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To: WallStBum who wrote (45)	7/5/1998 6:34:00 AM
From: out_of_the_loop	Read Replies (2) \| Respond to of 582

The role of H. pylori in the pathogenesis of peptic ulcer disease (PUD) has been accepted in medical practice since the late 80's. There was a lot of initial doubt about it being the cause of the disease because the organism is so prevalent in people, especially older people. There may be a resurgence of doubt, according to a GI friend of mine. At this point, however, it is considered the etiologic factor to most PUD. The symptoms of PUD may overlap those of other gastric disease, the most important of which is cancer. H. pylori may co-exist with cancer and many people consider it the cause of chronic inflammation that may cause the genetic alterations that lead to cancer. The standard method of diagnosis of H. pylori is gastric biopsy. Many people think that the breath test is more sensitive than the biopsy in finding H. pylori. The problem is the small percentage of patients with cancer will not be identified without looking in their stomachs and finding the tumor. There are blood tests for H. pylori antibodies but these are often hard to correlate with active infection since many people have them after exposure but may not have active inflammation caused by the bacteria. So, even asymptomatic people, and people with both PUD symptoms and cancer will have the antibody. The breath test identifies a metabolite of the bacterium and thus is a better predictor of active infection, but can't find the cancer. So, it's a matter of risk and economics. Do you want to biopsy everyone and find the low prevalence cancers or do you want to play the odds that most people with PUD caused by H. pylori will be identified, then treated? The ones who fail to completely respond may be then biopsied. Stomach cancer, excluding lymphoma, has a 5% five-year survival, so a delay in diagnosis is not tolerable if you are the patient. If you are the insurance company, it's OK because it's not your life. The bottom line is the breath tests work, but I cannot comment on their use in practice. I do not know the actual number of tests, either blood or breath, for the detection of H. pylori. I do know I have seen a lot of biopsies looking for it. Probably up to 5% of our biopsies are for this; maybe more. We see about 14,000 biopsies per year in our community hospital of 400 beds and its related clinics, so this guesstimate is 700 biopsies looking for H. pylori per year. It is huge on a national scale. The question is how gastroenterologists feel about using the breath test either in place of, or in addition to, biopsy. Also, will insurance companies pay for both tests or only one? A link with a literature search on H. pylori breath tests is here(you may need to cut and paste rather than click): www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&uid=9458491&dopt=m&dispmax=20