Complicated helicobacter and gastritis case with negaitive culture

[nikolay]

I am in a middle of a bit complicated case with myself. I am 37 y old male, who do not smoke and drink (actually I drink but rarely), do sports often, my stomach was good although having the experience now it might be that I had gastritis from years as sometimes I got some symptoms when I eat too much, but nothing which can says I have stomach issues. Never limit what I eat or sort of it and my stomach could handle it. The only sickness I have is hypertension for which I take pills from 20 years and also I am bit overweight.

Will try to make the longer story short but I am known for not able to summarise 1 y ago I got very sick with vomiting one evening and though it was a virus as I was ok after a day. Then after 1 week ago I got the same symptoms but more mild, with some pains in the night. Go to a doctor and he was thinking I had a gastritis, made me a blood test but it was negative so treating me for something like "upset stomach", but it didn't solved. I get dyspepsia symptoms for a month with feeling sick, full, have bloating etc. Then he put me for a few weeks on famotidine and I was feeling better. From then on if I stop the famotidine I get worse, If I take it, I feel better. However about 3 months after all started I went to urea C13 breath test which was surely positive (well above the cut off value).

The doctor put me immediately on 2x20mg esomeprasole, 2x500mg clariromycin, 2x1000 amoxicilin for 10 days. I feel better, my white tongue cleared at the last days, I continued 1 week more with 1x20mg esomeprasole and all seemed fine. However when I stopped the PPI I got very strong acid reflux although dyspepsia seemed better. As I was impatient I done another UBT 3 weeks after the treatment which was negative (I know it was early). The doc gave me some simple antacid Talcid which was helping for the acids. And this situations continued. I done again UBT 8 weeks after treatment (not taking PPI or AB or anything meanwhile) and it was again negative. So the doc again was not sure but gave me famotidine for some 2-3 months, which was correct based on the negative test. For this time I was fine although I didn't feel my stomach really like before and I still have the white coating on my tongue.

Then after about 3 months I stopped the famotidine and I got again the same symptoms with acids, sensitive to food, feeling sick from time to time, etc. Agreed with the doctor to do endoscopy, which revealed I have erosive gastritis, and fast urease test was positive for HPylori again. The doctor gave me this time 2x20mg esomeprasole, 2x1000 amoxicilin and 2x500 levofloxacin for 10 days. This time I didn't feel so better like the first treatment. Just didn't feel that the I am much better, even I feel some acids with 2x20 esomeprasole and doctor increased it to 2x40 for the second half 5 days. The white coating on my tongue which I use like an indicator for the inflamation was not fixed. I continued to take 1x20 esomeprasole for 2 more weeks but after stopping it was almost the same as before - dyspepsia symptoms and feeling acids and burns but at least the reflux symptoms are better then before (not sure why).

I need to say that in the last 15 or more years I didn't take any antibiotics, although as a kid I was often sick so probably taking some. Only 10y ago in 2007 I was treated with levofloxacin for throat inflammation, I remember that levofloxacin was just released in my country and the docs said they give me something very new and good, which fixed me really fast then.

6 weeks after the treatment, meanwhile taking just simple antacids from time to time and do not taking any H2 or PPI I done UBT in another lab. Positive for HPylori. Nice. Now the case was - 2 unsuccessful treatments. I know it can happen and I wanted the best so I gone to the microbiology lab, they told me which doctor can do endoscopy and get proper samples (culturing Hpylory here is not common and probably there are only one or two labs which do it) and I underwent another endoscopy with taking samples for culture from very experienced doctor. He saw again erosive gastritis and put me on 2x20 esomeprasole for 14 days. However today I take my results from the lab (actually the same where I've done the UBT) and the result is negative for HPylori. So I have positive UBT and negative culture and I am stuck again on the road. Tomorrow I have a meeting with the head of the lab to discuss the situation but I perfectly know that culture is not always possible.

I though the culture and antibiotic resistance test will resolve my issues once and forever but I am very disappointed as I feel that I am there where I was year ago... I've done all correct but it didn't helped. So I would be very grateful if you gave me some advise as I bounce between options, the doctor says that based on these results he needs the opinion of the lab and he cannot give me any meds at the moment.
- Do I need to wait 2 weeks now (as am taking PPI) and confirm the infection with stool test or another UBT?
- Is there any sense in trying another culture with another endoscopy while this one failed ?
- If I move forward with third "blind" therapy which antibiotics? Do I include pepto bismol (which is not available in my country but I can bring it from abroad) ?

Thanks for your help!

[Helico_expert]

H. pylori is not easy to be cultured. many laboratory has the same problem and hence they give up trying.

it is surprising to see you have negative blood test. the C13 or C14 UBT is usually very sensitive too. I wonder why you kept getting inconsistent results.

what about histology? what did the report say?

assuming that your last UBT is correct and you indeed have H. pylori, then I think based on that is enough for antibiotic treatment.

H. pylori cannot become resistant to amoxicillin and so you can always use it.

You can ask your doctor if he is able to prescribe you
Rabeprazole 20mg x3
Amoxicillin 1000mg x3
Bismuth 240mg x4
rifabutin 150mg x2

[nikolay]

Its getting more complicated with the amount of the doctors you visit.

This morning I was discussing my case with the head of the lab which is probably the best known expert in helycobacter in my county from scientific point of view. She said that based on the gastric stomach I have and the last positive UBT in their lab, although culture is negative, we can conclude I have positive Helicobacter and send me back to the doctor for 14 day quadruple therapy but not mentioning the antibiotics. Then I told the doctor that I was previously treated with claritromicin, ammoxicilin and levofloxacin but still he gave me ammoxicilin and claritromicin, saying this is the main antibitics for that condition no matter I already had such therapy. Anyway I though it might be a valid therapy (this time with bismuth and 14 instead of 10 days) but since I also read a lot go back to the lab asking for opinion. They said that it's not good and they wouldn't prescribe it but they don't write prescriptions and I need to go back to the doctors insisting for different antibiotics. And they mentioned tetracycline and metronidazole as eventual options. Anyway I didn't go to the same doctor, as I have some other options (I hate to argue with doctors what needs to be prescribed to me as I am not a doctor).

Also about histology from the endoscopy - there is such but no results yet, next week probably. They should test for Hpylori and probably it's ready but I can't get it now. Also getting again inconsistent result like negative will be another nail in my coffin of uncertainty. As you say since I have so much inconsistent results I am suspicious to both positive and negative and I am thinking that I want to see at least two positive results to start another treatment. I just don't believe anything at the moment, I'm just more on the thinking that labs do mistake too often, so better to see 2 positive results. I might need to stop the PPI and wait 3 weeks to do again UBT in another lab. Of course if the histology is positive then the things are clear and I should start treatment.

Regarding you proposed treatment I have few questions:
1. Is rabeprazole better than esomeprasole? Here they prescribe 90% of the time esomeprasole.
2. In the lab they suggested tetracycline instead of ammox. I guess because taking into account that I might eventually have resistance to ammox? Is there such option to hpylori to be resistive to amoxicilin? I know it's rare, but it might happen probably.
3. You say 3x day, isn't it too strong as the standard is 2x? How much days? 10 or 14 ?
4. For the bismuth I can buy pepto bismol from UK - better liquid or pills?

Thank you very much for your help, I really appreciate I can find competent advice in Internet which is so rare these days.

[Helico_expert]

1. there are many brands of PPI. they all function the same. Just different side chain. however, some people are better in metabolising certain PPI. for example, if you are very good in metabolising omeprazole, you will need higher dose to get the right effect.

Rabeprazole is probably better because the pathway of metabolising it is different. So it's more effective in most people.

2. PPI + Bis + Tet + met is also a very good treatment. Metronidazole resistance may be overcome by having higher dose. Some people doesnt like to mix amoxicillin with tetracycline because they might counter interact each other. by some doctors claim that amox and tetra still work in killing HP.

3. Amox is a very safe drug. 3g a day is fine. some people were even given 5g a day.

4.popto bismol is fine. either liquid or pill is ok.

[nikolay]

Ok, if I start treatment will try to obtain rabprazole if possible in my country. Over here the doctors prescribe mostly Nexium, as this is the most expensive and considered "top" PPI. However for my first treatment I was using another esomeprasole drug which was half the price of Nexium and I think for me it is more effective, just changed nexium with it (at least it's half the price ). I am not in any way knowledgeable in pharmacy and chemistry but Nexium is esomeprazole magnesium dihydrate and the cheap one is esomeprazole magnesium trihydrate , not sure if this makes any difference. By the way I read in some papers that both tetracycline and metronidazole are not so sensitive to acidity like clarytromicin, so maybe PPI choice and dosage not so important in the standard quadruple therapy.

Also I found that I am not correct about absence of bismuth - over here there are in pharmacies bismuth tablets 120mg with bismuth subcitrate, and pepto bismol is Bismuth subsalicylate. Is there any preference for one of them or doesn't matter?

[Helico_expert]

if you find esomeprazole is effective on you, just go for it.

bismuth subcitrate or subsalicylate, anyone will do. Here we use bismuth subcitrate 120 mg tablet.

[nikolay]

Somehow the histology result is not yet ready. Not sure if they didn't screwed something as it's already 3 weeks, probably yes. Will wait 1w more to see. Now I decreased the PPI to 20mg per day and I immediately can feel it.

Also I've done one of these tests https://www.amazon.co.uk/Stomach-Ulcer- ... test+stool today and it came negative. However I am still taking PPI and also not sure if these tests are reliable at all. From next week if histology is not ready, I will stop PPI, wait 2 weeks and will do UBT and another stool test. Unfortunately this bacteria is so hard to detect... Everything is so slow, you need to wait weeks and months.

[Helico_expert]

you can try switch PPI to ranitidine. double or triple dose of standard ranitidine. you can keep taking ranitidine until the night before breath test.

[nikolay]

Before PPI I was taking most of the time famotidine when wanted to feel better. I will switch to it 2x40mg, although I even prefer to stop it for 2 weeks before breath test to be sure all is correct.

[nikolay]

Something came in my mind. Since I still have the option for hpylori negative gastritis, and I am not taking any nsaids, not drinking alcohol, any chemicals, etc, how possible is to have erosive gastritis from my antihypertensive drug which contains irbesartan 150 mg and Hydrochlorothiazide 12.5mg and I am taking daily. I don't believe too much in that hypotheses as I use that drug already 8 years, and before I have similar for another 5 years probably (also containing Hydrochlorothiazide). This is the only drug which I take daily from many years. Gastritis is not common side effect of this medicine but who knows. Did you have any experience with such patients?

Thanks.