Interpreting the Latest Guidelines for the Treatment of H. pylori Infection from the American College of Gastroenterology (Yao Yu, ed.)
Abstract: Helicobacter pylori (H. pylori) infection remains a chronic infection with worldwide prevalence. Although its prevalence is declining in many parts of the world, it remains an important factor associated with peptic ulcer disease, gastric cancer, and dyspeptic symptoms. It is controversial whether H pylori should be tested in patients with functional dyspepsia and gastroesophageal reflux disease, in patients receiving nonsteroidal anti-inflammatory drugs (NS AI Ds), in patients with iron deficiency anemia, and in those at high risk for gastric cancer. H pylori eradication testing should be performed in patients with peptic ulcer disease treated for H. pylori infection, in individuals with persistent dyspepsia, in patients with H. pylori-associated MAL T lymphoma, and in patients who have undergone resection for early gastric cancer. Recent findings suggest that the H p y l o r i eradication rate achieved with a first-line regimen of proton pump inhibitor (PPI), methylethromycin, and amoxicillin has fallen to 70-85%, partly due to increased resistance of the pathogen to methylethromycin. 7-d regimen may have a higher H p y l o r i eradication rate than 14-d regimen. 7 – 1 4 d bismuth-containing quadruple therapy is another first-line treatment option and is the most common rescue regimen for patients with persistent H p y l o r i infection. 1 O d sequential therapy has shown efficacy in Europe, but further validation is needed in North America. Recent data suggest that a 10-d regimen of combination therapy with PIPI, levofloxacin, and amoxicillin is more effective and better tolerated than bismuth-containing quadruple therapy in the treatment of persistent H p y l o r i infection, although this regimen still needs to be validated in the United States.
It is recommended that: ( 1) patients with active peptic ulcer disease, a history of peptic ulcer, or mucosa-associated lymphoid tissue (MALT) lymphoma should be tested for H p y/o n infection; ( 2) those with uninvestigated dyspeptic symptoms, but without blood, anemia, early satiety, unexplained weight loss, progressive dysphagia, or swallowing should be tested for H p y/o n infection. ( 2) A “test and treat” strategy for H p y l o r i infection should be used for patients under age 55 years who have uninvestigated dysphagia symptoms but no blood, anemia, early satiety, unexplained weight loss, progressive dysphagia, painful swallowing, recurrent vomiting, family history of GI cancer, or previous malignancies of the esophagus or stomach. Although the vast majority of people with H pylori infection do not have clinical manifestations, there are many definite clinical signs associated with the infection. The indications for the diagnosis and treatment of H. pylori infection are shown in Table 1. Table 1 Indications for diagnosis and treatment of H pylori infection
Confirmed indications Active peptic ulcer (gastric or duodenal ulcer) Confirmed history of peptic ulcer (no prior treatment for H p y l o r i infection) Gastric MAL T lymphoma (low grade malignancy) Early endoscopic resection for gastric cancer Uninvestigated dyspeptic symptoms (depending on prevalence of H p y l o r i infection)
Controversial indications Non-ulcer dyspepsia Gastroesophageal reflux disease Patients receiving NSAIDs Unexplained iron deficiency anemia High risk group for gastric cancer
1 The It is well documented that there is a significant correlation between Hepatitis B infection and the pathogenesis of P UD. The clinical and economic importance of H_p y l o r i eradication in patients with P UD has hardly been questioned. A Mehta analysis covering 24 randomized controlled clinical trials (including 2,102 patients with P UD) showed that successful eradication of TH. The rate of ulcer remission was significantly higher in patients with gastric and duodenal ulcers than in patients with persistent H_p y l o r i infection, and a recent analysis of 52 clinical trials by Ferd et al. found that H p y l o r eradication therapy was associated with significantly higher rates of ulcer remission than short-term ulcer medication (e.g., H2 blockers (H2, RAs) or proton pump inhibitors (PPIs)). This study also found that the rate of healing of duodenal ulcers was higher than that of gastric ulcers. The study also found that oral eradication therapy was better than no therapy at all at preventing recurrence of duodenal ulcers and gastric ulcers and was better at preventing recurrence of gastric ulcers (not duodenal ulcers) than acid inhibitor drugs used in maintenance therapy. Hepyloric eradication therapy was less costly in the treatment of duodenal ulcers lasting more than 1 year and in the treatment of gastric ulcers lasting more than 2 years. Therefore, the authors concluded that H _p eradication therapy reduces the recurrence rate of P UD and is less costly.
1. 2 Gastroduodenal bleeding
In a prospective randomized controlled study of 82 Taiwanese patients with a history of ulcer bleeding, Li et al. showed that after successful H-p eradication and ulcer healing, routine use of maintenance acid inhibitors to prevent ulcer recurrence was not necessary. These findings were confirmed by a recent systematic evaluation of cotrimoxazole.
1 The 2 The 1 Gastric MAL T lymphoma
Studies have confirmed that H. pylori infection plays an important role in the pathogenesis and history of MAL T lymphoma . Between 60% and 90% of patients with gastric MAL T lymphoma show tumor regression after treatment with H. pylori. Several recent prospective studies of the long-term outcome of MAL T lymphoma patients after eradication therapy for H. p y l o r infection have given attention to the fact that, after more than 5 years of follow-up, eradication of H. p y # o r i ~ resulted in durable remission in patients with low-grade malignant MAL T lymphoma with a relapse rate ( 3 % to 13 %).
1 The 2 The The “detect and treat” strategy provides a symptom-based treatment option for patients under age 55 with uninvestigated dyspepsia without alarming symptoms. A detailed discussion of the role of H. pylori eradication therapy in addressing uninvestigated dyspepsia can be found in the recent clinical treatment guidelines published by the American Gastroenterological Association. 2. Areas of controversy regarding the benefits of H. pylori eradication therapy (1) there is evidence that only a small but significant subgroup of patients with functional dyspepsia can benefit from H. pylori eradication therapy; (2) there is no clear evidence that eradication of H. pylori persistently exacerbates or improves symptoms in patients with gastroesophageal reflux disease (GERD), and treatment for H. pylori is not yet available. p y l o r i treatment should not be discouraged in view of producing or J J I 1 ~ I J G E R D .
( 3 ) H �. p y l o r i and nonsteroidal anti-inflammatory drugs (NS AI Ds) are 2 independent risk factors for the development of P UD. Therefore, all patients with peptic ulcer, whether or not they are on NS AI D therapy, should be tested for H.p. and treated if positive; ( 4 ) The available data suggest an association between H.p y l o r i infection and iron deficiency, but the cause and long-term effects have not been demonstrated; ( 5 ) Although there is some evidence that curing H.p y l o r i infection may (5) Although some evidence suggests that curing H. pylori infection may prevent the progression of intestinal metaplasia to gastric adenocarcinoma, there is a lack of definitive statistics to prove that it reduces the incidence of gastric adenocarcinoma. H. pylori eradication therapy in patients at high risk for gastric cancer should be tailored to the individual and should take into account other possible signs of disease.