Yes, H. pylori-positive gastrointestinal mucosa-associated lymphoma stages I and II1 may be cured by clearing only Helicobacter pylori (Hp).
We all check for Hp and treat it if we have it, right?
The academic community in general thinks that Hp is a bit over-tested and over-treated, too commercialized, rather like the health care products, so this article does this science.
Helicobacter pylori (Hp) is a microaerobic Gram-negative bacillus, because it grows in the harsh stomach acid, out of human surprise, the discoverer also won the Nobel Prize. hp is the most common chronic bacterial infection in humans, human 58,000 years ago since the first migration from Africa to other continents can be detected Hp infection, a conservative estimate 50% of humans are affected globally, with more in developing countries. Most are infected by age 10, and more than 80% are infected by age 50. High housing density, overcrowding, large number of siblings, sharing a bed, lack of running water and eating salty food increase infection. Humans are the main source of infection, and bred primates such as cats can be infected. People who swim frequently in rivers, streams, swimming pools, drink stream water or eat raw vegetables are more likely to be infected.
Who needs to be tested for Hp?
Indications for testing are.
● Low-grade mucosa-associated lymphoid tissue (MALT) lymphoma of the stomach.
● A history of active peptic ulcer disease or peptic ulcer disease.
● Early gastric cancer.
Controversial indications [1-3].
● Patients <60 years of age and without alarming features (unconscious wasting, dysphagia, painful swallowing, iron deficiency anemia of unknown origin, persistent vomiting, palpable mass or lymph node enlargement, family history of upper gastrointestinal cancer) presenting with dyspepsia
● Prior to long-term treatment with NSAIDs or long-term use of low-dose aspirin
● Unexplained iron deficiency
● Adults with immune thrombocytopenia – limited evidence suggests that eradication of H. pylori infection raises platelets in some adult patients with idiopathic thrombocytopenic purpura. Our study concluded that Hp clearance raises platelets in patients, a conclusion that cannot be drawn from thousands of studies abroad (whether this is an academic oops is to be determined).
There are insufficient data to support routine testing for Hp in all asymptomatic individuals with a family history of gastric cancer or in patients with lymphocytic gastritis, hyperplastic gastric polyps, and severe pregnancy vomiting.
There are insufficient data to support routine testing for Hp in all asymptomatic individuals with a family history of gastric cancer or in patients with lymphocytic gastritis, hyperplastic gastric polyps, and pregnancy induced emesis.
Endoscopy is not used solely to determine H. pylori status.
The use of PPIs within one to two weeks of testing and the use of bismuth/antibiotics within four weeks of testing can decrease susceptibility to H. pylori. Where feasible, PPIs should be discontinued one to two weeks prior to testing and testing should be performed at least four weeks after the last administration of bismuth/antibiotics.
The choice of Δ test depends on local availability. Serologic testing for H. pylori should not be performed.
If biopsy urease testing is not available, a gastric biopsy should be performed for histology.
§ For patients with peptic ulcers with active bleeding on upper gastrointestinal endoscopy, testing for H. pylori when there is no evidence of ongoing bleeding, urea breath testing or fecal antigen testing can be performed and PPIs can be safely discontinued for one to two weeks prior to testing.
Endoscopy
Determined by one of three methods: biopsy urease test, histology, and, less frequently, bacterial culture.
The sensitivity and specificity of the biopsy urease test are approximately 90% and 95%, respectively, and the one-hour sensitivity and specificity of the rapid urease test are comparable to the results of the 24-hour agar gel test (89% to 98% and 89% to 93%, respectively), and increasing the number of gastric biopsy specimens from one to four also increases the sensitivity of the test.
The sensitivity and specificity of histology for the diagnosis of H. pylori infection were 95% and 98%, respectively. However, this method can detect other characteristic diseases such as cancerous lesions.
Although bacterial culture is highly specific, H. pylori is less sensitive because it is difficult to culture.
Non-invasive tests
The radiation dose in the 14C test is about 1 microCi, which corresponds to one day of background radiation exposure [4]. Despite this small radiation dose, non-radioactive 13C testing is preferred in young children and pregnant women. Sensitivity and specificity are approximately 88% to 95% and 95% to 100%, respectively. False positives are rare, but false negatives can occur with the administration of proton pump inhibitors.
Fecal antigen testing, with sensitivity and specificity of 94% and 97% respectively is comparable to breath testing, and rapid monoclonal immunochromatographic fecal antigen testing has high specificity, but its use is limited by its low sensitivity (96% and 50% respectively). The presence of gastrointestinal bleeding reduces specificity.
Serological assays, with low specificity, have an overall sensitivity and specificity of 85% and 79%, respectively.
The 13C-urea assay, less commonly used clinically, has a sensitivity of 92% to 100% and a reported specificity of 96% to 97%.
PCR assays are more expensive and can detect lower amounts.
Confirmation of clearance
Due to the high level of Hp resistance, all treated patients, clearance needs to be confirmed. This can be confirmed by urea breath testing, stool antigen testing, or endoscopy-based testing. The choice of test depends on the need for upper gastrointestinal endoscopy (e.g., follow-up for bleeding peptic ulcers) and local availability. After two courses of antibiotic therapy, endoscopy with biopsy for culture and sensitivity is performed in patients with persistent H. pylori infection. Testing to confirm eradication should be performed at least 4 weeks after completion of antibiotic therapy. PPIs should be stopped for at least 1-2 weeks. Serologic testing should not be performed to confirm eradication because patients may continue to produce antibodies after eradication.
Treatment
Amoxicillin + clarithromycin + bismuth + proton pump inhibitor for 10-14 days if not allergic to penicillin; if allergic to penicillin, amoxicillin to metronidazole/tenidazole or levoxyl. The eradication rate of clarithromycin triple therapy (without bismuth) in the United States is less than 80% [5]. The rate of resistance to quinolones is high in North America [6] and is not expected to be low in China, where levofloxacin resistance reduces the eradication success of levofloxacin-containing regimens by 20-40% [5]. Side effects occur in up to 50% of patients [7], but are usually mild and less than 10% of patients discontinue treatment due to side effects [8].
PS. levoxyl has a broad antimicrobial spectrum, is inexpensive, has few side effects, is preferred for prophylaxis in adults with granulomatous deficiency guidelines, and is recommended to be used sparingly for treatment in order to reduce drug resistance. Because, in case one day one’s immunity is low after chemotherapy, there are no good drugs for prophylaxis.