Helicobacter Pylori: A microscopic Stomach Bug that Causes GI Ulcer, Stomach Cancer, and Causes 14,500 U.S. Deaths per Year
While some American's eat out more than others, some eat a bit too hardy, as 'Jack' was doing. That's also likely where 'Jack' got his stomach infection.
'Jack's' first sign his stomach was infected with Helicobacter Pylori was when he started to violently vomit blood during an otherwise quiet dinner conversation with friends at a local eatery. Jack's friends and family called 911, paniced and were grief stricken: how do you stop somebody who's violently vomiting blood? How do you stop them from dying?
Acccording to available data, about 14,500 people, some younger, some older, but mostly those between ages 45 and 84 die a similar death each year in the United States. This data is only for the U.S., and in the U.S., about 40% of the entire population is infected with Helicobacter Pylori stomach infection. In other countries, such as Russia and China, the incidence is 70%, and it's as high as 80-90% in Africa and South America.
Clearly, there's a relationship between the infection and the problems of contaminated water. There's also a direct correlation between oral-oral and fecal-oral contamination.
Helicobacter Pylori is a curved bacterium which is flagellaeted, that means it has multiple 'whip-like' tails which propel it deep into the lining of the stomach. There it eats when you eat, and poops into the lining of your stomach wall- causing irritation of the acid producing cells and a 4-6x increase in acid production. This increase in acid production causes bleeding ulcers, and also predisposes people to stomach cancer.
'Raul's' All You Can Eat Fajita Bar & Grill
So, how does somebody get infected with Helicobacter Pylori? Likely they were eating a bit too much at 'Raul's' and their waiter, 'Jose', did not wash his hands after going and using the bathroom. On accident, 'Jose' stuck his thumb into your beans or rice, as he set the plates on the table, and BAM you just got infected.
'Jose' had no symptoms, his stomach was fine, and he didn't think it was 'that' important to wash up. You still got infected. Could this happen at a Church or Synagogue meal? Sure. How about at your aunt's house. Again: sure. But, more than anything, Americans eat out 2-4 times per week at resturants- where if anyone during an entire shift was seen washing their hands, it was a very rare day! One resturant that is an exception: Subway resturants.
We neither own stock, nor have friends or relatives who own an interest in a Subway resturant. But, Subway is the only resturant where you can go and see that when money is handled, or other objects handled- the person next washes their hands. Then before that person touches your food- they put on gloves. They also change gloves between each meal. A Kosher Rabbi may not agree with all of their meat choices, but even the Rabbi would be happy with their hygiene! Other resturants really need to pay closer attention to how well this hygiene practice is appreciated by patrons.
That's a large part of the problem. Most Americans, and most others in the world think 'hygiene' is something you say to a guy named 'Gene" (Hi, Gene!). Having clean water available, and using it to clean contaminated table surfaces, fruits, vegetables, and hands is crucial.
Right now, in Germany, there's another E. coli infection where a couple thousand people in Germany are ill and 25 have died. While a rare occurrance in Germany, it's very common in South America and Africa, and the poor there do not have major radio or television networks to describe how very common their outbreaks are, and they lack scientists and medical workers to assess and report the high rate of foodborne illnesses and what to do to prevent another horrible infection or death. The folks in the third world have much higher incidence of GI infections and related deaths- you just never hear about them and not much is said, unless it's a slow news day and the numbers are larger than usual. Sad, but true.
Presenting Symptoms in the Office
Presenting symptoms are usually: none! We typically treat 4-5 patients every week (many times more) every week of every month. Typically, during an evaluation for fatigue, or for weight loss, or for a general physical, we'll perform a CBC (Complete Blood Cell count) and we find the patient has anemia.
Now we need to 'define' anemia: it's a low Hemoglobin level (indicating a low iron level), indicating an inability to carry enough oxygen to the tissues and brain, and it is caused either because the person has an iron poor diet (some vegetarians) or has a source of bleeding (heavy menstrual cycle) or our favorite: active bleeding small ulcers in the gut! There are other causes as well for anemia, but that discussion requires another article.
Next we need to understand that scientists at the local area labs are using 'normal' values for people who live at sea level. At sea level normal hemoglobin values are 12.0 to 16.0. Revised 'normative hemoglobin values' for 7,000 feet are 14.8 to 17.7, based on the need to have more red blood cells to carry oxygen in an oxygen poor environment. BUT only one lab in the state has revised numbers for 'our" mountain areas, and the other labs won't revise their numbers based upon science and altitude. Our local health care providers (scientists) need to understand this critical bit of mislabeled 'normal' information.
Most labs operating in the State won't revise their normative numbers based upon zip codes, and we therefore have people being told their labs values are 'normal' when their lab values, to an educated and thoughtful scientist, reflect anemia!
For example, tonite, we saw a patient who saw an area 'specialist', who ordered a Complete Blood Cell Count, (CBC). We obtained a copy of the CBC, and noted her hemoglobin value was 12.9, we ordered a TIBC (Total Iron Binding Capacity test to evaluate how much iron her blood could carry, and ordered a Serum Iron lab test which showed how very low her iron level was. We also ordered her a Helicobacter Pylori test which popped positive for antibodies to the bacterial infection.
Was the infection active, or had she made antibodies and was she fighting off the infection in a safe and efficient manner?
Our patient waited over 2 hours to be seen this evening, and was gracious enough to await our visit as it was obvious to her that the patient before her was from overseas and suffered from a very serious illness. (Yes we have several patients who travel from overseas to see our staff since we offer expertise, technology, and a compassion rarely found elsewhere).
Our patient with the positive H. Pylori test had been fatigued for some time, but had attributed it to: altitude, lots of work, the fires, and just general life stress. She was less than happy that the original doctor she saw who failed to advise her that a 12.9 hemoglobin was abnormally low at 7,000 feet. However, she was happy that for us, it justified a work-up to identify the cause, and to initiate treatment if warranted (which it was).
What's more significant was this physician had a prior year result available which showed our patient's hemoglobin as 14.3, from which a 12.9 value was much lower than a year earlier: that's a 10% loss of value in under a year and a value which clearly warrants evaluation. (Wouldn't you like to earn 10% on your retirement money each year? Such a HUGH return, ah, loss justified evaluation). When a lab test is considered 'Within Normal limits' it's often called 'WNL' which we affectionally call 'We Never Looked' as in providers who should reasonably know certain 'numbers' or 'norms' as not normal, but forget to act as the patient's scientist looking objectively at the data as well as at the history and physical exam, and doing so at 7,000 feet.
Depending on the other tests, including hemoglobin, we often order iron tests and an H. Pylori test. Typically, both the iron test comes back low and the H. pylori test comes back positive. The person we're seeing has active bleeding ulcers, although the blood loss is small or slow and none is vomited, and none has been seen in the toilet.
When a person does not see it, and their 'usual' senses fail to notice it: we call it a 'silent killer'. It's also a killer of enough Americans every year to eliminate every man, woman and child in a medium sized city of 14,500! Everyone graveyard dead from a small bug, which can, itself, be killed!
Our lady was like many patients: she had mixed feelings. She was relieved that she'd discovered, based upon science, why she'd been so tired. She was upset with us that she had to wait so long, but felt the wait provided her answers nobody else cared enough to provide. She felt honored to give her 'time' to waiting for another person who had problems far worse than hers and said a kind prayer for the other patient. Finally she was thrilled when we described exactly how we could kill the 'bug' and then get her hemoglobin and gut back into healthy working order! It would take over 90 days, but she had 'full disclosure' and was 'fully happy'! Our lady also shared her patience with another who seriously needed kindness and understanding.
This evening was our latest ever: we finished at 10:46 p.m. we're tired as are the patients, but we had one of our best days of the year. We were able to provide others with well thought out plans and therapies which would help with their currect problems and prevent future potential nightmares. What an honor to be involved in such wonderful healing!
Let's Kill the Bug!
There are a few different 'protocols' for treatment. In practice, each of the treatments is about 93% effective. The first, and most commonly advertised 'cocktail' of several drugs is pre-packaged and is called 'PrevPac' which costs about $600 for 14 days of therapy. The problem with Prevpac: up to 50% of the people who take it can not finish it due to either nausea, vomiting or diarrhea, or a combination of all three due to the antibiotic 'Biaxin' being in the pre-packaged coctail. Biaxin is a great antibiotic, however, about 50% of Americans can not tolerate it.
The next most popular pre-packaged product is Pylera. Cost of Pylera, with another med prescribed to complete the 'cocktail' is about $400 for 14 days of treatment. Next, in the pre-packaged products is Helidac, which also costs several hundred dollars for 14 days of initial therapy.
Many insurers, while they'd pay tens if not hundred of thousands of dollars to treat you in the ICU for a severe GI bleed, won't pay for the pre-packaged cocktails. The insurers want you to get each drug written out separately, by your provider, with detailed eye-to-eye instructions on how to use all 3 or 4 or 5 of the medications for 14 days. It's way cheaper for the insurers (about $80-$120). Unfortunately, many of you don't want to show up for the in-person critical discussion. You also want to miss the follow-on discussion for what needs to be done for another 2 months to prevent reinfection. And you also seem to want to miss the discussion for what we need to do to treat the anemia.
Those of you who do show up for treatment, if you do not take notes, often get the the cocktail wrong, even though you've received written instruction on exactly what to do. We call it the 'OZ' effect. Then again, much of the patient response to the treatment is referred to the 'OZ' effect.
While we highly respect the kindly and considerate Doctor Oz, he's horrible and very non-compliant as a patient, and admits as much in Time magazine, and shares this with people to encourage them to do what he HAD to learn to do. He had to quit fighting people who were trying to help him overcome a problem which he could not solve on his own. He had to show up for appointments (a major problem for Mister Oz), and had to get the required tests done in a timely manner (something a proscratinating Oz admits was not to his benefit). So, what else is new? While health care providers have some very wise and helpful advice, they make the WORST patients anyone could ask for!
So then: the question is how much of Mister Oz is in you? Do you procrastinate? Do you ignore early warning symptoms? Does this describe one of your family members who's lost their healthy color (anemia), or one who has stomach upset, or one who feels tired, or one who just is not doing okay?
Once successfully, and completely treated for 14 days, 93 of 100 people will need to do nothing other than follow the follow-on program. The follow-on program has two components: the first is acid suppression for another 2 months; the second element is to treat the iron deficient anemia, which at 7,000 feet is critical!
First, stomach acid suppression needs to last for 2 more months of treatment (60 days) and is meant to accomplish two things. First we need to reduce acid production, which has been kicked-up to 4-6 times normal for months to years. The body needs to 're-learn' what a normal level is. Next, by reducing the 4-6x acid levels, we'll prevent further ulcer production. Open areas, (ulcers) are no longer protected by 'healthy' gastric mucosa and are more likely to become re-infected. Thought it was enough fun the 1st time with the 1st infection? Want to try a 2nd re-infection? Unfortunately, many patients and providers fail to get together 2 weeks after the initial therapy to enter this second critical phase in treatment for 60 days of very important acid reduction therapy.
Second, we need to understand: your blood volume is replaced every 90 days. At 7,000 feet this concept is critical! If you have anemia, you'll need to take iron to rebuild your blood cells for 90 days. If your provider likes you, they'll also insist you take a stool softener with each iron dose (otherwise you are likely to become constipated).
Finally, recall that this advice applies to 93% of you reading this who've been infected. Seven out of every 100 will not get better- that's because for that 7% of you we need to use a different group of antibiotics. The first and cheaper coctail failed. Problem is we'll not know this until 2-4 months after diagniosis since various numbers and symptoms will appear during this time: please do not ignore the symptoms- call us and follow-up instead.
Other (Cancer) Related Considerations
Name a type of stomach cancer, and every study done to date implicates Helicobacter Pylori as a cause, or partial cause. We could list several cancer types, but it would be too much for most people to bear reading. Having one type of stomach cancer is enough: why read details on each of the several types, especially when the cause is the same? The key: get the infected person treated, do the follow up care for the 60 and 90 day segments, and do it for all the right and wise reasons cited above.
One critical concern: treat the infection to help prevent cancer. Next be physically active: obesity and inactivity complicates every known risk factor for cancer, and complicates the risk for the progression of cancer.
Finally, there are a few simple GI 'everyday' things a healthy minded person can do: Eat blueberries, they're rich in anthocyanins, which may further reduce GI tumor growth; eat cruciferious veggies such as broccoli, cauliflower, and brussel sprouts as they're known to specifically reduce the risk for a number of GI cancers; eat spinach which can help prevent DNA mutations and prevent cancers; and eat tomatoes as they possess a number of cancer preventing compounds. Remember: wash your fruit and veggies. Remember hygiene is not the same as 'Hi, Gene!'
Finally, consider seriously, learning Yang Style, Tai Chi, as it heals many physical problems and prevents even more physical problems from ever occurring. In one of our future columns we'll discuss Tai Chi. While we note most of medicine is western, the eastern concepts of Tai Chi are equally valuable as treatments.
Remember: We focus on 'best' treatments, not standard treatments. And always remember the joke: the patient has failed The Three Best 'standard' treatments;' Dr Jones' tells the patient he's forced to rely on an 'alternative' treatment which is 96% effective, instead! Work with us to maximize your health; realize denial is a strong force which can divert your focus and your attention; and always be patient and open minded as many options usually exist for any given condition.
'Jack', 'Raul' and any of a number of 'people' who's names we put in quotes could be anybody: they could be you! And that's the point. In a typical week we see 3-4 new patients/day. We typically see 20-35 patients/day, that's 150 people/week, and while open from 12 noon until 8 p.m., it a rare day when we finish our day before 9 p.m. The latest we've been open is now 10:46 p.m., and yes we care deeply for and about our patients!
Helicobacter is everywhere. One in three of you reading this will have the infection. How many of you want to die from bleeding to death? How many of you want to go on to develop stomach cancer? Make an appointment. Show up, and discuss those things we need to discuss. You'll be glad you did!
Medication Protocols to Treat and Kill H. Pylori Infection
There are many fine things that pharmaceutical companies and their staffs do. One of the things that they do that is not fine or okay and is when they rip-off and charge Americans more money for medications than they charge anyone else in the entire world! The word for their conduct: irrational greed!
The insurers, who usually find a middle ground, have refused to pay the absurd costs for certain medical items. One such absurd cost is for 'pre-packaged' treatments for H. Pylori infection. The reps for the companies don't even show their face at any office with the pre-packaged meds as they consider the samples too 'valuable'.
So basically, the drug companies pre-package and put together an antibiotic/PPI cocktail of meds that cost about $80-$120 total and they charge $350-$650 and expect patients to feel intimidated to pay when their insurers refuse the absurd charges. Rest assured, the insurers refuse to pay for the 'pre-packaged' therapies, since any provider can 'take a few minutes' and write out each of the separate meds and explain to the patient how to use them together for 2 weeks.
Problem is, many providers and many patients get 'confused'. To their credit, the prepackaged meds help prevent confusion: but it's not worth $200-400 for confusion 'assistance'. To help prevent future confusion for those in our community, and for our patients in particular, below we've written what, when, and why meds need to be taken together, and what individual medications would be equal to in the pre-packaged treatments.
First, let's start by saying each pre-packaged cocktail is a mixture of antibiotics, and PPI's (Proton Pump Inhibitors-which shut down over production of stomach acid that's been pushed up from normal to 4-6x normal). Finally some cocktails have Peptobismol, and use it for several chemical benefits- the exact nature of how and why it works would be several pages long and involve moderate amounts of chemical property understandings and equations: just trust that the Pepto is necessary for some cocktails.
Before we get started, remember, the most cost effective Pharmacies (cheapest cost) for you and your insurer is at Walmart, Sam's and Smith's. The pre-packaged cocktails get about 93% kill efficiency. Lets get started with the breakdown of the First and most popular and highest cost product, at about $650 for a Prevpac. The Prepac is actually (3 drugs):
Amoxicillin 500 mg 2 caps taken 2x/day x 14 days
Biaxin 500 mg 1 cap taken 2x/day x 14 days
Prevacid 30 mg 1 cap taken 2x/day x 14 days (any other PPI can be used here)
Second product is: Helidac (3 drugs plus a 4th drug):
Tetracycline 500mg taken 4x/day x 14 days
Metronidazole 250mg taken 4x/day x 14 days
Pepto 262mg taken 4x/day x 14 days
You also have to buy (on your own or get another RX for the PPI) such as:
Omeprazole 20mg taken 2x/day x 14 days
Third product is Pylera (4 drugs):
Tetracycline 375mg taken 4x/day x 14 days
Metronidazole 375mg taken 4x/day x 14 days
Pepto 420mg taken 4x/day x 14 days
Omeperazole 20mg taken 2x/day x 14 days
The 'alternative' cocktail we use at Adobe is a variation, of one of a few cocktails and results in about a 97% cure rate in Santa Fe. As you know, 97% beats 93%- so we favor this cocktail below, but it takes some thinking. You must purchase the 4 meds and also buy and properly use the 5th med -the Pepto exactly as directed, or you'll get poorer results:
1) Amoxicillin 500mg 2 caps taken 3x/day x 14 days (#84 caps)
2) Doxycycline 50mg 1 cap taken 2x/day x 14 days (#28 caps)
3) Metronidazole 250mg 1 cap taken 3x/day x 14 days (#42 caps)
4) Omeperazole 20mg 1 cap taken 2x/day x 14 days (#28 caps)
5) Peptobismol 2 tabs or 2 caplets taken 4x/day x 14 days (#112 tabs or caplets)
(Yes we know that Pepto is not sold in #112 caplet or tab counts- you'll have to buy more. Toss or save the extra tabs or caplets for later). Buy and use at the same time and take either caplets or tabs of Pepto (caplets cost more but can be swallowed, versus tabs which must be chewed. Not everyone likes the taste of chewed Pepto).
Let's Prevent Re-Infection!
So, after 2 weeks we have between a 93% and 97% kill of the infection! Next we must take the following 60 days and suppress the presence of 4-6x/normal stomach acid, or we risk re-infection with the H. Pylori. This critical step is one most providers skip or miss, and one reason why some patients get reinfected.
A healthy lining of the stomach, without open ulcers, helps prevent another H. Pylori infection. We know that a PPI will help reduce the acid production, and we used it 2x/day in each of the cocktails during 'intensive' therapy.
Our new approach is not 'intense'. Our plan of care is a moderative approach to gently remind the gut to produce less acid (our goal is not to have 'no' acid, as acid is required for normal healthy digestion). So, we're using this 60 days to 're-educate' the gut to produce a lesser (normal) production of stomach acid with a PPI once a day for 60 days.
Based on cost and availability we generally prescribe Omeperazole 20mg once/day for the 60 days. But we're not done, please read below for our follow-on plan to get our patient back to good health.
Resolving the Anemia, While Preventing Constipation!
Finally we're at the last step in getting the body back to a healthy state. At 7,000 feet this is a critical consideration to remember! As we'd noted, most area labs list a 'normal' Hemoglobin (Hgb) Level (oxygen carrying capacity of blood) to be 12-16 mg/dl. While those numbers were fine for sea level, we're not at sea level!
At 7,000 feet the revised normals for Hbg are about 14.8-17.7. If somebody has lower numbers, they will have problems at altitude. Hemoglobin has at its' center a molecule of iron. No iron, or not enough iron and soon we have little to no Hgb!
Our next plan then is to recall that every 90 days each person replaces nearly all of their entire blood volume! One amazing feat! That means it'll take about 90 days of treatment, with iron, to replace the lost Hgb. However, whenever you give a person iron, without a stool softener, that poor individual will likely develop constipation.
There may be many things a person wants in life, but constipation is not on anybody's wish list. So, to be considerate of our fellow humans, we always order a stool softener whenever we order iron.
There are a number of tablets and liquid that can be consumed to take a dose of iron. Iron at high levels is toxic so please do not do that foolish American idea where if some is good, then more is better!
There are several iron preparations. Ferrous Gluconate is one of the more easily tolerated preparations and less constipating than ferrous sulfate. By prescription, Iron Gluonate is in a 325 mg tablet (65 mg of elemental iron).
If buying iron without a prescription, get 65mg of elemental iron (ask the pharmacist if you can not find the information on the supplement box). A typical dose would be 65mg of elemental iron once or twice/day depending on how low the Hgb value is.
Finally, we return to the topic on constipation prevention, recalling that iron is very constipating for most people. For every dose of 65mg of elemental iron, use a stool softener. A typical stool softener, and a cost effective one is docusate sodium, which comes in 100mg dosages. For every iron dose, take a stool softner dose. Follow this plan and in 90 days we're ready for the next step: labs follow-up.
Follow-up Lab Testing
Once the 60 days of PPI are finished and the 90 days of iron and stool softener are done, it's time for lab tests. The simplest and most cost effective test is a CBC or Complete Blood Cell count. Generally the CBC has a HGB value which has returned to normal (for 7,000 ft), and the 'indicies' which are other numbers such as the MCV, MCH and MCHC are normal.
If the HGB and CBC are normal, we're done, and you're healed! If the numbers are abnormal, then we have a further evaluation to consider. In 97% of the cases you're fine. In 3% of cases, we need to sit down and discuss the exactness of the follow-on work-up. Since you're probably in the 97% group- congratulations!
Dietary Fiber and Diverticulosis
From an article in the journal Gastroenterology, February 2012 (A High Fiber Diet Does Not Protect Against Diverticulosis). The study findings challenge the 'common view' that fiber intake protects against diverticulosis.
In looking at 2,100 people who were screened for fiber intake before colonoscopy, colonscopy revealed diverticulosis in 42% of patients. In adjusted analysis, the higher the fiber intake- the higher the rate of diverticulosis! Low fiber intake was associated with lower incidence of diverticulosis-or exactly the opposite of 'common thought' on how to treat diverticulosis to prevent it worsening.
Bowel movement frequency and constipations were not positively related with diverticulosis. Current 'thought' and treatment for diverticulosis needs to change.