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H PYLORI NEGATIVE ULCER
Paul Nacier MD
Fellow American College of Physicians
Fellow American Gastroenterology Association
AMA Member
AMHE Member
Chief of Endoscopy KJMC, Brooklyn, NY
H PYLORI NEGATIVE ULCER

Introduction
H PYLORI NEGATIVE ULCER

Introduction
 Until
1983, most peptic ulcers were considered
“idiopathic”
H PYLORI NEGATIVE ULCER

Introduction
 Until
1983, most peptic ulcers were considered
“idiopathic”
 “Ulcer disease is an infectious disease” as
proven by Warren and Marshall
H PYLORI NEGATIVE ULCER

Introduction
 Until
1983, most peptic ulcers were considered
“idiopathic”
 “Ulcer disease is an infectious disease” as
proven by Warren and Marshall
 The pendulum is swinging: increase incidence of
H Pylori negative ulcer.
H PYLORI NEGATIVE ULCER

Incidence
H PYLORI NEGATIVE ULCER

Incidence
 The
frequency is not exactly known but it is
rising as the treatment or eradication of H
Pylori is more successful.
H PYLORI NEGATIVE ULCER

Causes
H PYLORI NEGATIVE ULCER

Causes
 The
more common are false negative H Pylori
results such as
H PYLORI NEGATIVE ULCER

Causes
 The
more common are false negative H Pylori
results such as
Testing while on proton pump inhibitor, or
recently on Bismuth or antibiotic
H PYLORI NEGATIVE ULCER

Causes
 The
more common are false negative H Pylori
results such as
Testing while on proton pump inhibitor, or
recently on Bismuth or antibiotic
Sampling error from biopsy site
H PYLORI NEGATIVE ULCER

Causes
 The
more common are false negative H Pylori
results such as
Testing while on proton pump inhibitor, or
recently on Bismuth or antibiotic
Sampling error from biopsy site
Biopsy from a “burn out” atrophic body
gastritis with H pylori serology positive
and lower serum pepsinogen I level
H PYLORI NEGATIVE ULCER

Causes
 The
more common are false negative H Pylori
results such as
H Pylori biopsy negative, but histological
evidence of past infection or recently
treated infection
False negative by CHLO test in upper GI
bleeding.
H PYLORI NEGATIVE ULCER

Causes
 And
other more common causes are
H PYLORI NEGATIVE ULCER

Causes
 And
other more common causes are
NSAID’s prescribed or OTC or
surreptitious.
H PYLORI NEGATIVE ULCER

Causes
 The
less common are
H PYLORI NEGATIVE ULCER

Causes
 The
less common are
Chron’s disease and other granulomatous
conditions
H PYLORI NEGATIVE ULCER

Causes
 The
less common are
Chron’s disease and other granulomatous
conditions
Sarcoidosis
H PYLORI NEGATIVE ULCER

Causes
 The
less common are
Chron’s disease and other granulomatous
conditions
Sarcoidosis
Ischemia
H PYLORI NEGATIVE ULCER

Causes
 The
less common are
Chron’s disease and other granulomatous
conditions
Sarcoidosis
Ischemia
Bile reflux
H PYLORI NEGATIVE ULCER

Causes
 The
less common are
Chron’s disease and other granulomatous
conditions
Sarcoidosis
Ischemia
Bile reflux
ZE syndrome
H PYLORI NEGATIVE ULCER

Causes
 The
less common are
Chron’s disease and other granulomatous
conditions
Sarcoidosis
Ischemia
Bile reflux
ZE syndrome
Penetrating carcinoma of the pancreas
H PYLORI NEGATIVE ULCER

Causes
 The
less common are
Mastocytosis
H PYLORI NEGATIVE ULCER

Causes
 The
less common are
Mastocytosis
Helicobacter Helmani
H PYLORI NEGATIVE ULCER

Causes
 The
less common are
Mastocytosis
Helicobacter Helmani
Isolated H Pylori duodenal colonization
(older age, diseases of the duodenal
mucosa) which needs second look
gastroscopy with duodenal biopsy or
HPSA stools or urea breath test.
H PYLORI NEGATIVE ULCER

Causes
 Idiopathic
H PYLORI NEGATIVE ULCER

Causes
 Idiopathic
They
are exceedingly rare. It has been
noted a higher gastrin level and peak acid
output, and a rapid gastric emptying of solid
and liquid resulting in a higher exposure of
the duodenum to acid, causing mucosal
ulceration. (Ke Mccoll, Gut 1993,34,762-8)
H PYLORI NEGATIVE ULCER

Clinical Implications and Complications
H PYLORI NEGATIVE ULCER

Clinical Implications and Complications
H
Pylori negative ulcers can be refractory.
“They lack the beneficial effect of H Pylori
infection on antisecretory therapy” (James
Freston, Alimentary Pharmacology Therapy,
vol. 15, issue 2, pages 2-5). More long term
therapy
H PYLORI NEGATIVE ULCER

Clinical Implications and Complications
 Recurrent
ulcers, obstruction and perforation.
In a 12 month period: 2.5% of recurrence in
patients treated for H Pylori compare to
13.4% in H Pylori negative cases
H PYLORI NEGATIVE ULCER

Clinical Implications and Complications
 More
probability of rectal bleeding: 16% of
patients admitted for UGI bleeding could be
H Pylori negative. (Lawrence Ct, Gastro 128,
2005, 1845-52)
H PYLORI NEGATIVE ULCER

Clinical Implications and Complications
 In
some parts of the world with an incidence of
90% positivity for H Pylori, therapy for ulcer is
based on “empirical treatment and eradication
without testing”. Such an approach could be
subject to change.
H PYLORI NEGATIVE ULCER

Management
H PYLORI NEGATIVE ULCER

Management
 Review
causes
H PYLORI NEGATIVE ULCER

Management
 Review
causes
 Long term therapy
H PYLORI NEGATIVE ULCER

Management
 Review
causes
 Long term therapy
 HPSA, C13 UBT test
H PYLORI NEGATIVE ULCER

Management
 Review
causes
 Long term therapy
 HPSA, C13 UBT test
 Second look gastroscopy and duodenal biopsy
AMHE
37th Annual Convention - Montebello, Quebec
Wednesday July 28, 2010