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