Abdominal Pain…Think of H Pylori
A teenage patient recently came to the office because of abdominal pain. It all started a couple of weeks before. She had never had stomach issues prior to that. It started as a dull, aching pain in the middle of her abdomen,not sharp nor did it radiate to other parts of her body.
She denied any fever, diarrhea or vomiting. Initially she didn’t think much of it, but it persisted and actually got worse. She had tremendous bloating and burping. Now she was nauseated and actually had a noticeable decrease in appetite. Did anything make the pain worse? She felt better after eating something.But when her stomach was empty, especially at night, things did seem worse. Mom gave her some antacids which did help a lot, Now she was taking them regularly just for some relief. When I asked if she had done any recent traveling or swimming in a lake or river she said that because of Covid, she hasn’t really been anywhere for the past eight months.
Her weight was nearly the same as it was at her last physical a year ago. She had no fever and her vitals were completely normal. A thorough exam proved normal as well.
I explained that there were a number of things being considered.These included a possible gastro-esophageal refluxor a hiatal hernia where the upper portion of the stomach herniates above the diaphragm causing increased acid in the esophagus.,Also possible gall bladder disease or a number of infectious causes such as Giardia, which is an amoeba-like organism that one gets through ingesting infected water.That is why I asked about swimming in a lake or a river. There are a number of viral and bacterial agents that can cause abdominal pain. Not all of these cause diarrhea or vomiting. Another cause of abdominal pain can be from Helicobacter pylori which is a bacteria that can cause inflammation of the stomach leading to ulcers.
I wanted to proceed in a systematic fashion to avoid unnecessary tests. She was given a container for stool specimens in order for me to do a GI PCR panel which tests for a number of viral and bacterial organisms.
A stool sample was needed to test for H pylori. She was instructed to keep a detailed “GI diary” about her diet and details of her pain. Then she began a trial of an acid blocker to be taken daily. Since the results of the stool tests would take a few days I wanted to see her in five days to go over everything. If all the tests were negative and she wasn’t better with the acid blocker, then I would need to step up the workup and possibly get a GI specialist involved.
When she came back for the follow up appointment, the H pylori test was positive. All the other studies were negative. When I asked if she was any better she thought maybe a little…but mom shook her head and said that she was really about the same.
What is H pylori?
It is a bacteria that is more common than people think. Most people acquire it in childhood and of those who are infected most are asymptomatic. It is very prevalent in developing countries where there is overcrowding. One article stated that in these developing countries, 50% of children by the age of five are infected. In the United States that number is approximately 5% by the age of five years. It is felt to be spread person-to-person. One usually gets it by eating improperly cleaned food, drinking contaminated water, or poor hygiene after going to the bathroom.
It is not clear why some people develop symptoms and others do not.
The typical symptoms are a dull “gnawing” pain in the upper abdomen, bloating and burping, nausea and sometimes vomiting, and decreased appetite and weight loss. Many report that the pain is worsened when their stomach is empty, and as a result it may be much worse at night.
If untreated, it causes inflammation of the lining of the stomach (gastritis) which can progress to an ulcer, and in some patients can lead to stomach cancer.
H pylori was discovered by two physicians in 1982.Prior to their landmark work ulcers were thought to be caused by stress and life-style. At this time ulcer medications were one of the more common drugs prescribed worldwide. One of the common procedures done by surgeons was gastric resections for ulcer disease. Once H pylori was discovered and treated the incidence of ulcer disease dropped dramatically. When was the last time you heard of a person “having an ulcer”? As a result of their work, the two physicians were awarded the Nobel Prize in 2005.
H pylori would certainly explain all of the symptoms that my patient had been experiencing over the past three weeks.
The treatment for H pylori was well established.Nowwe would aggressively start treating it with three medications. She would take Amoxicillin and Clarithromycin, both antibiotics, for two weeks. In addition she would take a stomach acid suppresser, a proton pump inhibitor such as Prilosec, for six weeks.
I did talk to a GI specialist about my treatment plan. He agreed but added that we should check her after the treatment to be sure the H pylori was eradicated.
He recommended that I do a breath test instead of a stool study as it would be more accurate. In the breath test, one swallows a pill, liquid or pudding that contains tagged carbon molecules. If one has H pylori, the carbon is released as the ingested material is broken down and this is measured during the breath test.