Factors to consider before getting treated with PPIs

Dear Doctor: Because of the potential risks of proton pump inhibitors, should I have an H. pylori breath or stool test to make sure I have this bacterium before committing to long-term treatment with a PPI?

Dear Reader: That's an excellent question, and it reflects our increasing knowledge about both the bacterium and PPIs. First identified in 1982, Helicobacter pylori is a bacterium that causes chronic inflammation of the stomach lining and stomach, as well as duodenal ulcers; it can also lead to gastric cancer and a slow-growing type of cancer known as MALT lymphoma. In fact, H. pylori is the most common chronic bacterial infection in humans. As for PPIs, they can cause deficiencies in some nutrients and increase the risk of infection with the bacterium C. difficile.

Because these PPIs (Nexium, Prilosec, Prevacid, Aciphex, Protonix, Dexilant) decrease the acidity in the stomach, allowing for healing of inflamed tissues, they're used to treat inflammation in the stomach; ulcers of the stomach or the duodenum; and acid reflux.

Whether you should take PPIs long-term depends on your condition. In most cases for which the medication is prescribed long-term, you would have an endoscopy to visualize the esophagus, stomach and the duodenum (first portion of the small intestine). If the endoscopy found a stomach or duodenal ulcer, your gastroenterologist would have tested for H. pylori with a rapid urease test or with a biopsy test. So if you had an endoscopy that found an ulcer, you likely already have your answer.

If you didn't have an endoscopy and have been diagnosed with gastritis, then I would recommend checking for H. pylori. If you're infected, you could be treated with antibiotics instead of a long-term PPI. The breath test for H. pylori evaluates the bacterial infection's ability to break down urea, a chemical compound excreted in urine, and produce carbon dioxide. This is a very good test with an 88 to 95 percent sensitivity in picking up the organism, but the sensitivity decreases substantially if you are already taking a PPI.

One study in those taking the PPI Prevacid found the sensitivity of the urea breath test decreased by 33 percent. The stool test for H. pylori has a sensitivity of 94 percent in picking up the organism. It is also more cost-effective than the breath test. But again, if you are already taking a PPI or even Pepto-Bismol, the sensitivity significantly decreases.

If you're considering taking a PPI long-term for acid reflux (heartburn), there has been no proof that treating an H. pylori infection would improve the acid reflux unless you had an ulcer in the duodenum. Again, this is something that would be seen on endoscopy. Regarding acid reflux, you should first look at stopping cigarette smoking, alcohol, caffeine and chocolate before considering long-term use of a PPI.

In summary, if your doctor diagnoses you with gastritis, an H. pylori stool test would be of benefit. If your doctor suspects an ulcer, then I would recommend getting an endoscopy, during which you would be tested for H. pylori.