DIGESTIVE SYSTEM

Discovery of Helicobacter pylori

 Robin Warren and Barry Marshall demonstrated HP in petri dishes unintentionally left for day
 Marshall developed symptoms after drinking a beaker with HP culture
 Proved that HP, not stress or spicy foods, caused ulcers
 Demonstrated that antibiotics treated the infection

Local prevalence among patients with dyspepsia

60% among 136 dyspepsia adult patients using RUT
42% among 375 dyspepsia patients using RUT and histopath
60% among 52 dyspepsia patients
22.77% in 382 dyspepsia patients who underwent EGD

We recommend dyspepsia patients under the age of 60 have non-­­invasive test for H. pylori and therapy
for H. pylori if positive.

Significant benefit in testing and treating for H. pylori compared to prompt EGD
Trend toward benefit and cost favouring test and treat compared with PPI

PPI Antibiotics Bismuth

Esomeprazole Amoxicillin
Lansoprazole Clarithromycin
Omeprazole Metronidazole
Pantoprazole Levofloxacin
Rabeprazole

Regimen Drugs Duration

Triple therapy
Quinolone therapy
Rifabutin triple
Bismuth quadruple
Non- Bismuth quadruple
PPI + Amox + Clarith Concomitant: 14 days
PPI + Amox + Metro
PPI + Amox + Levox
PPi + Amox + Rifabutin
Bismuth + PPi + Amox + Clarith
Bismuth + PPi + Amox + Metro
Bismuth + PPi + Tetra + Metro
PPI + Amox + Clarith + Metro Concomitant: All X 14 days
Sequential:
PPI+Amox X 5 days, then
PPI+Clarith+Amox X 5 days
Helicobacter pylori eradication

 In areas with high clarithromycin resistance (>15%)

PPI – clarithromycin-containing triple therapy without prior susceptibility testing
should be abandoned.
Quadruple, concomitant (PPI, amoxicillin, clarithromycin and a nitroimidazole)
therapies are recommended.
 In areas of low clarithromycin resistance
Triple therapy is recommended as first line empirical treatment

H. pylori resistance patterns

 All 14 strains isolated showed sensitivity to all the first line antibiotics namely metronidazole,
amoxicillin, clarithromycin and tetracycline
 No resistant strains were isolated based on the Etest method

Etiology of travelers Diarrhea

Did not seek care/ treatment Sought care/treatment

Symptoms Duration: 3 days Before: 1.4 days
After: 1.5 days
Management 55% given loperamide
57% given antibiotics
Duration of Symptoms Loperamide + antibiotics: 9.6 hours
Antibiotics alon e: 21.8 hours

Golden Rule to prevent GI infections:

“Boil it, cook it, peel it, or forget it!”

TREATMENT
 Balanced electrolyte rehydration in the elderly with severe diarrhea or any traveler with cholera-like
watery diarrhea is recommended
 The use of probiotics and prebiotics for acute diarrhea in adults, except in postantibiotic- associated
illness, is not recommended
 Bismuth subsalicylates can be administered to control rates of passage of stools
 Empiric anti-microbial therapy for routine acute diarrhea infection, except TD, is not recommended.
 Antibiotics for community- acquired diarrhea should be discouraged as these are mostly caused by
viruses and course not shortened
 Organism Preferred therapy Alternative agents Efficacy
Campylobacter jejuni Azithromycin Ciprofloxacin, Proven if started
Vancomycin within 3 days symptom
onset
Clostridium difficile Metronidazole Vancomycin Proven in severe cases
Non- typhoidal Amoxicillin or Trimethoprim- Proven in children with
Salmonella ceftriaxone sulfamethoxazole toxic status, in children
under 3 months of age,
in at-risk children, and
if systemic or focal
infections
Salmonella typhi Third-generation Chloramphenicol Proven
cephalosporins
Shigella Azithromycin, Cefixime, ciprofloxacin Proven
ceftriaxone
Yersinia Trimethoprim- ceftriaxone Proven in severe
sulfamethoxazole disease or bacteremia
Vibrio cholerae Azithromycin Doxycycline (>8 years), Reduces duration by
ciprofloxacin 50% and shedding
ETEC Azithromycin (only for Trimethoprim- To be considered in
traveler’s diarrhea) sulfamethoxazole selected cases

Antibiotic Dose Duration

Azithromycin 1000mg Single dose
500mg 3 days
Levofloxacin 500mg 1 or 3 days
Ciprofloxacin 750mg Single dose
500mg 3 days
Ofloxacin 400mg 1 or 3 days
Rifaximin 200mg 3x a day 3 days

TREATMENT FOR SHIGELLA

DRUG DOSE
Ciprofloxacin 15mg/kg PO BID x 3 days
Pivmecillinam 20mg/kg PO QID x 5 days
Ceftriaxone 50-100 mg/kg IM x 2-5 days
Azithromycin (for adults) 6-20mg/kg PO OD x 1-5 days
TREATMENT OF TYPHOID FEVER

DRUG ADULT CHILD DURATION

Ciprofloxacin 500mg PO BID; 30 mkd in 2 doses 7-10 days
400mg IV GID (max: 1g daily)
Ofloxacin 400 mg PO or IV BID 15-30 mkd PO in 2 7-10 days
doses
(max: 800mg/d
Ceftriaxone 2 g IV OD or BID 50-100 mg/kg IV in 1 10-14 days
doses
(max: 4g /d)
Cefotaxime 1-2 g IV every 6-8H 150-200 mkd IV in 3-4 10-14 days
doses (Max: 8g /d)
Cefixime 200mg PO BID 20 mkd in 2 doses 10-14 days
(max: 400mg /d)
Azithromycin 1g PO then 500mg 10-20 mkd OD 5-7 days
daily or 1g OD (max: 1g/day)
Meropenem 1-2 g IV every 8H 20-40 mkd every 8H 10-14 days
(max: 6g/day)

Indications for treatment of HBV

Viral replication
HBeAg (+): HBV DNA > 20,000 IU/ml
HBeAg (-) HBV DNA > 2,000 IU/ml

PLUS

Liver damage
Biochemical: ALT (>2x ULN)
Fibrosis on non-invasive imaging
Inflammation/fibrosis on biopsy
GOALS OF TREATMENT

GOALS APASL, 2015 EASL, 2017

Ultimate Goal Global eradication of HBV infection
Goal of Therapy Improve QOL and survival by
preventing progression to cirrhosis
Prevention of transmission
Regression of fibrosis and cirrhosis
Endpoints of therapy HbsAg loss + antiHBs
Undetectable HBV DNA
Improve survival and QOL by
preventing progression and HCC
development
Prevent mother to child
transmission,reactivation and
prevention of extrahepatic
manifestations
Suppression of HBV DNA HBeAg
loss + antiHBe Normal ALT

CLASS DRUGS DOSE PRECAUTIONS

POTENTIAL SE
D-Cyclopentanes Entecavir 0.5mg daily Lactic acidosis in cirrhotics; Test for
HIV
Nucleotide Tenofovir 300mg daily Nephropathy, osteomalacia, lactic
reverse acidosis, check creatinine; test for
transcriptase HIV
inhibitor
Nucleoside Lamivudine 100mg daily Well- tolerated, low cost, slow
analogues decline, resistance
Relapse rate 37-50 % in 1y
Acyclic Adefovir 10mg daily Acute renal failure, lactic acidosis,
nucleotide check creatinine, serum phosphate,
phosphonates U S/A
Telbivudine 600mg daily Crea kinase elevation, myopathy,
neuropathy, 25% resistance
L nucleoside Clevudine 30mg daily Myopathy in 13%
pyrimidine
analogue
Immune Interferon 5 M IU daily or Flu-like symptoms, fatigue, mood,
modulator alpha 2 10 M IU TIW cytosine, anorexia, weight loss,
Pegylated (2a) 1.5 mcg/kg or Check CBC and TSH every 3 months
interferon (2b) 180mcg weekly
alpha