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Physician Spotlight: Srinivas Seela, MD

Srinivas Seela moved to Orlando after finishing his fellowship in Gastroenterology at Yale University School of Medicine. During his training, he spent a significant amount of time in basic and clinical research, and has penned several articles in gastroenterology literature.

His interests include advanced and therapeutic endoscopic procedures, colorectal cancer screening, Gastro Esophageal Reflux Disease (GERD), metabolic and other liver disorders.

Seela is board certified in both Internal Medicine and Gastroenterology. He is a member of the American Gastroenterological Association (AGA), the American Society for Gastrointestinal Endoscopy (ASGE), the American Association for the Study of Liver Diseases (AASLD), and Crohn's Colitis Foundation (CCF).

In addition to an assistant professorship at the University of Central Florida School of Medicine, Seela is also a teaching attending physician at both the Florida Hospital Internal Medicine Residency and Family Practice Residence (MD and DO) programs. He is on the board of directors at the Orange County Medical Society and is a regular contributing writer for Orlando Medical News.

Digestive and Liver Center of Florida provides a wide range of services and treats gastrointestinal and liver conditions. The Endo-Surgical Center of Florida provides colonoscopy, upper endoscopy, advanced diagnostics, therapeutic procedures, and radiofrequency ablation for patients with Barrett's Esophagus and non-surgical hemorrhoid treatment.

"We do everything we can to make sure that our patients have a positive, educational experience, because that's what we would want if the roles were reversed," said Seela.

The Endo-Surgical Center of Florida has been recognized by the American Society for Gastrointestinal Endoscopy for quality and safety and it is accredited by The Joint Commission. Prevention of colon cancer is a top priority at the center

In our forum segment, Dr. Seela shares with our readers diagnosis and new trends in treating H. pylori.

In Other Words...with Dr. Srinivas Seela

H. pylori is a spiral shaped, microaerophilic, gram negative bacterium. H. pylori infection occurs when a type of bacteria called Helicobacter pylori (H. pylori) infects the stomach. This usually happens during childhood. A common cause of peptic ulcers, H. pylori infection may be present in more than half the people in the world.

For most people, it doesn't cause ulcers or any other symptoms. If H.pylori is present, medications are available to treat.

Infection with H. pylori is a cofactor in the development of three important upper gastrointestinal diseases: duodenal or gastric ulcers (reported to develop in 1 to 10% of infected patients), gastric cancer (in 0.1 to 3%), and gastric mucosa-associated lymphoid-tissue (MALT) lymphoma (in <0.01%). The risk of these disease outcomes in infected patients varies widely among populations. The great majority of patients with H. pylori infection will not have any clinically significant complications.

Treatment Trends

Helicobacter pylori treatment has changed the natural history of peptic disease in this country and around the world. In addition, such treatment has affected other consequences of H pylori, in particular some of the mucosa-associated lymphoid tissue (or MALT) lymphomas and other specific disease categories that benefit from its eradication. But the treatment has changed.

Standard treatment involved a 7-day regimen of a proton pump inhibitor (PPI) plus amoxicillin and clarithromycin for patients who could tolerate it. Metronidazole was a substitute for amoxicillin in patients who were penicillin allergic. There has been a component alternative with bismuth-based therapies for patients who have amoxicillin allergy or clarithromycin resistance: a tetracycline/metronidazole/bismuth combination plus a PPI. This is a 10-day regimen.

We have seen, however, that the efficacy of these regimens has declined. This prompted a group of primarily Canadian experts on H pylori and evidence-based medicine to convene a 2-year analysis that culminated in a final evaluation in Toronto, Canada--hence, the Toronto Consensus Conference on Helicobacter pylori Infection in Adults. This consensus conference resulted in several important take-home messages that should change the way we practice and treat H pylori.

First, recognize that drug-resistance patterns have changed during the past decade and a half. Clarithromycin resistance, which was initially quite low, at 1%-8%, has risen to 16%-24%. Metronidazole resistance was relatively high to begin with and has remained relatively stable at 20%-40%. Tetracycline resistance and amoxicillin resistance are virtually unheard of at less than 1% for tetracycline and 1%-3% for amoxicillin, and thus they remain incredibly good drugs.

Prevalence of secondary resistance for clarithromycin and metronidazole has gone up dramatically with the use of antibiotics for UTIs and URIs .Resistance is up to 67%-82% for clarithromycin and 52%-77% for metronidazole. Thus, the effectiveness of these drugs has been drastically reduced.

Consensus Recommendations

It is recommended that extending the treatment from 7 or 10 days to 14 days is and should be the new standard. The eradication rates for the 7- to 10-day regimens have fallen to approximately 50%, whereas with a 14-day regimen by either intention-to-treat or per protocol, the eradication rates were in excess of 95%. Therefore, a regimen lasting 14 days is the new rule across all treatment regimens for H pylori, regardless of which line of therapy is used.

If the initial regimen for a given patient included clarithromycin or levofloxacin and had failed, these drugs should not be used at all.

Similarly, levofloxacin has been used in patients whose initial triple therapy had failed; in that case, triple therapy would include levofloxacin, amoxicillin, and a PPI for 14 days. Levofloxacin does have a fairly high resistance pattern.

Probiotics were not useful to attenuate side effects of the 14-day antibiotic treatment, nor were probiotics helpful proactively to improve the eradication rate.

14-Day Regimen is the new approach for treatment

In conclusion, the consensus committee recommends a 14-day regimen and recognizes the high resistance patterns. But be careful when prescribing the bismuth-based therapy. The standard packaging for the tetracycline/metronidazole/bismuth combination drug is for 10 days. The recommendation now is to use this regimen for 14 days. You would have to give a pack and a half.

Substitute one of the standard bismuth subsalicylate preparations, and prescribe two tablets four times a day plus the PPI, tetracycline, and metronidazole.

Think about new treatments, new options. Think about H pylori as a 14-day-treatment disease. This is the new standard, and we believe the consensus on this is quite strong.

The new guidelines also recommend that patients <60 years with dyspepsia be tested for Helicobacter pylori and treated if positive. H.pylori prevalence is ethnicity specific and pretest probability should be based on the risk factors of the population.

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