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Editor,—The Maastricht Consensus Report (Gut1997;41:8–13) has recommended broadening the guidelines on eradication of Helicobacter pylori to include certain dyspeptic patients without confirmed peptic ulceration. Although this policy may improve dyspeptic symptoms in certain subgroups of patients without ulcers,1 an overall benefit from eradication of H pylori in non-ulcer dyspepsia has yet to be established. Furthermore, while a “test and treat” strategy may have cost benefits,2 potential dangers to individual patients should be considered. Such dangers are illustrated by a patient who was recently admitted under our care with fulminant pseudomembranous colitis following triple therapy for the treatment ofH pylori.
The 40 year old woman had complained to her general practitioner of colicky epigastric pain, associated with reduced stool frequency over the previous 12 months. Following a positive 13C breath test, she was prescribed a two week course of bismuth chelate 120 mg four times daily, metronidazole 400 mg three times daily and amoxycillin 500 mg four times daily. Two weeks later she was admitted to hospital with severe diarrhoea and abdominal pain. Examination revealed a pulse of 120 beats/min and a systolic blood pressure of 80 mm Hg. Her abdomen was distended, with localised peritonism in the right iliac fossa. Following resuscitation, she underwent laparotomy, when the diagnosis of severe, generalised pseudomembranous colitis was confirmed, and a subtotal colectomy was undertaken. Clostridium difficile toxin was later identified on stool examination. Examination of the resection specimen revealed a partially obstructing Dukes’ B carcinoma of the mid-transverse colon. She was treated with enteral vancomycin 250 mg three times daily and, after a prolonged stay on the intensive care unit, made a full recovery.
This case illustrates two important lessons. Firstly, it shows the potential dangers of linking gastrointestinal symptoms to positiveH pylori breath and serological tests without further investigation. A presumptive diagnosis of H pylori related pain was based on the combination of epigastric pain and a positive breath test. In retrospect the original symptoms were probably caused by her transverse colon carcinoma. Although rare in this age group, this diagnosis should have been considered, given her change in bowel habit. Furthermore, if a negative upper gastrointestinal endoscopy had been obtained, the nature and severity of her symptoms might have led to a search for an alternative explanation.
Secondly, this case emphasises the potential dangers of antibiotic treatment regimens in the treatment of H pylori. The eradication therapy given in this case has now been largely superseded by shorter treatment courses incorporating a proton pump inhibitor, combined with a combination of two antibiotics, usually amoxycillin or clarithromycin and metronidazole. Minor side effects, including taste disturbance, diarrhoea and rashes are relatively common, but more serious events have also occurred. Clostridium difficilepositive diarrhoea and fulminant pseudomembranous colitis have been described following helicobacter eradication regimens containing amoxycillin3 4 and clarithromycin,5 although not previously with such dramatic consequences. The presence of a partially obstructing carcinoma in this patient’s colon may have influenced the severity of the problem at presentation.
The authors of the Maastricht Consensus statement admit that the evidence for benefit from H pylori eradication in functional dyspepsia and in the prevention of gastric cancer is equivocal. Although life threatening complications such as this are rare, clinicians should consider potential risks when H pylori eradication therapy is being considered without a proven benefit.
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