What is the best treatment approach for recurring abdominal pain radiating to the back in a patient previously diagnosed with antral gastritis and treated for H. pylori (Helicobacter pylori) infection?

Treatment of Recurring Abdominal Pain with Radiation to Back in Antral Gastritis and H. pylori

For patients with recurring abdominal pain radiating to the back with previously diagnosed antral gastritis and treated H. pylori infection, a proton pump inhibitor-based triple therapy regimen is strongly recommended to eradicate any persistent H. pylori infection, followed by acid suppression therapy if symptoms persist.

Diagnostic Approach for Recurring Symptoms

Confirm H. pylori Eradication Status

1. Urea Breath Test (UBT) or Stool Antigen Test (SAT)

   • Sensitivity: 95% and 88-90% respectively
   • Specificity: 95% and 91-100% respectively 1
   • Must be performed at least 4 weeks after completion of previous therapy
   • Avoid testing while on PPIs (stop 2 weeks prior) to prevent false negatives

2. Avoid serological testing for confirmation

   • Antibodies remain elevated for months after eradication 1
   • Not useful for confirming eradication

Endoscopic Evaluation

• Indicated if:
  • Age >45 years with new-onset symptoms
  • Alarm symptoms present (weight loss, anemia, dysphagia, persistent vomiting)
  • Previous treatment failure
  • Symptoms persist despite confirmed eradication 1

Treatment Algorithm

1. If H. pylori Infection Persists:

• First-line treatment: Proton pump inhibitor (PPI)-based triple therapy

  • PPI (standard dose twice daily)
  • Amoxicillin (1g twice daily)
  • Clarithromycin (500mg twice daily)
  • Duration: 14 days 2, 1

• Alternative if previous clarithromycin treatment failed:

  • PPI (standard dose twice daily)
  • Amoxicillin (1g twice daily)
  • Metronidazole (500mg twice daily)
  • Duration: 14 days 2

2. If H. pylori Has Been Successfully Eradicated:

• PPI therapy:

  • Standard dose once daily for 4-8 weeks
  • Evaluate response and taper if symptoms improve 1

• Consider other causes of recurring pain:

  • NSAID-induced gastritis (discontinue NSAIDs if possible)
  • Functional dyspepsia
  • Biliary pathology (especially with back radiation)
  • Pancreatic disorders 1

Special Considerations

Monitoring Treatment Effectiveness

• Confirm eradication with UBT or SAT at least 4 weeks after completion of therapy 1
• Complete the full course of antibiotics even if symptoms improve 1
• Poor compliance can lead to treatment failure and antibiotic resistance

Nutritional Support

• Evaluate for nutritional deficiencies, particularly iron and vitamin B12, which are common in H. pylori-associated gastritis 1
• Supplement as needed

Pain Management

• Avoid NSAIDs as they can exacerbate gastritis
• Consider antispasmodics for pain with cramping features

Common Pitfalls to Avoid

1. Inadequate testing before retreatment

   • Failing to stop PPIs before testing (leads to false negatives) 1
   • Using serology to confirm eradication (remains positive for months)

2. Incomplete treatment courses

   • Poor compliance is a major cause of treatment failure 1
   • Emphasize importance of completing full antibiotic course

3. Overlooking acid suppression during long-term therapy

   • H. pylori infection with acid suppression can increase corpus gastritis 3
   • This may explain development of corpus atrophy in patients on long-term acid suppression

4. Missing other causes of abdominal pain

   • Pain radiating to the back warrants consideration of pancreatic or biliary pathology
   • Functional dyspepsia can persist even after successful H. pylori eradication 4

Evidence for Symptom Resolution

Studies show that eradication of H. pylori results in resolution of clinical symptoms in approximately 80% of patients with recurrent abdominal pain 5. However, some patients may have persistent dysmotility symptoms associated with inflammation, particularly in the cardia and antrum, even after successful eradication 4.