CLINICAL GUIDELINES DANISH MEDICAL BULLETIN DANISH MEDICAL BULLETIN 1 This guideline has been approved by the Danish Society for Gastroenterology October 20, 2010 Correspondence: Peter Bytzer, Department of Medicine, Køge Hospital, DK-4600 Køge, Denmark E-mail: pmby@regionsjaelland.dk Dan Med Bull 2011;58: (4):C4271 SUMMARY National Danish guidelines for the diagnosis and treatment of Helicobacter pylori (Hp) infection have been approved by the Danish Society for Gastroenterology. All patients with peptic ulcer disease, gastric cancer, and MALT lymphoma should be tested for Hp. We also recommend testing in first degree relatives to pa- tients with gastric cancer, in NSAID-naive patients, who need long-term NSAID therapy, and in patients presenting with dyspep- sia and no alarm symptoms. Non-endoscoped patients can be tested with a urea-breath test or a faecal antigen test. Endo- scoped patients can be tested with a rapid urease test. PPI ther- apy should be stopped at least 1 week prior to Hp testing. All infected patients should be offered Hp eradication therapy. First- line treatment is 7-day triple therapy with a proton pump inhibi- tor and clarithromycine in combination with metronidazole or amoxicilline. Quadruple therapy for 2 weeks with bismuthsubsali- cylate, tetracycline, metronidazole and a proton pump inhibitor is recommended in case of treatment failure. Hp testing should be offered to all patients after eradication therapy but is mandatory in patients with ulcer disease, noninvasive gastric cancer or MALT lymphoma. Testing after eradication should not be done before 4 weeks after treatment has ended. INTRODUCTION Approximately 20% of all Danes are infected with Helicobacter pylori (H. pylori). Because of a cohort phenomenon the preva- lence increase with increasing age and very few children and young persons are infected today. Up to 85% of all infected will never develop any symptoms or complications. Around 15% will get sick or will die due to the infection. The cumulated risk of dying from an H. pylori infection before age 85 has been esti- mated at 1:35 for males and 1:60 for females [1]. There is a well established association to peptic ulcer disease, noncardia gastric cancer and MALT lymphoma in the stomach, whereas the associa- tion to functional dyspepsia and various diseases outside the gastrointestinal tract remains controversial. This guideline addresses diagnosis and treatment of Helicobacter pylori infection in all types of patients with or without gastroin- testinal symptoms, both in primary and secondary care. WHO SHOULD BE TESTED FOR H. PYLORI? The recommendations with the associated levels of evidence are summarized in Table 1. Table1: Who should be tested for H. pylori? All patients with peptic ulcer disease (gastric ulcer, duo- denal ulcer, anastomosal ulcer), previous ulcer disease, gastric cancer (incl. noninvasive cancer) and MALT- lymphoma should be tested for H. pylori Ia An H. pylori test-and-treat strategy can be applied to patients with uninvestigated dyspepsia and no alarm symptoms Ia 1. degree relatives to patients with gastric cancer should be tested for H. pylori III NSAID-naive patients, who need long-term NSAID ther- apy, should be tested for H. pylori Ib In cases with unexplained iron deficiency anaemia H. pylori status can be determined III H. pylori testing can be applied in functional dyspepsia, but the symptomatic effect of eradication therapy is modest at best Ia H. pylori infection and/or eradication therapy has no relation to the presence or intensity of GERD Ib ABSOLUTE INDICATIONS • Uncomplicated and complicated peptic ulcer disease (gastric ulcer, duodenal ulcer, anastomosis ulcer) • Previous ulcer disease • MALT-lymphoma • Gastric cancer COMMENTS International guidelines [2-4] agree on these indications. In con- trast to previous guidelines we now recommend that all patients with duodenal ulcer disease should be tested before eradication therapy because the prevalence of H. pylori among these patients in Denmark and in other western countries is around 40-60% [5- 8]. All patients with complicated ulcer disease (bleeding or perfo- ration) must be tested. H. pylori eradication therapy reduces the Diagnosis and treatment of Helicobacter pylori in- fection Peter Bytzer, Jens Frederik Dahlerup, Jens Ravn Eriksen, Dorte Jarbøl, Steffen Rosenstock,& Signe Wildt