Reflux oesophagitis and Helicobacter pylori infection in elderly patients

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.

The association between serious upper gastrointestinal bleeding and incident bisphosphonate use: a population-based nested cohort study

Background

Oral bisphosphonates are commonly used to prevent / treat osteoporosis. However, bisphosphonate treatment is not without risk and serious adverse effects, including upper gastrointestinal bleeding (UGIB) have been described. We sought to determine if new users of bisphosphonate drugs were more likely to suffer a serious UGIB within 120 days of drug initiation.

Methods

This was a population-based nested cohort study utilizing administrative healthcare data in British Columbia, Canada. Community based individuals ≥ 65 years with a new prescription for a bisphosphonate between 1991 and 2007 were included. A multivariate logistic regression model was used to examine the relationship between older age and the development of a serious UGIB within 120 days of new exposure to oral bisphosphonate drugs.

Results

Within the exposure cohort (n = 26,223), 117 individuals had suffered a serious UGIB within 120 days of incident bisphosphonate use. Cases tended to be > 80 years old, and were significantly more likely to have had a past history of gastric ulcer disease, a remote history of serious UGIB, and had been dispensed proton pump inhibitor (PPI) medications (p < 0.001 for all comparisons). After adjustment for confounding covariates, those > 80 years were more than twice as likely to suffer a UGIB when compared to those ≤ 80 years (adjusted OR = 2.03; 95% CI 1.40–2.94). A past history of serious UGIB was the strongest predictor of UGIB within 120 days of incident bisphosphonate use (adjusted OR = 2.28; 95% CI = 1.29–4.03) followed by PPI use (adjusted OR = 2.04; 95% CI = 1.35–3.07). Males were 70% more likely to suffer an UGIB compared to females (adjusted OR = 1.69; 95% CI = 1.05–2.72).

Conclusions

Upper GIB is a rare, but serious, side effect of bisphosphonate therapy more often afflicting older individuals. At the same time, concern about potential rare adverse events should not discourage clinicians from prescribing bisphosphonate drugs, particularly in older patients who have already sustained a fragility fracture. Clinicians must remain cognizant of potential adverse events associated with bisphosphonate use and should routinely ask about pre-existing GI disorders and concurrent medication history prior to prescribing these drugs.

The relationship between helicobacter pylori infection and gastro-esophageal reflux disease

BACKGROUND

Gastro-esophageal reflux disease is a common condition, affecting 25%-40% of the population. Increasing attention has been paid to the relationship between Helicobacter pylori infection and reflux esophagitis.

AIM

The aim of this study was to investigate the association between CagA+ H. pylori and endoscopically proven gastro-esophageal reflux disease.

PATIENTS AND METHODS

The study group included 60 hospital patients with gastro-esophageal reflux disease between 2007 and 2009 as compared with 30 healthy patients from a control group that was age and sex matched. Helicobacter pylori CagA+ was identified by an immunological test (Immunochromatography test) (ACON, USA).

RESULTS

Helicobacter pyloriCagA+ was present in 42/60 (70%) of the patients with gastro-esophageal reflux disease and in 11/30 (36.6%) patients in the control group (p=0.002). The Odds ratio = 0.8004 with 95% Confidence Interval = from 0.3188 to 2.0094. The relative risk=1.35 that indicates an association between Helicobacter pylori and disease.

CONCLUSIONS

The presence of Helicobacter pylori is significantly increased in patients with gastro-esophageal reflux disease as compared with the control group.

H pylori infection and reflux oesophagitis: A case-control study

AIM: To examine the relationship between H pylori and gastro-oesophageal reflux disease (GORD) in Iran.

METHODS: In this study 51 GORD patients (referred to endoscopy at Taleghani hospital) were compared with 49 age-sex matched controls. Diagnosis of H pylori was made by gastric mucosal biopsy and rapid urease test (positive if the result of one or both diagnostic methods was positive). Updated Sydney system was used to report histopathological changes.

RESULTS: The frequency of H pylori infection based on rapid urease test and histology was 88.2% (45) in patients and 77.6% (38) in controls, which showed no significant difference. The frequency of H pylori infection was significantly higher in the antrum than in the corpus and cardia. The mean activity, inflammation, and gastritis scores were also higher in the antrum of patients than in the antrum of controls. The mean scores were significantly higher in the corpus of controls than in the corpus of patients. Diffuse active gastritis was observed in a significantly larger number of controls, while the frequency of diffuse chronic gastritis was higher in patients. There was no significant difference in the frequency of other histological findings between patients and controls.

CONCLUSION: H pylori infection cannot prevent GORD in this region.

Effect of Helicobacter pylori eradication on the outcome of reflux esophagitis and chronic gastritis in the elderly. A randomized, multicenter, eight-month study

BACKGROUND

The effect of Helicobacter pylori eradication on the clinical outcome of esophagitis in elderly patients is controversial.

AIM

To evaluate the effect of H. pylori eradication on clinical outcome of esophagitis and on chronic gastritis and its activity.

MATERIALS AND METHODS

Sixty-one symptomatic elderly patients with esophagitis and H. pylori infection were randomized into two groups. Group 1 (PPI-only, 30 patients) was treated with pantoprazole 40 mg daily for 2 months followed by pantoprazole 20 mg daily for a further 6 months; group 2 (PPI + eradication, 31 patients) was treated as group 1 plus a 1-week course of amoxicillin 1 g twice daily and clarithromycin 250 mg twice daily. Endoscopy with gastric biopsies, 13C-UBT and clinical visits were repeated after 2 and 8 months.

RESULTS

After 8 months, the intention-to-treat H. pylori eradication rates were 19.2% in group 1 vs. 80.7% in group 2 (p < 0.0001). No differences between group 1 and group 2 were observed in symptoms improvement (77 vs. 77%, p = n.s.) and healing rates of esophagitis (92.3 vs. 88.5%, p = n.s.). A significant decrease in the prevalence of moderate/severe chronic gastritis (from 52.2 to 4.7%, p = 0.002) and its activity (from 38 to 4.7%, p = 0.02) was observed in the antrum of patients of group 2, and not in patients of group 1. While a nonsignificant reduction in the chronic gastritis activity (from 28.6 to 4.7%, p = 0.09) was observed in the corpus of the eradicated patients of group 2, conversely a significant worsening of the chronic gastritis activity was found in the corpus of group 1 patients (from 25 to 60%, p = 0.05).

CONCLUSION

The eradication of H. pylori infection does not affect the clinical outcome of esophagitis, while it improves chronic gastritis and its activity in elderly patients on short- and long-term treatment with PPIs. These findings suggest that H. pylori infection should be eradicated in elderly patients with esophagitis who need maintenance treatment with PPI.

Review article: influence of Helicobacter pylori on gastro-oesophageal reflux disease in Japan

There is circumstantial evidence that infection with Helicobacter pylori is relatively protective for the occurrence of gastro-oesophageal reflux disease (GERD). It has been suggested that the Japanese population are protected against reflux oesophagitis by their high prevalence of H. pylori associated gastritis. Such gastritis, when becoming chronic, can lead to gastric atrophy, thereby reducing the likelihood of GERD. If this hypothesis is correct, the effects of H. pylori induced gastritis may be an important factor determining the earlier lower prevalence of oesophagitis in Japan, where this infection is especially common. In support of this idea a reduced prevalence of H. pylori infection in Japan, as is now being observed in young Japanese adults, may be, at least in part, responsible for the upsurge in the number of cases of reflux disease in Japan. Concomitantly, H. pylori eradication therapy in patients with gastritis or peptic ulcer disease, which is associated with an increase in gastric acid secretion, may also be at least partly responsible for the increased prevalence of reflux oesophagitis in the Japanese population.

Meta-analysis: the relationship between Helicobacter pylori infection and gastro-oesophageal reflux disease

BACKGROUND

The relationship between Helicobacter pylori infection and its treatment and gastro-oesophageal reflux disease (GERD) is controversial.

AIMS

To establish if H. pylori infection is associated with the presence of GERD and if anti-H. pylori treatment leads to de novo GERD or rebound/exacerbation of GERD.

METHODS

A search of MEDLINE and EMBASE databases was made. Pooled odds ratios (OR) were calculated for de novo GERD and rebound/exacerbated GERD after anti-H. pylori therapy in case-control studies and in therapeutic trials.

RESULTS

Fourteen case-control studies and 10 clinical trials were included. Among case-control studies, pooled OR for the association between H. pylori negative status and GERD was 1.34 [95% confidence interval (CI) 1.15-1.55]. Among therapeutic trials, pooled OR for the association anti-H. pylori therapy - GERD was 2.54 (95% CI 1.92-3.37). The OR for de novo GERD was 3.25 (95% CI 2.09-5.33), and for rebound/exacerbated GERD was 2.39 (95% CI 1.75-3.34). Associations were higher among Asian studies than among North American and European studies.

CONCLUSIONS

This meta-analysis shows significant association between absence of H. pylori infection and GERD symptoms, and a positive association between anti-H. pylori therapy and occurrence of both de novo and rebound/exacerbated GERD. The significance of these associations appears to have been inflated by the effect of single trials and by geographical variations.

Prevalence of Helicobacter pylori in patients with gastro-oesophageal reflux disease: systematic review

OBJECTIVES

To ascertain the prevalence of Helicobacter pylori in patients with gastro-oesophageal reflux disease and its association with the disease.

DESIGN

Systematic review of studies reporting the prevalence of H pylori in patients with and without gastro-oesophageal reflux disease.

DATA SOURCES

Four electronic databases, searched to November 2001, experts, pharmaceutical companies, and journals.

MAIN OUTCOME MEASURE

Odds ratio for prevalence of H pylori in patients with gastro-oesophageal reflux disease.

RESULTS

20 studies were included. The pooled estimate of the odds ratio for prevalence of H pylori was 0.60 (95% confidence interval 0.47 to 0.78), indicating a lower prevalence in patients with gastro-oesophageal reflux disease. Substantial heterogeneity was observed between studies. Location seemed to be an important factor, with a much lower prevalence of H pylori in patients with gastro-oesophageal reflux disease in studies from the Far East, despite a higher overall prevalence of infection than western Europe and North America. Year of study was not a source of heterogeneity.

CONCLUSION

The prevalence of H pylori infection was significantly lower in patients with than without gastro-oesophageal reflux, with geographical location being a strong contributor to the heterogeneity between studies. Patients from the Far East with reflux disease had a lower prevalence of H pylori infection than patients from western Europe and North America, despite a higher prevalence in the general population.

Improvement of reflux symptoms 3 years after cure of Helicobacter pylori infection: a case-controlled study in the Japanese population

BACKGROUND

Development of reflux esophagitis is one of the adverse effects that cause concern in relation to curative treatment of Helicobacter pylori infection. However, recent studies present a rather negative association between curative treatment and development of reflux esophagitis or reflux symptoms. Therefore, this issue has remained controversial. Accordingly, we investigated the long-term adverse effects of H. pylori eradication treatment in special reference to development of reflux symptoms.

PATIENTS AND METHODS

We conducted a case controlled study by mailing structured questionnaires on past (before curative treatment or 3 years previously) and current status. A case was an endoscopically confirmed peptic ulcer patient with confirmed cure of the infection after eradication treatment 3 years previously and a control was one who had not undergone the eradication treatment during the same period. We studied 241 pairs who matched for age, gender, and type of ulcer disease (GU, DU or GDU). Of these pairs, 81.3% were male and the mean age was 52.6 +/- 9.6 year (range 23-76).

RESULTS

The rates of patients with improved reflux symptoms in the case and control groups were 65.4% and 30.4%, respectively, with the rate being significantly greater in the case group. On the contrary, the rates of those with worsened reflux symptoms were similar (5.1% and 7.6%). Regarding general events, the rate of patients with decreased frequency of hospital visits and of those who regularly used antiacid medications were significantly decreased in the case group. Furthermore, the case group experienced significantly fewer hospital admissions for various diseases in this 3-year period. However, a significantly greater number of case group patients than control subjects gained weight.

CONCLUSION

Reflux symptoms as well as general well-being were significantly improved after cure of H. pylori infection.

Influence of Helicobacter pylori infection on severity of oesophagitis and response to therapy in the elderly

BACKGROUND

The prevalence both of Helicobacter pylori infection and oesophagitis is higher in the elderly, than in adult and young populations. However the relationship between Helicobacter pylori infection and the clinical behaviour of oesophagitis has not yet been clarified.

AIM

To evaluate the influence of Helicobacter pylori infection on the severity and clinical outcome after treatment of oesophagitis in elderly patients.

METHODS

A total of 271 elderly patients (134 male, 137 female, mean age = 79.2 years, range 65-96) with grade 1 to 3 oesophagitis were studied. At baseline, the patients were divided into 3 groups according to Helicobacter pylori infection: Group 1 = 88 Helicobacter pylori-negative patients; Group 2 = 59 Helicobacter pylori-positive patients and Group 3 = 124 Helicobacter pylori-positive patients who underwent a one-week proton pump inhibitor-based triple therapy for the eradication of Helicobacter pylori infection. All patients were treated with proton pump inhibitors for two months; patients in Group 3 were also treated for one week with proton pump inhibitors plus two antibiotics. After two months, endoscopy and histology were repeated.

RESULTS

At baseline, 32.5% of patients were Helicobacter pylori-negative and 67.5% were Helicobacter pylori-positive. No baseline differences in severity of oesophagitis were found between Helicobacter pylori negative and positive patients. After proton pump inhibitor therapy, the complete resolution of oesophagitis was observed in 80.7% of Group 1, 76.3% of Group 2 and 75.8% of Group 3 (p=ns). Dividing patients also according to the severity of oesophagitis, no difference in healing rates between the three Groups were observed.

CONCLUSIONS

In this elderly population, Helicobacter pylori infection did not influence the severity of oesophagitis at baseline or the response to short-term treatment with proton pump inhibitors. Furthermore, Helicobacter pylori eradication therapy did not influence the healing rate of oesophagitis.

Review article: an approach to Helicobacter pylori infection in the elderly

The prevalence of Helicobacter pylori infection increases with age world-wide, reaching levels of 40-60% in asymptomatic elderly subjects and over 70% in elderly patients with gastroduodenal diseases. However, the percentage of H. pylori-positive elderly patients who are treated for their infection remains very low. Data are now available that demonstrate the benefit of curing H. pylori infection in elderly patients with H. pylori-associated peptic ulcer disease and severe chronic gastritis. Furthermore, the cure of H. pylori may prevent the progression of intestinal metaplasia and gastric atrophy. New studies are needed to clarify the role of eradication in elderly patients with non-ulcer dyspepsia and gastro-oesophageal reflux disease and in those who use non-steroidal anti-inflammatory drugs. H. pylori infection may be easily diagnosed by histological evaluation, rapid urease test or culture performed on gastric biopsies taken during endoscopy. However, the biopsy site must be carefully selected in elderly patients. For non-invasive monitoring of H. pylori infection after treatment, the 13C-urea breath test has significantly higher accuracy than serology in the elderly; further studies are needed to clarify the role of the H. pylori stool antigen test in old age. One-week proton pump inhibitor-based triple therapy regimens, including clarithromycin, amoxicillin and/or nitroimidazoles, are highly effective and well tolerated in elderly patients. Low doses of both proton pump inhibitors and clarithromycin (in combination with standard doses of amoxicillin or nitroimidazoles) are sufficient. Low compliance and antibiotic resistance are the main factors related to treatment failure in old age.

No protective role of Helicobacter pylori in the pathogenesis of reflux esophagitis in patients with duodenal or benign gastric ulcer in Korea

Little is known about the relationship between H. pylori infection and reflux esophagitis. To evaluate whether or not H. pylori plays a protective role in the pathogenesis of reflux esophagitis, the prevalence rates of reflux esophagitis depending on H. pylori status in consecutively diagnosed duodenal ulcer or benign gastric ulcer patients were evaluated. In addition, the incidence rates of reflux esophagitis depending on H. pylori status were evaluated for those patients who received follow-up endoscopy at least 6 months after eradication treatment. The prevalence rates of reflux esophagitis were 8.0% (2 patients) in the 25 H. pylori-negative duodenal ulcer group patients and 6.5% (36 patients) in the 555 H. pylori-positive duodenal ulcer group patients, and there was no statistical difference. Similarly, that of gastric ulcer patients was 9.4% (32 patients) in the 340 H. pylori-positive group patients, slightly higher than that in the 41 H. pylori-negative group patients 4.9% (2 patients), but without statistical significance. After eradication treatment the reflux esophagitis incidence rates were 2.5% (2 patients) in the 81 H. pylori-eradicated duodenal ulcer group patients and 7.7% (3 patients) in the 39 noneradicated duodenal ulcer group patients, and there was no statistical difference. Similarly, those of gastric ulcer patients were 6.8% (3 patients) in the 44 H. pylori-eradicated and 8.7% (2 patients) in the 23 noneradicated group patients again without statistical difference. These results suggest that H. pylori does not play a protective role in the pathogenesis of reflux esophagitis in patients with duodenal or gastric ulcer in Korea.

Inverse background of Helicobacter pylori antibody and pepsinogen in reflux oesophagitis compared with gastric cancer: analysis of 5732 Japanese subjects

BACKGROUND

The relationship between Helicobacter pylori and reflux oesophagitis remains controversial.

AIMS

To evaluate the relationship between H pylori and reflux oesophagitis in a large number of Japanese subjects.

SUBJECTS

A total of 5732 consecutive Japanese subjects during a health screening were enrolled.

METHODS

Gastrointestinal endoscopy was performed on all subjects. We simultaneously measured serum anti-H pylori antibody and pepsinogen as markers of H pylori infection together with gastric atrophy. The risk of reflux oesophagitis was evaluated in relation to these markers, and the results were compared with those of gastric cancer.

RESULTS

Reflux oesophagitis was found in 108 subjects. Both positivity for H pylori antibody (adjusted odds ratio (OR) 0.67 (95% confidence interval 0.45-1.0)) and "low" pepsinogen indicating gastric atrophy (OR 0.35 (0.18-0.68)) were negatively associated with reflux oesophagitis. After subjects were classified into four groups based on positivity or negativity for H pylori antibody and "low" pepsinogen, the prevalence of reflux oesophagitis showed a decreasing trend as H pylori induced gastric atrophy became more severe. The risk of gastric cancer showed an increasing trend, exactly the opposite to that of reflux oesophagitis.

CONCLUSIONS

Analysis of a large series of Japanese subjects revealed a decreasing prevalence of reflux oesophagitis in conjunction with progress of gastric atrophy induced by H pylori infection. This pattern was completely opposite to that of gastric cancer cases. A protective role of H pylori for reflux oesophagitis through the development of gastric atrophy has been suggested.

Helicobacter pylori and gastroesophageal reflux disease: lack of influence of infection on twenty-four-hour esophageal pH monitoring and endoscopic findings

The precise role of Helicobacter pylori infection in gastroesophageal reflux disease (GERD) is a matter of intense debate. Twenty-four-hour esophageal pH monitoring has a higher accuracy than endoscopy for the diagnosis of GERD, but the correlation between H. pylori infection and esophageal pH-metric parameters has almost never been assessed. Therefore, we evaluated the relationship between the infection and the presence of disturbances not only in endoscopy but also in 24-hour esophageal pH monitoring. One hundred consecutive patients undergoing 24-hour esophageal pH monitoring because of symptoms suggestive of GERD were included in the study. Esophageal manometry was carried out to study the position and the pressure of the lower esophageal sphincter (LES). Prevalence of H. pylori infection was evaluated by histology (hematoxylin and eosin stain) and rapid urease test. The mean age of the patients was 50 +/- 15 years; 50% were men and 56% had an abnormal pH-metry (DeMeester score more than 14.7). The prevalence of H. pylori in patients with abnormal pH-metry was 57% (95% CI, 42-70%) and was 52% (95% CI, 39-64%) in those with normal pH-metry (nonsignificant differences [NS]). In the multivariate analysis, H. pylori infection did not correlate with an abnormal pH-metry (odds ratio, 0.8; 95% CI, 0.4-1.8; NS). The proportion of cases with abnormal pH-metry among infected patients was 54% (95% CI, 41-66%) and was 59% (95% CI, 44-72%) among uninfected patients (NS). Mean values of pH-metric parameters (+/-SD), respectively for H. pylori-positive and -negative patients, were total score (30 +/- 33 vs. 36 +/- 38), number of reflux episodes (7 +/- 7 vs. 11 +/- 11), number of episodes more than 5 minutes (3.7 +/- 5 vs. 3.8 +/- 5), longest reflux episode (2.4 +/- 2 minutes vs. 3.1 +/- 3 minutes), and fraction time (%) with pH less than 4 (total, 6 +/- 7 vs. 6.8 +/- 8; upright, 3.9 +/- 4 vs. 4.5 +/- 5; supine, 7.4 +/- 12 vs. 7.2 +/- 10) (all findings were NS). Endoscopic findings, respectively for H. pylori-positive and -negative, were hiatus hernia (41% vs. 41%), endoscopic esophagitis (Savary-Miller) (54% vs. 46%), and Barrett's esophagus (15% vs. 11%) (all findings were NS). Finally, differences were not demonstrated in the pressure of the lower esophageal sphincter (12 +/- 8 mmHg vs. 14 +/- 12 mmHg) among H. pylori-positive and -negative patients. H. pylori infection is not associated with gastroesophageal reflux disease, as evaluated endoscopically and with 24-hour esophageal pH monitoring.

Relationship between intestinal metaplasia of the gastro-oesophageal junction, Helicobacter pylori infection and gastro-oesophageal reflux disease: a prospective study

BACKGROUND

The role of Helicobacter pylori infection and/or gastro-oesophageal reflux disease in pathogenesis of intestinal metaplasia in gastric cardia is still unclear.

AIMS

To prospectively evaluate prevalence of inflammation and intestinal metaplasia of cardia in relationship to Helicobacter pylori infection in patients with gastro-oesophageal reflux disease and in healthy controls.

PATIENTS

A total of 122 consecutive patients with gastro-oesophageal reflux disease and 49 control subjects were included.

METHODS

During endoscopy, a total of six biopsies were taken from antrum, corpus and cardia. Helicobacter pylori infection was assessed by histology and rapid urease test. Degree of chronic gastritis, inflammatory activity and Helicobacter pylori colonization were scored from 0 to 3.

RESULTS

No difference in prevalence was observed between gastro-oesophageal reflux disease patients and controls as far as concerns Helicobacter pylori (41% vs 38%), inflammation of cardia (59.5% vs 70%) and intestinal metaplasia of cardia (18% vs 19%). Inflammation of cardia was significantly (p<0.001) associated with Helicobacter pylori irrespective of gastro-oesophageal reflux disease symptoms. Cardial intestinal metaplasia was more frequently (p=0.03) found in infected subjects ((27%) than in uncolonized subjects (13%). No relationship was observed between gastro-oesophageal reflux disease and carditis and cardial intestinal metaplasia. Cardial intestinal metaplasia was more frequently detected in association with carditis (26% vs 6%, p=0.001).

CONCLUSIONS

Inflammation and intestinal metaplasia of the gastric cardia are not markers of gastro-oesophageal reflux disease but are related to Helicobacter pylori.

Barrett's oesophagus: diagnosis and management

Gastro-oesophageal reflux disease and its sequela, Barrett's oesophagus, are the major recognized risk factors for oesophageal adenocarcinoma, a tumour whose frequency has increased dramatically in Western countries over the past few decades. Barrett's oesophagus develops through the process of metaplasia in which one adult cell type replaces another. The metaplastic, intestinal-type cells of Barrett's oesophagus are predisposed to develop genetic changes that eventuate in cancer. This report reviews the recent controversy regarding diagnostic criteria for Barrett's oesophagus, and provides practical guidelines for identifying the condition. The risks and benefits of the proposed medical, surgical and endoscopic therapies for Barrett's oesophagus are discussed in detail, and the approach to management recently endorsed by the American College of Gastroenterology is summarized.

Review article: is Helicobacter pylori status relevant in the management of GORD?

There is growing interest in the relationship between H. pylori infection and gastro-oesophageal reflux disease (GORD). However, this relationship is complex, as yet not fully elucidated, and probably based on a multiplicity of factors. The prevalence of H. pylori infection in patients with GORD is similar, more often lower than in matched controls. There is a negative correlation between H. pylori infection and the severity of GORD. There are many hypothetical mechanisms by which H. pylori infection may protect from the development of GORD. Conversely, there are many possible mechanisms by which H. pylori infection could theoretically foster the GORD. Patients after H. pylori eradication may develop GORD, and this seems to suggest a protective role of H. pylori infection, but other possible explanations include weight gain after H. pylori eradication, changes in dietary habits and smoking, and pre-existing GORD. H. pylori infected patients treated by various acid-inhibiting therapies such as proton pump inhibitors (PPIs), H2-receptors antagonists (H2-RA) or vagotomy, have an increase of their corpus gastritis severity, both in the activity of inflammation and in the density of organisms. Long-term therapy of GORD in H. pylori infected may lead to rapid progression of atrophic gastritis intestinal metaplasia and dysplasia, and increase the risk of developing gastric cancer. More recently it has been shown that H. pylori infection may interfere with the acid suppressive therapies used for treating GORD. In our opinion the progression of gastritis depends on the threshold of acid output at which H. pylori can 'flourish'. Recently interest is growing on gastric transitional zones and Helicobacter ecology. Any decrease of acid secretion changes the behaviour of H. pylori: the activity of gastritis improves in the antrum, but it deteriorates in the body. During proton pump inhibitor treatment, H. pylori redistribution occurs within the stomach, from an antral to a corpus or fundus prevalent pattern; corpus-fundus gastritis, exacerbated by PPI therapy, may result both in a diminished acid secretion and gastro-oesophageal reflux. The interest in Barrett's oesophagus is growing due to the associated risk of adenocarcinoma. The literature seems to demonstrate that the prevalence of H. pylori infection of the stomach in Barrett's oesophagus patients is not different from that exhibited by controls, roughly one-third of the subjects. Intestinal metaplasia of the gastric cardia seems to be equally frequent in patients with and without GORD. Finally, it appears unlikely that a causal relationship exists between H. pylori infection and Barrett's-associated adenocarcinoma.

Negative association between Helicobacter pylori infection and reflux esophagitis in older patients: case-control study in Japan

BACKGROUND

Recent studies have clarified a close association between H. pylori infection and gastritis, peptic ulcer disease, and gastric cancer, but there is little information concerning the relationship between H. pylori infection and reflux esophagitis (RE). We investigated the relationship between H. pylori, RE, and corpus gastritis.

SUBJECTS AND METHODS

Ninety-five patients with RE and 190 sex- and age-matched asymptomatic healthy controls demonstrating no localized lesions in the upper GI tract were studied and evaluated for H. pylori infection, histologic gastritis, serum gastrin, and pepsinogens (PGs).

RESULTS

H. pylori infection was significantly lower in RE patients than in asymptomatic controls (41% vs. 76%, p <.01). Histologic gastritis of both the antrum and corpus was significantly less frequent (antrum; p <.01, corpus; p <. 01), and serum levels of PGI and the PG I/II ratio were significantly higher in RE patients than in controls (PGI; p <.05, PG I/II ratio; p <.01). When the subjects were divided into two age groups (59 years of age and younger and 60 years of age and older), a significant difference was found only among patients over 60 years of age (29% vs. 85%, p <.01). Among subjects in this age group, gastritis in both the antrum and corpus were significantly milder in RE patients than in controls. Although the prevalence of H. pylori infection was similar between the two groups of patients under 59 years of age, corpus gastritis was significantly milder in patients than in controls (p <.05).

CONCLUSIONS

A significantly low prevalence of H. pylori infection was found in RE patients over 60 years of age but not in those under 59 in comparison with sex- and age-matched controls. The relative lack of corpus gastritis might play a role in the pathogenesis of RE in our population through preservation of the acid secretion area.

Helicobacter pylori and gastroesophageal reflux disease

The nature of the relationship between Helicobacter pylori (Hp) infection and gastroesophageal reflux disease (GERD) remains unclear. This article reviews the current body of knowledge regarding the association between these two common entities. The authors examine the potential interactions of Hp and GERD from epidemiologic and pathophysiologic viewpoints and summarize and critique the prevalence and eradication studies that have been performed to date. Special consideration is given to the possible effects that long-term use of proton pump inhibitors may have on Hp gastritis.

Prevalence and distribution of Helicobacter pylori in gastroesophageal reflux disease: a study from the East

OBJECTIVES

The relationship between Helicobacter pylori infection and gastroesophageal reflux (H. pylori) disease (GERD) is controversial. In Asian populations, the prevalence of H. pylori infection is high and GERD is relatively uncommon. The aim of this study was 1) to test the hypothesis that H. pylori protects the esophagus against GERD, and 2) to study the pattern of H. pylori colonization and gastritis in GERD.

METHODS

We conducted a prospective case-control study in which patients with GERD and asymptomatic controls were compared for the prevalence of H. pylori infection. Diagnosis of GERD was based on symptoms of heartburn that improved with acid-suppressive therapy and/or endoscopic evidence of erosive esophagitis. H. pylori status was determined by serology and, when endoscopy was indicated, was confirmed by rapid urease test and histology. Gastric biopsies were examined under hematoxylin and eosin and Giemsa stains. Density of H. pylori colonization and activity of gastritis at different parts of stomach were graded and compared according to Updated Sydney system.

RESULTS

A total of 106 patients with GERD and 120 age- and sex-matched, asymptomatic controls were enrolled. The prevalence of H. pylori infection was significantly lower in GERD patients (31%) compared with controls (61%, p < 0.001, odds ratio 0.229, 95% confidence interval 0.13-0.41). H. pylori-infected GERD patients showed significantly more severe gastritis in the antrum than in other parts of stomach (mean inflammatory scores: antrum; 3.3 +/- 1.63*, body; 1.85 +/- 1.31; fundus; 1.65 +/- 0.58; cardia, 1.65 +/- 1.39; *p < 0.005). H. pylori colonization was found less commonly and at lower density at the cardia compared with other parts of the stomach.

CONCLUSIONS

H. pylori infection protects against the development of GERD, and carditis is unlikely to play an important role.

Gastro-oesophageal reflux disease and Helicobacter pylori: an intricate relation

Heartburn is a common symptom affecting 21-44% of the adult population on a monthly basis. Oesophagitis is less common, affecting 2% of individuals. Epidemiological studies have shown that patients with gastro-oesophageal reflux disease (GORD) have similar incidence rates of Helicobacter pylori infection as do controls. Some groups have reported that there is a lower incidence, deducing that infection does not cause, and in some way confers protection against GORD. Additional supportive evidence is available from reports of GORD development following successful H pylori eradication. The mechanisms involved are complicated. Individuals with H pylori induced pangastritis and subsequent hypochlorhydria may be protected whereas those with an antral predominant gastritis, as in duodenal ulcer disease, with an increased acid output may be prone to development of GORD. Recent evidence has linked H pylori infection with the development of inflammation of the gastric cardia---carditis. Reports are available which show that carditis is a frequent finding in patients with GORD. The incidence of both cardia and oesophageal carcinoma is increasing. The relation between GORD, carditis, intestinal metaplasia, and cardia carcinoma is unclear. Intestinal metaplasia may result from multifocal atrophic gastritis, linked to H pylori infection or from GORD and the development of Barrett's oesophagus. Long term follow up studies will be required to assess the malignant potential of these histological entities and whether or not H pylori infection has an aetiological role.

The role of gastric carditis in metaplasia and neoplasia at the gastroesophageal junction

Adenocarcinomas at the gastroesophageal junction appear to arise from foci of intestinal metaplasia that develop either in the distal esophagus or the proximal stomach (the gastric cardia). Metaplasia is usually a consequence of chronic inflammation, and it is logical to assume that intestinal metaplasia at the gastroesophageal junction develops as a result of chronic inflammation in the epithelia that normally line the junction region. Intestinal metaplasia in the esophagus is known to be a sequela of chronic inflammation in squamous epithelium caused by gastroesophageal reflux disease, whereas intestinal metaplasia in the distal stomach is often a consequence of chronic gastritis caused by Helicobacter pylori infection. For the gastric cardia, the contributions of gastroesophageal reflux disease, H. pylori infection, and other factors to inflammation, metaplasia, and neoplasia are not clear. If physicians are to develop meaningful preventive strategies and specific therapies for tumors of the proximal stomach, a clear understanding of pathogenesis is important. Recent studies on pathogenetic factors for inflammation in cardiac epithelium (gastric carditis) have yielded contradictory results, perhaps because of fundamental differences in the techniques used by different investigators for identifying and sampling the gastric cardia. This report explores the roots of the controversy regarding the role of gastric carditis in the development of metaplasia and neoplasia at the gastroesophageal junction and suggests practical guidelines for biopsy protocols to be used in future studies that will be necessary to resolve these disputes.

Review article: Helicobacter pylori and gastro-oesophageal reflux disease-clinical implications and management

A significant proportion of patients with gastro-oesophageal reflux disease (GERD) have Helicobacter pylori infection, but it is unclear whether or not H. pylori should be treated in this clinical setting. The aim of this review was to critically assess the relationship between H. pylori and GERD and its potential implications for the management of GERD. Data for this review were gathered from the following sources up to April 1998-the biomedical database MEDLINE, a detailed review of medical journals, and a review of abstracts submitted to relevant international meetings. On average, 40% of GERD patients carry H. pylori infection, with a reported infection prevalence ranging from 16% to 88%. To date, there has been no reported controlled trial of effective H. pylori therapy in GERD. GERD has been reported to develop de novo following the cure of H. pylori in peptic ulcer disease. In the presence of H. pylori, proton pump inhibitor therapy appears to accelerate the development of atrophic corpus gastritis, a potentially precancerous condition. Conversely, proton pump inhibitor therapy seems to become less effective after cure of H. pylori. The mechanisms underlying these important contrasting phenomena are poorly understood. The relationship between H. pylori and GERD is complex, and it is difficult to give definitive guidelines on the management of H. pylori infection in GERD. Controlled trials of H. pylori therapy in GERD are urgently needed, as well as further long-term data on both the natural history of gastric histopathological changes in the H. pylori-positive GERD patient treated with proton pump inhibitors, and the impact of H. pylori status on the clinical efficacy of antisecretory therapy. Pending these data, it is perhaps advisable to advocate cure of H. pylori in young patients with proton pump inhibitor-dependent GERD who, in the absence of anti-reflux surgery, are faced with the likelihood of long-term medical therapy.

Helicobacter pylori and dyspepsia

It is clear that non-ulcer (or functional) dyspepsia is a heterogeneous syndrome that includes a subset of patients with unrecognized gastroesophageal reflux. Patient heterogeneity combined with inadequate study methodology has led to enormous confusion in interpreting the relationship between Helicobacter pylori and non-ulcer dyspepsia. The possibility that H. pylori is associated with gastroesophageal reflux disease may explain, in part, the difficulty in establishing a link between non-ulcer dyspepsia and H. pylori infection. It is unclear whether the prevalence of H. pylori is increased in non-ulcer dyspepsia over and above the background population. H. pylori does not appear to be linked to heartburn or other specific upper gastrointestinal tract symptoms. The results of eradication trials in H. pylori-infected patients with non-ulcer dyspepsia have been equivocal and generally flawed. There is no doubt that H. pylori is not a sufficient cause of non-ulcer dyspepsia, because it is well documented in the literature that dyspepsia can occur in the absence of infection and infection can occur in the absence of symptoms. At this stage, there is insufficient evidence to support the hypothesis that H. pylori is etiologically linked to non-ulcer dyspepsia, but data from well designed large randomized controlled trials of eradication therapy, are awaited with great interest.

Different management for Helicobacter pylori positive and negative patients with gastro-oesophageal reflux disease?

Available evidence would suggest that Helicobacter pylori infection does not contribute to the pathogenesis of gastro-oesophageal reflux disease. The prevalence of H pylori infection in patients with reflux disease is no greater than that in control populations. There are some data suggesting that the organism has a protective role: patients with duodenal ulcers develop reflux disease after H pylori eradication, whereas in patients with oesophageal reflux those with H pylori infection have less severe reflux changes. There is also evidence indicating that the presence of H pylori augments the anti-secretory properties of both the H2 receptor antagonists and proton pump inhibitors (PPIs), suggesting that eradication therapy may not be beneficial. However, the considerable recent interest in the association between H pylori and reflux disease has largely been generated by studies outlining the interactions between H pylori infection and acid suppression in the long term. In H pylori positive patients, therapy with PPIs is associated with a proximal extension of the infection and its associated gastritis. In addition long term PPI therapy is reported to be associated with an accelerated development of atrophic gastritis, suggesting that H pylori should be diagnosed and treated. Although these latter findings in particular need confirmation, H pylori eradication therapy should be considered in this patient group, at least until there is evidence to the contrary.

Helicobacter pylori infection, reflux esophagitis, and atrophic gastritis: an unexplored triangle

OBJECTIVE

H. pylori causes chronic gastritis, which may progress to peptic ulcer, gastric atrophy, or gastric cancer. However, little is known about the role of H. pylori infection in reflux esophagitis and the relationship between reflux esophagitis and atrophic gastritis needs to be clarified. We sought to identify the possible interrelationships among Helicobacter pylori infection, reflux esophagitis, and atrophic gastritis, to signal areas in which researchers should consider focusing their attention.

METHODS

A broad-based Medline search was performed to identify all related publications addressing H. pylori infection, atrophic gastritis, gastroesophageal reflux disease (GERD), secretion of gastric acid, and gastric motility published between 1966 and July 1997.

RESULTS

Whereas some studies have shown no significant association between H. pylori infection and reflux esophagitis, others have observed that the prevalence of H. pylori infection was lower in patients with GERD, implying a protective role. Eradication of H. pylori leads to occurrence of reflux esophagitis in some cases, but the mechanisms inducing posteradication reflux esophagitis are unknown. H. pylori infection may lead to atrophic gastritis (and hence hypochlorhydia) through both bacterial and host factors, although gastric atrophy and subsequent intestinal metaplasia are hostile to H. pylori because of hypochlorhydria. Although it has been reported that long-term proton pump inhibitor therapy for refractory reflux esophagitis may induce or enhance the development of gastric atrophy in H. pylori-infected patients, this relationship has been disputed.

CONCLUSIONS

H. pylori infection may be negatively associated with reflux esophagitis, but this requires confirmation. Research then needs to focus on whether this is explained through motility- or acid-related mechanisms. The potential costs of maintenance antireflux therapy may need to be taken into account when evaluating the cost effectiveness of anti-H. pylori therapy.

Trends in the management of gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease is common, with up to 10% of the general population experiencing heartburn on a daily basis. It is a chronic condition and follow-up studies indicate the presence of symptoms at least 20 years after initial diagnosis. In addition to lifestyle modifications, management usually involves the use of an acid suppressant from the H2-receptor antagonist or proton pump inhibitor groups or a prokinetic agent at some stage. In terms of initial symptom resolution and mucosal healing the proton pump inhibitors are consistently superior to the other available agents. However, while it is possible to keep the majority of patients in remission while taking medications, almost all patients have a recurrence of symptoms within six months of stopping medications. The introduction of laparoscopic fundoplication has produced promising initial results but the long-term benefits of this procedure remain to be established. The role of Helicobacter pylori eradication in the management of gastro-oesophageal reflux disease needs further evaluation.

Does Helicobacter pylori infection contribute to gastroesophageal reflux disease?

Helicobacter pylori organisms that infect the stomach conceivably could contribute to esophageal inflammation in patients with gastroesophageal reflux disease (GERD) through any of at least three potential mechanisms: 1) by causing an increase in gastric acid secretion; 2) by spreading to infect the gastric-type columnar epithelium that occasionally can line the distal esophagus; and/or 3) by secreting noxious bacterial products into the gastric juice. Studies regarding these potential mechanisms are discussed in this report. Most investigations have found no apparent association between H. pylori infection and reflux esophagitis. Presently, infection with H. pylori does not appear to play an important role in the pathogenesis of GERD.