Background

Abdominal pain is the most frequent presenting symptom in US emergency departments. The current standard care in the ED for upper abdominal pain involves ruling out severe causes (i.e. biliary disease, perforated viscous etc) and consideration of empiric gastric disease treatment with histamine blockers, antacids, or proton-pump inhibitors.

H. pylori is a bacterium that infects the stomach causing dyspepsia.  It persists throughout life unless treated with appropriate antibiotics. Although H pylori infections are not immediately life threatening, treating symptomatic patients’ infection with antibiotics is potentially curative and can reduce the risk of complications such as ulcer recurrence and gastric cancer.

A previous study conducted by the same authors established that it is feasible to test patients with nonspecific abdominal pain for H. pylori infection in ED. Prevalence of H. pylori infection in symptomatic patients in this study was estimated to be 25%. Gastroenterology guidelines recommend a test-and-treat strategy for patients with uninvestigated dyspepsia in an outpatient setting with a high prevalence (>10%).

Clinical Question

Is a test-and-treat strategy (ie: rapid testing followed by initiation of treatment for patients with positive results) feasible for ED patients with H. pylori infections?

Population

Emergency department patients 18 years or older presenting with symptoms of upper abdominal pain which the ED attending physician determined could be due to dyspepsia, gastritis, or peptic ulcer disease.

Intervention

13C urea breath test was administered to each subject and those that tested positive were treated with triple therapy. Those who where treated were retested in the ED at 6 weeks.

Control

N/A

Outcomes

The authors collected a vast array of data including:
• H pylori testing rates and results as well as treatment compliance and eradication rates.
• Symptom resolution (change in pain severity / interference with daily life)
• Proportion of subjects who received specific treatments in the ED (imaging, medication, admission rates)
• Subsequent health care use related to the abdominal pain (outpatient, ED, hospitalizations)
• Risk difference in proportion of patients who tested positive for H. Pylori by demographic, clinical, and treatment characteristics

Design

Prospective cohort feasibility study of ED patients at an urban academic ED for a test-and-treat strategy

Excluded

• Received proton-pump inhibitor within past 2 weeks
• Received antibiotics or bismuth within the previous 30 days
• Pregnant
• Inability to walk to the urea breath test machine
• Tested for H pylori within the previous 3 months
• Living outside the continental United States

Primary Results

  • 49 (23%) of eligible subjects tested positive for H pylori
  • Among those that returned for retesting and also reported treatment compliance the eradication rate was 87% (20/23) (95% CI 68% to 95%)
  • Eradication rate was 41% (20/49) (95% CI 28% to 55%) among all H pylori positive subjects and 61% (20/33) (95% CI 42% to 77%) among those reporting treatment compliance
  • 11% reduction in cross-sectional imaging in H pylori-positive patients (95% CI -22% to 0%) (95% CI 68% to 95%)
  • Subjects who tested positive for H pylori had 24% lower risk of receiving abdominal testing after ED discharge compared to subjects who tested negative (95% CI -13% to -35%)

Strengths

  • The test-and-treat strategy for H pylori infection in the ED setting has not been investigated in the past
  • The authors collected data on a variety of aspects (ie demographics, further imaging and medical workup)
  • Looked at patient centered outcomes like interference of daily activities, pain resolution, reduction of radiographic imaging

Limitations

  • Although eradication rates are promising among those who tested positive for H pylori infection, it is impossible to know whether H pylori was the underlying cause of the abdominal pain to begin with
  • 25% of subjects were lost to follow up and only 47% of subjects where successfully retested for H pylori if they were positive. There may be selection bias if the patients who did not follow up are systematically difference from those that did follow up
  • Compliance and follow up data other than the actual urea retest were all based on patient telephone surveys
  • Authors did not control the timing sequence of diagnostic imaging conducted in the ED and the urea breath test testing so it is difficult to estimate the effect of the urea breath test results on other diagnostic evaluations performed in the ED
  • Did not assess inter-rater reliability of the data abstractors who performed chart review

Author's Conclusions

"A test-and-treat strategy is feasible in the ED setting and could benefit symptomatic patients."

Our Conclusions

This study showed that it is feasible to conduct a urea breath test in the ED for H pylori and that initiation of treatment with triple therapy for H pylori can be expedited in patients found to be positive.
The ability to diagnose H. pylori infections in the ED in patients presenting with abdominal pain suggestive of gastritis, dyspepsia, or peptic ulcer disease may also be valuable in other ways. Patients in this study with positive H pylori urea tests in the ED received less cross-sectional imaging in the ED, less opiate prescriptions upon ED discharge, and had a lower risk of further abdominal testing in general after ED discharge.
However, it is still important to remember that even if a patient in the ED with abdominal pain has a positive urea breath test, this does not mean that an H. pylori infection is the sole cause of their abdominal pain and does not rule out other potential concomitant acute abdominal pathologies.

Potential Impact To Current Practice

Availability of urea breath test machines in the Emergency Department could allow providers to diagnose a common cause of abdominal pain and initiate management without waiting for primary care of GI follow up.

Bottom Line

• A test-and-treat strategy for H. pylori infection is feasible in an ED setting using a urea breath test.
• Patients testing positive for H. pylori may receive less testing and workup for abdominal pain in the ED and as an outpatient.
• Remember though, being H. pylori positive does not rule out other abdominal pathologies.

Read More

Meltzer AC et al. Rapid (13) C urea breath test to identify Helicobacter pylori infection in emergency department patients with upper abdominal pain. W J Emerg Med. 2013; 14:278-282. PMCID: PMC3656711