Peptic disease and Helicobacter pylori — viva

Opening (must-hit)

"In a child with dyspepsia and an alarm feature such as melaena, I investigate with upper endoscopy and biopsy rather than a non-invasive test-and-treat strategy. I only treat H. pylori if it is found endoscopically and disease is present, and I tailor eradication to susceptibility for 14 days, then confirm cure at least four weeks later off the proton-pump inhibitor." [1] [5]

Branch A — Why endoscopy, not a breath test

Examiner: Why not just do a stool antigen test and treat if positive? Candidate: In children the guidelines explicitly reject non-invasive test-and-treat. Most infected children never ulcerate, so a positive non-invasive test does not prove causation. Endoscopy confirms the ulcer, confirms the organism, and gives me tissue for susceptibility testing. [1] [2]

Branch B — Confirming the organism

Examiner: How do you make a confident endoscopic diagnosis of H. pylori? Candidate: I need more than one positive test: a positive culture, or positive histology plus a positive rapid urease test. I biopsy antrum and corpus and send tissue for culture and susceptibility. This avoids treating on a single false-positive. [1]

Branch C — Choosing eradication

Examiner: The strain is clarithromycin-resistant. What regimen? Candidate: I use a susceptibility-guided regimen for 14 days. With clarithromycin resistance I favour bismuth-based quadruple therapy at weight-appropriate paediatric doses, following local dosing tables. Susceptibility-guided treatment outperforms empiric therapy. [5] [6]

Branch D — Confirming cure

Examiner: When and how do you check it worked? Candidate: A urea breath test or monoclonal stool antigen test, at least four weeks after antibiotics and after stopping the proton-pump inhibitor for two weeks, so I do not get a false-negative from suppressed organisms. I do not use serology. [1] [8]

Branch E — The bleeding child

Examiner: He arrives with fresh haematemesis and a heart rate of 140. What now? Candidate: This is an emergency. Airway, breathing, circulation first: large-bore access, crossmatch, fluid and blood guided by perfusion and haemoglobin, and intravenous acid suppression. I arrange urgent endoscopy for diagnosis and haemostasis and involve surgery early. H. pylori status waits. [11] [1]

Branch F — The functional mimic

Examiner: A different 12-year-old has periumbilical pain, normal growth, and no alarm features. Same approach? Candidate: No. That picture fits a functional abdominal pain disorder. I make a positive Rome-based diagnosis, explain the biopsychosocial model, and avoid endoscopy and antibiotics unless alarm features appear. [2] [1]

Branch G — Treatment failure

Examiner: You confirm eradication failed. What next? Candidate: I repeat endoscopy with fresh culture and susceptibility testing, choose a tailored second-line regimen from those results, and reinforce adherence. I avoid empirically cycling antibiotics, which breeds resistance. [5] [1]