Patterns of gastritis and the effect of eradicating Helicobacter pylori on gastro-oesophageal reflux disease in Western patients with non-ulcer dyspepsia

Effect of gastric helicobacter pylori colonization in the development of erosive esophagitis in patients with hiatal hernia

Background/Aims

There may be various factors that determine gastroesophageal reflux disease (GERD) as a result of hiatal hernia (HH) (such as the size of the hernia, age, other host and environmental factors) and the presence of protective factors to explain the absence of reflux disease should not be ignored. Helicobacter pylori (Hp) infection can prevent the development of GERD or cause it. This study aimed to determine whether Hp colonized in the stomach and hernia affects the development of erosive esophagitis (EE) in patients with HH.

Materials and Methods

In this case-controlled study, 111 patients with HH were eligible for the study. Study group with EE (n = 61, 55%) and control group without EE (n = 50, 45%) were formed. Groups were compared for gastric Hp and Hp in the hernia.

Results

While the frequency of Hp in the antrum was 55.7% in the group with EE, it was 30% in the control group (p = 0.01, OR: 2.94 in 95% CI 1.34-6.46). The rates in terms of HP frequency in the corpus were 43.6% and 32.1%, respectively, (p = 0.45). Hp colonization in HH was detected in 18 cases (29.50%) and 14 cases (28%), respectively, (p = 0.86). In regression analysis, antral Hp was found to be effective in the development of EE (p = 0.01).

Conclusion

As a result of this study, we think that antral Hp may have a causative role in the development of reflux esophagitis, but the presence of Hp in HH does not have an effective role in reflux esophagitis formation.

The Spectrum of Helicobacter-Mediated Diseases

Helicobacter pylori is the leading cause of peptic ulcer disease. The infection has been implicated in more than 75% of duodenal ulcer cases and 17% of gastric ulcer cases. H. pylori has been classified as a human carcinogen, since it is the main cause of distal gastric adenocarcinoma and B cell mucosa-associated lymphoid tissue lymphoma. Evidence also links H. pylori with extragastric conditions including iron deficiency anemia, idiopathic thrombocytopenic purpura, and vitamin B₁₂ deficiency. Studies indicate that H. pylori may be protective against other conditions of the gastrointestinal tract (e.g., reflux esophagitis and related pathologies) and elsewhere in the body (e.g., asthma). The infection is asymptomatic in the vast majority of cases; more serious outcomes occur in only 10-15% of infected individuals. Despite extensive research over the past 3 decades, there is no effective vaccine, and the circumstances leading to disease development remain unclear. In addition, there is now a growing prevalence of antimicrobial resistance in H. pylori. This review discusses these important issues.

Endoscopic Reflux Esophagitis and Reflux-Related Symptoms after Helicobacter pylori Eradication Therapy: Meta-Analysis

Backgrounds: The etiology of gastroesophageal reflux disease (GERD) including reflux esophagitis and non-erosive reflux disease is multifactorial and a recent meta-analysis showed no association between the development of GERD and Helicobacter pylori eradication in both Western and East-Asian populations. However, the problem remains that various inclusion criteria are used in these studies, which hinders meta-analysis. With a focus on reflux esophagitis with endoscopic mucosal injury, we meta-analysed to evaluate the association between eradication and reflux esophagitis and symptoms using a clearly defined set of inclusion criteria. Methods: We conducted a meta-analysis of studies published up until March 2020, which compared the incidence of reflux esophagitis and symptoms between patients undergoing H. pylori eradication therapy in a randomized placebo-controlled trial (Category A); between patients with successful and failed eradication (Category B); and between patients with successful vs. failed eradication, receipt of placebo, or no-treatment H. pylori-positives (Category C). Results: A total of 27 studies were included. Significant statistical effects were found for development of endoscopic reflux esophagitis [relative risk (RR): 1.46, 95% confidence interval (CI): 1.16-1.84, p = 0.01] or de novo reflux esophagitis (RR: 1.42, 95% CI: 1.01-2.00, p = 0.03) in the case group that received eradication in all studies, especially in Western populations. There was no significant difference in the incidence of symptoms after eradication between patient and control groups, regardless of category, location of population, or baseline disease. Conclusions: Eradication therapy for H pylori increases the risk of reflux esophagitis, irrespective of past history of esophagitis. In contrast, no effect was seen on reflux-related symptoms.

High-dose PPI-amoxicillin dual therapy with or without bismuth for first-line Helicobacter pylori therapy: A randomized trial

BACKGROUND

A reliably highly effective high-dose proton-pump inhibitor plus amoxicillin (dual Helicobacter pylori therapy) has remained elusive. We compared whether the addition of bismuth to high-dose dual therapy would improve the efficacy of high-dose dual therapy as first-line treatment.

METHODS

This was an open-label, randomized single-center study of 160 treatment-naive patients with H. pylori infection who were randomly assigned to 14-day therapy with esomeprazole 40 mg twice a day plus amoxicillin 1 g three times a day with or without bismuth potassium citrate 600 mg (elemental bismuth 220 mg) twice a day. Antibiotic resistance was determined by agar dilution method and eradication by ¹³ C-urea breath test.

RESULTS

The per-protocol eradication rates were 96.1%; 95% CI = 88.9%-99.2% (73/76) without bismuth vs 93.3%; 95% CI = 85.1%-97.8% (70/75) with bismuth (P = 0.494). The intention-to-treat eradication rates were 92.5%; 95% CI = 84.4%-97.2% (74/80) without bismuth and 88.8%; 95% CI = 79.7%-94.7% (71/80) with bismuth (P = 0.416). Resistance to amoxicillin, clarithromycin, metronidazole, and levofloxacin was 0%, 31.7%, 81.4%, and 40.7%, respectively. Smoking reduced treatment effectiveness limited to those not receiving bismuth. The per-protocol eradication rates were 70% (7/10) vs 100% (66/66) in smokers vs non-smokers without bismuth (P = 0.002), and 100% (10/10) in smokers vs 92.3% (60/65) in non-smokers with bismuth (P = 1.0). The adverse event rates were 7.5% (6/80) without bismuth vs 11.3% (9/80) with bismuth (P = 0.416).

CONCLUSIONS

Fourteen-day high-dose dual therapy was both effective and safe for first-line treatment in a region of high prevalence antibiotic resistance. Adding bismuth only improved treatment effectiveness among smokers.

Potential roles of Helicobacter pylori treatment, body mass index and waist circumference in the causation of erosive esophagitis: a randomized clinical trial (HEROES-GERD)

BACKGROUND

In recent decades, the prevalence of gastroesophageal reflux disease (GERD) and obesity has been increasing while Helicobacter pylori infection has been decreasing.

OBJECTIVE

To evaluate if H. pylori treatment, excess body weight and other anthropometric measurements are associated with incident erosive esophagitis, as a secondary objective of a trial which tested the efficacy of treatment of H. pylori on the symptoms of functional dyspepsia.

SUBJECTS/METHODS

Upper gastrointestinal endoscopy and anthropometric assessments were performed, at baseline and after 12 months, in H. pylori positive patients with functional dyspepsia who had no baseline reflux symptoms or esophagitis. Patients were randomly assigned to receive omeprazole, amoxicillin, and clarithromycin (antibiotic group; n = 201) or omeprazole plus placebo (control group; n = 203). The primary outcome was the incidence of esophagitis 12 months after randomization, according to treatment groups, and the association of BMI and other anthropometric measurements.

RESULTS

Four hundred and four patients were included (mean age, 46.1 years; 78.7% women). The 12-month follow-up endoscopic esophagitis rates for the antibiotic and control groups were 10.9% (22/201) and 9.4% (19/203), respectively (p = 0.60). The number needed to harm was 67. Baseline anthropometric measurements were performed in 94% (380/404) of patients. The 12-month follow-up esophagitis rates for overweight and normal body weight patients were 13.6% (29/213) and 6.0% (10/167), respectively (p = 0.015); rates for patients with and without increased baseline waist circumference were 15.4% (24/156) and 6.7% (15/224), respectively (p = 0.006). Following logistic regression, only the combination of increased baseline body mass index and waist, but not H. pylori treatment, was independently associated with new-onset esophagitis (OR 2.88; 95% CI: 1.28-6.45).

CONCLUSIONS

Excess body weight and concomitant increased waist circumference, but not H. pylori treatment, predicts new-onset esophagitis.

Interactions between Helicobacter pylori and gastroesophageal reflux disease

Interactions between Helicobacter Pylori (HP) and gastroesophageal reflux disease (GERD) are a complex issue. Several pathophysiological factors influence the development and the course of GERD, HP infection might be only one of these. Many studies emphasize the co-existence of these diseases. HP infection could contribute to GERD through both a protective and an aggressive role. Gastric acid secretion is a key factor in the pathophysiology of reflux esophagitis. Depending on the type of gastritis related to HP, acid secretion may either increase or decrease. Gastritis in corpus leads to hypoacidity, while antrum gastritis leads to hyperacidity. In cases of antral gastritis and duodenal ulcers which have hyperacidity, the expectation is an improvement in pre-existing reflux esophagitis after eradication of HP. In adults, HP infection is often associated with atrophic gastritis in the corpus. Atrophic gastritis may protect against GERD. Pangastritis which leads to gastric atrophy is commonly associated with CagA strains of HP and it causes more severe gastric inflammation. In case of HP-positive corpus gastritis in the stomach, pangastritis, and atrophic gastritis, reflux esophagitis occurs frequently after eradication of HP. Nonetheless, as a predisposing disease of gastric cancer, HP should be treated. In conclusion, as the determinative factors affecting GERD involving in HP, detailed data on the location of gastric inflammation and CagA positivity should be obtained by the studies at future.

H. pylori and Barrett's Esophagus: Implications for Populations and Practice

In this edition of the American Journal of Gastroenterology, Wang and colleagues report the results of an analysis of six different case-control studies examining the relationship between Helicobacter pylori (H. pylori) infection and Barrett's esophagus. They present a cogent argument that there is an inverse association between these two that is mediated via GERD. This is broadly consistent with previous reports. While further establishing this inverse association, the findings should not materially influence our routine clinical practice regarding GERD or H. pylori infection.

ACG Clinical Guideline: Treatment of Helicobacter pylori Infection

Helicobacter pylori (H. pylori) infection is a common worldwide infection that is an important cause of peptic ulcer disease and gastric cancer. H. pylori may also have a role in uninvestigated and functional dyspepsia, ulcer risk in patients taking low-dose aspirin or starting therapy with a non-steroidal anti-inflammatory medication, unexplained iron deficiency anemia, and idiopathic thrombocytopenic purpura. While choosing a treatment regimen for H. pylori, patients should be asked about previous antibiotic exposure and this information should be incorporated into the decision-making process. For first-line treatment, clarithromycin triple therapy should be confined to patients with no previous history of macrolide exposure who reside in areas where clarithromycin resistance amongst H. pylori isolates is known to be low. Most patients will be better served by first-line treatment with bismuth quadruple therapy or concomitant therapy consisting of a PPI, clarithromycin, amoxicillin, and metronidazole. When first-line therapy fails, a salvage regimen should avoid antibiotics that were previously used. If a patient received a first-line treatment containing clarithromycin, bismuth quadruple therapy or levofloxacin salvage regimens are the preferred treatment options. If a patient received first-line bismuth quadruple therapy, clarithromycin or levofloxacin-containing salvage regimens are the preferred treatment options. Details regarding the drugs, doses and durations of the recommended and suggested first-line and salvage regimens can be found in the guideline.

Association between Pattern of Gastritis and Gastroesophageal Reflux Disease in Patients with Helicobacter Pylori Infection

BACKGROUND

Reflux disease is a common gastrointestinal problem. The association between reflux disease and gastritis pattern is controversial. AIM: To determine the association between reflux disease and gastritis pattern in patients with Helicobacter pylori (H. pylori) infection.

METHODS

470 patients with dyspepsia and reflux disease were enrolled in this study. The inclusion criteria were willing to participate in the study, age over 40 years, and having the criteria of ROME III for at least 3 months. Patients with history of H. pylori eradication therapy during the 3 months before the study, a history of gastric surgery, and gastric cancer were excluded. All of the participants underwent upper endoscopy and two biopsy samples were taken from antrum, body, and fundal areas.

RESULTS

H. pylori infection rate was 367 (78.1%) with mean age of 59.8 ± 11.4 years. Of them 131 patients (35.7%) were male. Reflux disease was detected in 273 (74.4%) patients. 216 (58.9%) and 102 (27.8%) patients had non-erosive reflux disease (NERD) and gastroesophageal reflux disease (GERD), respectively. Corpus predominant and antral predominant gastritis were seen in 72 (19.6%) and 129 (35.2%) patients, respectively. Antral gastritis was significantly associated with GERD (p<0.01). In regression analysis, antral predominant gastritis had a significant association with GERD (OR=1.92; 95%CI: 1.22- 3.12). The same result was observed in mild to moderate antral and greater curvature gastritis (OR= 1.26; 95%CI: 0.25-6.40 and OR= 3.0; 95%CI: 0.63-14.17, respectively).

CONCLUSION

According to these finding ,we could suggest that the pattern of gastritis could be associated with reflux disease and GERD.

Diabetes mellitus is an independent risk for gastroesophageal reflux disease among urban African Americans

An association between gastroesophageal reflux disease (GERD) and diabetes mellitus (DM) has been reported. Studies have not been population-based and have failed to include a representative sample of African American subjects. The aim of the study was to determine if DM is independently associated with GERD among urban African Americans. Single-center, population-based survey utilizing a complex, stratified sampling design. To obtain a simple random sample of the entire African American community, targeted survey zones and hand-delivered invitations were identified. Participating subjects had to be self-described African American, age ≥18. Surveys were completed at a computer terminal assisted by a research coordinator. Four hundred nineteen subjects (weighted sample size of 21 264 [20 888-23 930]). GERD prevalence was 23.7% (95% confidence interval [CI] 23.2-23.9). GERD prevalence was 41.5 % in those with DM versus 20.6 % for those without (P < 0.001). Those with GERD had DM longer but had lower glycohemoglobin levels. The prevalence of ≥2 DM comorbidities was higher in those with GERD (odds ratio [OR] = 2.06; 95% CI 1.71-2.48). In the final model, age >40, DM, increasing body mass index, harmful drinking, and increasing smoking dependence were independently associated with GERD. For DM, there was significant effect modification by gender. In males, the risk was (OR = 4.63; 95% CI 3.96-5.40), while in females, the risk was markedly attenuated (OR = 1.79; 95% CI 1.61-2.00). Among urban African Americans, there is an independent association between DM and GERD that appears to be stronger in men. More information is needed to understand this association.

The effect of Helicobacter pylori eradication therapy on the development of gastroesophageal reflux disease

BACKGROUND

It is uncertain whether the Helicobacter pylori eradication therapy makes a role in the progression of gastroesophageal reflux disease (GERD).

METHODS

A meta-analysis was undertaken to investigate the effect of H pylori eradication therapy on the development of GERD.

RESULTS

Overall, 16 cohort studies were included. The authors demonstrated that H pylori eradication had no significant effect on the occurrence of GERD in these cohort studies (odds ratio = 0.87, 95% confidence interval = 0.66-1.14, I = 32.4%, P = 0.103).

CONCLUSIONS

In general, H pylori eradication has no significant effect on the development of GERD in the long term. However, eradication therapy should be taken once there is H pylori infection, because H pylori infection is acknowledged to be a major cause of acute and chronic gastritis and peptic ulcer diseases and has been established as a definite etiologic factor for gastric cancer.

Helicobacter pylori-Mediated Protection against Extra-Gastric Immune and Inflammatory Disorders: The Evidence and Controversies

A large number of studies link H. pylori infection with a reduced risk of developing extra-gastric conditions such as allergy, asthma, inflammatory bowel disease, coeliac disease and multiple sclerosis. The strength of the evidence for these protective associations is quite variable, and published studies often do not agree. This review article discusses some of the reasons for these discrepancies, and the difficulties faced when designing studies. Examples of some protective disease associations are described in detail, where the evidence is most abundant and thought to be more reliable. The most convincing of these are supported by published mechanistic data, for example with animal models, or incidence of disease exacerbation in humans following H. pylori eradication. Although controversial, this field is very important as the prevalence of H. pylori is decreasing throughout the world whilst many chronic diseases are becoming more common. These trends are likely to continue in the future, therefore it is important that we fully understand if and how H. pylori confers protection.

Helicobacter pylori Infection in Gastroesophageal Reflux Disease in the Asian Countries

Helicobacter pylori infection, a common infection in many countries, is related to the clinical course of upper gastrointestinal diseases. Gastroesophageal reflux disease (GERD) is a common esophageal disease in Western countries and its prevalence is increasing in Asian countries. The pathophysiology of GERD is multifactorial. Although no single factor has been isolated as the cause of GERD, a negative association between the prevalence of H. pylori and the severity of GERD, including Barrett's esophagus, has been demonstrated in epidemiological studies. The high prevalence of H. pylori infection affects the incidence of GERD in Asian countries. In the subjects with East Asian CagA-positive strains, acid injury may be minimized by hypochlorhydria from pangastritis and gastric atrophy. Additionally, host genetic factors may affect the development of GERD. The interactions between genetic factors and the virulence of H. pylori infection may be the reason for the low prevalence of GERD in Asian countries. H. pylori eradication is not considered pivotal in GERD exacerbation based on evidence from Western studies. A recent meta-analysis demonstrated that eradication therapy of H. pylori was related to a higher risk of developing de novo GERD in Asian studies. H. pylori infection remains an inconclusive and important issue in GERD in Asian countries.

Meta-analysis: eradication of Helicobacter pylori infection is associated with the development of endoscopic gastroesophageal reflux disease

OBJECTIVE

The role of Helicobacter pylori infection in the pathogenesis of gastroesophageal reflux disease (GORD) is controversial. We aimed to confirm the negative association between H. pylori infection and endoscopic GORD and further determine whether eradication of the infection is associated with the development of endoscopic GORD.

MATERIALS AND METHODS

Case-control studies comparing the prevalence of H. pylori infection between patients with and those without GORD, type A cohort studies comparing the incidence of GORD between patients with and those without anti-H. pylori eradication therapy, and type B cohort studies comparing the incidence of GORD between H. pylori-positive patients with and those without successful eradication were included. Moreover, the effects of H. pylori eradication on the development of GORD in randomized-controlled trials were also analyzed.

RESULTS

Overall, 43 studies were analyzed. Case-control studies showed a lower prevalence of H. pylori infection in patients with GORD [odds ratio 0.64, 95% confidence interval (CI) 0.49-0.83]. Type A cohort studies showed an increased incidence of GORD in patients whose H. pylori infection was successfully eradicated [risk ratio (RR) 2.50, 95% CI 1.46-4.26]. Type B cohort studies showed that patients whose H. pylori had been eradicated had a higher risk of GORD (RR 1.70, 95% CI 1.30-2.23). Moreover, randomized-controlled trials showed that H. pylori eradication leads to a higher risk of GORD (RR 1.99, 95% CI 1.23-3.22); subanalyses showed that the risk existed especially in Asian studies (RR 4.53, 95% CI 1.66-12.36).

CONCLUSION

H. pylori infection shows a negative association with the development of endoscopic GORD. Eradication of the infection may be a risk factor for de-novo endoscopic GORD, especially in Asian populations.

Endocrine impact of Helicobacter pylori: Focus on ghrelin and ghrelin o-acyltransferase

Ghrelin is predominantly produced by the gastric enteroendocrine cell compartment and is octanoylated by the recently discovered ghrelin o-acyltransferase (GOAT) before secretion into the bloodstream. This octanoylation is essential for many of the biological properties of ghrelin including appetite stimulation and anti-inflammatory properties as only the acylated form of ghrelin binds to the ghrelin receptor, the growth hormone secretagogue receptor (GHS-R). Given the gastric location of ghrelin production, it is perhaps not surprising that insult to the gastric mucosa affects circulating ghrelin levels in humans. Helicobacter pylori (H. pylori) infects more than fifty percent of the world’s population and once established within the gastric mucosa, can persist for life. Infection is associated with chronic gastritis, gastric atrophy and ulceration, reduced appetite and a lower body mass index (BMI). The large majority of studies investigating levels of circulating ghrelin and ghrelin expression in the stomach in patients with H. pylori infection indicate that the bacterium has a negative impact on ghrelin production and/or secretion. Eradication of infection restores ghrelin, improves appetite and increases BMI in some studies, however, a causative relationship between H. pylori-associated serum ghrelin decline and food intake and obesity has not been established. Most studies measure total ghrelin in the circulation although the measurement of the ratio of acyl/total ghrelin gives a clearer indication that the ghrelin acylation process is altered during infection and atrophy. GOAT is essential for the production of biologically-active, acyl ghrelin and the impact of H. pylori on GOAT expression and activity will be highly informative in the future.

Effect of Helicobacter pylori infection and its eradication on reflux esophagitis and reflux symptoms

OBJECTIVES

We evaluated the association between current Helicobacter pylori infection and reflux esophagitis and the effect of H. pylori eradication on reflux esophagitis in a healthy screening population.

METHODS

A total of 10,102 subjects in a comprehensive screening cohort were enrolled, and 4,007 subjects had follow-up after a median of 2 years. Effects of H. pylori infection on reflux esophagitis were estimated with odds ratios (ORs) and 95% confidence intervals (CIs) using multiple logistic regression analysis. We evaluated the change in prevalence of reflux esophagitis and reflux symptoms after H. pylori eradication vs. persistence.

RESULTS

The prevalence of reflux esophagitis (as classified by the Los Angeles system) was 4.9% (490/10,102). Whereas the prevalence of reflux esophagitis was 6.4% (319/4,971) in subjects without H. pylori infection, it was 3.3% (171/5,131) in subjects with infection (P<0.001). H. pylori infection had a strong negative association with reflux esophagitis in multivariate analysis (OR 0.42; 95% CI, 0.34-0.51). Compared with the prevalence of reflux esophagitis in the persistent infection group, the prevalence of reflux esophagitis increased after successful H. pylori eradication (OR 2.34; 95% CI, 1.45-3.76; P<0.001), which was comparable to that of the H. pylori-negative group (OR 2.42; 95% CI, 1.73-3.36; P<0.001). However, reflux symptoms had no association with H. pylori infection or eradication.

CONCLUSIONS

In a healthy screening population, H. pylori infection had a strong negative association with reflux esophagitis, but H. pylori eradication increased the prevalence of erosive esophagitis to the level of H. pylori-negative individuals. Long-term clinical significance of newly developed erosive esophagitis after H. pylori eradication should be evaluated prospectively.

Epidemiology of Helicobacter pylori infection and gastric cancer in Asia

In Asia, the prevalence of Helicobacter pylori (H. pylori) infection varies markedly in different countries. Higher prevalence rates are found in developing Asian countries while lower rates have been reported in more industrialized and developed countries. Within a country, the seroprevalence rates may vary between distinct geographic regions. H. pylori infection is an important etiological factor for the occurrence of non-cardia gastric adenocarcinoma. The incidence rate of gastric adenocarcinoma in Asia tends to mirror the seroprevalence rate of H. pylori infection; however, there are populations with high seroprevalence rates of H. pylori infection that paradoxically have low incidence rates of gastric adenocarcinoma. These diverse clinical outcomes are related to bacterial virulence factors, concomitant environmental factors, host susceptibility and immune response. This review summarizes the current epidemiology of H. pylori infection in Asia and analyzes these data in the context of gastric cancer epidemiology.

Gender difference of circulating ghrelin and leptin concentrations in chronic Helicobacter pylori infection

BACKGROUND

Both ghrelin and leptin are important appetite hormones secreted from the stomach. We examined whether demographic background, Helicobacter pylori infection, or its related gastritis severity could be associated with circulating ghrelin and leptin levels.

METHODS

This study prospectively enrolled 341 dyspeptic patients (196 females, 145 males), who had received endoscopy to provide the gastric specimens over both antrum and corpus for histology reviewed by the updated Sydney's system. The fasting blood sample of each patient was obtained for total ghrelin and leptin analysis.

RESULTS

Without H. pylori infection, there were similar ghrelin levels between female and male patients. In the H. pylori-infected patients, the males had lower plasma ghrelin levels than females (1053 vs. 1419 pg/mL, p < .001). Only in males, not in females, the H. pylori infection and its related acute and chronic inflammation scores were significantly associated with a lower ghrelin level (p < or = .04). The multivariate regression disclosed that only the chronic inflammation score independently related to a lower ghrelin level. Only in males, the ghrelin levels ranked in a downward trend for the gastritis feature as with limited-gastritis, with antrum-predominant gastritis, and with corpus-gastritis (1236, 1101, and 977 pg/mL). Leptin level was not related to H. pylori-related gastritis, but positively related to body mass index.

CONCLUSION

There should be a gender difference to circulating total ghrelin levels, but not leptin levels, in response to H. pylori infection and its related chronic gastritis.

Gastric Cancer Consensus conference recommends Helicobacter pylori screening and treatment in asymptomatic persons from high-risk populations to prevent gastric cancer

Gastric adenocarcinoma remains a common cause of death worldwide, and there is convincing evidence that this cancer is causally linked to Helicobacter pylori. The first Asian-Pacific Gastric Cancer Consensus brought together leading authorities in the field including the authors, and systematically reviewed all of the available evidence for the role of H. pylori, diet and other risk factors in this malignancy. The consensus conference boldly recommended population-based screening and treatment for H. pylori in particularly high-risk population settings. The evidence for these recommendations is summarized in this report, and the global and U.S. implications are considered.

Helicobacter pylori and non-malignant diseases

In recent years, the focus of Helicobacter pylori clinical research has been mainly on gastric malignancy. However, the role of H. pylori in non-malignant diseases, such as peptic ulcer, gastroesophageal reflux disease (GERD) and non-ulcer dyspepsia, as well as non-steroidal anti-inflammatory drug consumption, is still of great interest. A 1- to 2-week course of H. pylori eradication therapy is an effective treatment for H. pylori-positive peptic ulcer disease and a positive CagA status is a predictor for successful eradication of H. pylori. Antral prostaglandin-E2-basal levels appear to be critical for the development of aspirin-induced gastric damage in subjects without H. pylori infection. In clinical practice, among patients treated with proton-pump inhibitors, H. pylori status has no effect on the speed or degree of GERD symptom relief. For the management of dyspepsia in primary care, antisecretory therapy confers a small insignificant benefit compared to strategies based on H. pylori testing while these latter strategies may be cost-effective. H. pylori eradication therapy has a small but statistically significant effect on H. pylori-positive non-ulcer dyspepsia. An economic model suggests that this modest benefit may still be cost-effective but more research is needed.

Helicobacter pylori: testing and treatment

Helicobacter pylori is an important pathogen worldwide. Accurate diagnosis and appropriate therapy is important in clinical practice. Invasive tests that accurately identify current infection include the biopsy urease test and histology. The best noninvasive tests for diagnosis include the urea breath test and stool antigen testing. Proton pump inhibitor therapy can lead to false-negative H. pylori test results, and treatment should be stopped for 1-2 weeks prior to testing if possible. In the setting of bleeding peptic ulcer disease, urea breath testing is recommended to rule out a false-negative biopsy test result if needed. The current recommendations for when to test for H. pylori vary around the world. Well-accepted indications include active and past ulcer disease, and gastric-mucosa associated lymphoid tissue lymphoma. There is no universal agreement regarding whether all patients with functional dyspepsia should be tested and treated, although this is an evidence-based recommendation. There is also evidence that H. pylori eradication prevents peptic ulcer disease in those starting NSAIDs long term. Primary treatment remains triple therapy with 10-14 days probably being superior to shorter courses of therapy. Quadruple therapy is recommended if standard triple therapy fails. Salvage therapies with levofloxacin, rifabutin or furazolidone have been identified. Novel approaches to treatment include sequential therapy and use of adjuvants.

American College of Gastroenterology guideline on the management of Helicobacter pylori infection

Helicobacter pylori (H. pylori) remains a prevalent, worldwide, chronic infection. Though the prevalence of this infection appears to be decreasing in many parts of the world, H. pylori remains an important factor linked to the development of peptic ulcer disease, gastric malignanc and dyspeptic symptoms. Whether to test for H. pylori in patients with functional dyspepsia, gastroesophageal reflux disease (GERD), patients taking nonsteroidal antiinflammatory drugs, with iron deficiency anemia, or who are at greater risk of developing gastric cancer remains controversial. H. pylori can be diagnosed by endoscopic or nonendoscopic methods. A variety of factors including the need for endoscopy, pretest probability of infection, local availability, and an understanding of the performance characteristics and cost of the individual tests influences choice of evaluation in a given patient. Testing to prove eradication should be performed in patients who receive treatment of H. pylori for peptic ulcer disease, individuals with persistent dyspeptic symptoms despite the test-and-treat strategy, those with H. pylori-associated MALT lymphoma, and individuals who have undergone resection of early gastric cancer. Recent studies suggest that eradication rates achieved by first-line treatment with a proton pump inhibitor (PPI), clarithromycin, and amoxicillin have decreased to 70-85%, in part due to increasing clarithromycin resistance. Eradication rates may also be lower with 7 versus 14-day regimens. Bismuth-containing quadruple regimens for 7-14 days are another first-line treatment option. Sequential therapy for 10 days has shown promise in Europe but requires validation in North America. The most commonly used salvage regimen in patients with persistent H. pylori is bismuth quadruple therapy. Recent data suggest that a PPI, levofloxacin, and amoxicillin for 10 days is more effective and better tolerated than bismuth quadruple therapy for persistent H. pylori infection, though this needs to be validated in the United States.