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Helicobacter pylori: the silent killer

Book · January 2009

DOI: 10.13140/2.1.3513.8241

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 14
C UREA BREATH TEST (14C UBT)
Background. 14C urea breath test, traditionally known as 14C UBT, has revolutionized the
diagnosis of Helicobacter pylori (H pylori) infection and management of gastric diseases.
The test is accurate in diagnosis of H pylori infection and probably the only test which can
check accurately the eradication of H pylori infection after antibiotic therapy. There is no
need for endoscopy for diagnosis for H pylori infection. Subject swallows a special small
capsule which contains urea tagged with a minute quantity of 14C (exposure to subject is less
than what happens during a routine chest X-ray). If subject is infected with H pylori, the
urease enzyme of the bacterium breaks 14C-urea in the capsule in to 14CO and ammonium.
14
CO is absorbed in to blood and exhaled in the breath. After 10 minutes subject blows in to
a small bag which contains an indicator and a sensor. The sensor binds the 14CO of the breath
and indicator changed the color from pink to yellow suggesting that enough 14CO has been
tagged. 14C in the bag is read in an analyzer containing two shielded Geiger-Muller counters
mounted fact to face. It measures 14C activity and accurately tells whether subject is infected
or not infected with H pylori. If subject is infected, he needs a short course of antibiotics and
a repeat test is done after 4 to 8 weeks to check for eradication/cure of H pylori infection.

Indications. How can this test be exploited to manage patients with gastric diseases in
endemic area like Kashmir and control diseases like ulcer and cancer? We need to take
lessons from West where this test is been exploited to the best.

1. Dyspepsia. First dictum is to initiate what has been called a “test and treat policy”.
All patients with dyspepsia who are young (less than 30 years and in whom chances
of having a gastric cancer are negligible) and do not have alarm symptoms (GI Bleed;
dysphagia; mass abdomen; anemia; weight loss; protracted vomiting) should have
14
C-UBT and if infected should receive antibiotic therapy and retested at 4 to 8 weeks
for eradication/cure of H pylori. If dyspepsia settles, there is no need for endoscopy to
investigate such patients and thus these patients (constituting over 50 percent of
patients with stomach diseases) can say “NO-to-ENDOSCOPY”. Patients who are
elderly and have dyspepsia (where a chance of gastric cancer does exist) need more
careful study. “Test and treat” policy can be employed but if there are any indicators
of a serious illness or if patient is yet symptomatic after H pylori eradication/cure, an
endoscopy is advised to exclude gastric cancer or other such serious diseases.

2. GI Bleed. All patients who have upper GI bleed (black motions) should be tested for
H pylori infection and if infected treated with antibiotics. There is mounting evidence
that eradication of H pylori infection in such patients is the valuable in preventing
further episodes of GI bleeds (black motions).

3. NSAID therapy. Many patients who have joint problems and are advised to take pain
killers by doctors do not tolerate the drugs due stomach symptoms. Testing for H
pylori in these patients and eradication of infection in those infected improves pain
killer drug tolerance and relief of joint problems.
 4. H pylori eradication. 14C-UBT is the only way to check for eradication/cure of H
pylori infection. Endoscopy and biopsies of stomach (Rapid Urease test-RUT and
histology) is inaccurate to check for H pylori eradication. Thus all patients who are
known to be infected by any test and have taken antibiotics and want to check for cure
from infection, 14C UBT should be done.

5. Previous gastric surgery. Gastric cancer is common in Kashmir and many patients
have had surgery performed for such cancer. Also many patients with stomach ulcers
had had gastric surgery in the past. Both such groups of patients are high risks for
development of gastric cancer. Eradication of H pylori in such patients prevents
gastric cancer in future. Thus all patients who had gastric surgery in the past need to
be tested for H pylori infection by 14C UBT and if infected to be treated with
antibiotics to prevent gastric cancer.

6. High risk (for gastric cancer) healthy population. There are data available in
literature that diagnosis and treatment of H pylori infection in otherwise healthy
people does prevent development of ulcer and cancer of stomach. Thus high risk
people (with family history of gastric cancer or ulcer) should be tested for H pylori
infection and if infected treated with antibiotics to eradicate/cure infection. This shall
prevent occurrence of cancer in such persons.

7. General population. Should 14C-UBT be routinely performed in general population

in places with high enedemicity? The answer at present is “NO”. This is because of
the cost involved in performing the test is prohibitive to be used for general public
and there needs to be better methods to treat H pylori infection than use of combined
antibiotic therapy which involves costs as well as side effects. Once a vaccine is
available to treat H pylori infection eradication (intensive studies are on) of H pylori
in general population is a possibility and if it happens nearly all stomach diseases
shall be eradicated from humanity!!!

Precautions. Following precautions need to observe for ordering 14C UBT:

1. Patient should not have been on any antibiotics for 2 weeks prior to the test.
2. Proton pump inhibitors or H2-receptor blockers should be withheld for 48 to 96 hours
prior to test.
3. Patient should be on overnight fast or at least 4 hours nil by mouth.
4. For eradication of H pylori, test should be performed at 4 to 8 weeks after H pylori
eradication therapy.
5. Test cannot be performed if patient is pregnant.

Time taken to do the test. 20 minutes.

Adverse reactions. Test capsule has no known allergies or adverse affects.

Interpretation of test results. Test results are reported as (i) infected (test reading 2;
values >50 cpm); (ii) not infected (reading 0; values <25 cpm) or (iii) indeterminate (reading
1; values 25 to 50 cpm).
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