroidal anti-inflammatory drugs (NSAIDs). She recently immigrated from Cambodia. Vital signs are blood pressure is 118/63 mmHg, heart rate 98 beats/minute, respirations 20/minute, oxygen saturation 96% on room air, and she is afebrile. On physical examination, her conjunctivas are somewhat pale, and the remainder of the examination is unremarkable. Laboratory findings show WBC 13/mm3, hemoglobin 10.8 g/dL with an MCV of 77, platelets 210,000/mm3, BUN 38 mg/dL and creatinine 1.2 mg/dL. The patient undergoes esophagogastroduodenoscopy (EGD) which shows a non-bleeding gastric ulcer without visible vessels, mild gastritis, and a hiatal hernia. Her gastric ulcer biopsy is sent for culture and pathology with results pending. Campylobacter-like organism (CLO) testing performed on her biopsy specimen during her EGD is positive. She is currently receiving intravenous pantoprazole twice daily and intravenous fluids.
Which of the following is the most appropriate therapy given the results of the CLO test?
- A) Consult nephrology for acute renal failure
- B) Start octreotide drip
- C) Start on oral proton pump inhibitor, clarithromycin, and amoxicillin
- D) Switch pantoprazole intravenously twice daily to famotidine intravenously twice daily
- E) Transfuse 2 units of packed red blood cells
C) Start on oral proton pump inhibitor, clarithromycin, and amoxicillin
CLO stands for Campylobacter-like organism and is also known as the Rapid Urease Test. This diagnostic test is used for the detection of Helicobacter pylori by finding the presence of urease, an enzyme that is produced by Helicobacter pylori. Also, considering this patient’s background and clinical presentation, Helicobacter pylori infection is highest on the differential diagnosis list. Based on a meta-analysis on Global Prevalence of Helicobacter pylori infection published by the American Gastroenterological Association, the prevalence of H. pylori infection is highest in Africa, Latin America and the Caribbean, and Asian. The guideline (ACG Clinical Guideline 2017) directed therapy for H. pylori infection is first to ask the patient about any previous antibiotic exposure as this information will guide which specific antibiotics should be prescribed to the patient based on resistance. Triple therapy including clarithromycin, amoxicillin or metronidazole, plus a proton pump inhibitor (PPI) for 14 days is the standard therapy in regions where clarithromycin resistance is <15% and in patients with no prior history of macrolide exposure. This is indicated for this patient.
Answer choice A: Consult nephrology for acute renal failure, is incorrect. The patient’s elevated BUN is likely from the upper GI bleed induced by the gastric ulcer, though no active bleeding or visible vessels were found during the EGD. The patient should be given IV fluids and have the underlying cause treated before consulting nephrology.
Answer choice B: Start octreotide drip, is incorrect. Octreotide drip is indicated for the treatment of variceal bleeding; it is not recommended for acute non-variceal upper GI bleeding.
Answer choice D: Switch pantoprazole intravenously twice daily to famotidine intravenously twice daily, is incorrect. H2 blocking medications are inferior to PPIs for the management of upper GI bleeds secondary to peptic ulcer disease.
Answer choice E: Transfuse 2 units of packed red blood cells, is incorrect. This patient is not actively bleeding and is hemodynamically stable. Blood products should only be transfused if hemoglobin is <7 or if the patient is hemodynamically unstable.
Key Learning Point
A proton pump inhibitor, clarithromycin, and amoxicillin compose the standard triple therapy for H. pylori treatment.
