In September this year, the highly anticipated Kyoto Global Consensus on Helicobacter pylori Gastritis (hereinafter referred to as “Kyoto Consensus”) was officially released (Gut 2015, 64:1353), which aroused the keen attention of experts and scholars in the field. The consensus was developed by experts from the Japanese Society of Gastroenterology, the European H. pylori Group, the Asia Pacific Society of Gastroenterology and the International Classification of Diseases (ICD)-11 Gastroenterology Group, and focuses on 22 issues of most concern to clinicians, resulting in 24 consensus recommendations that provide reference for clinicians in many aspects of clinical practice, including diagnosis, treatment and monitoring of gastritis. However, studying the consensus is not to copy the content of the recommendations, but how to combine the consensus recommendations and our specific practice, and pay attention to and standardize the diagnosis and treatment of H. pylori gastritis in China deserves our consideration.
The Kyoto Consensus focuses on the following four themes.
①New classification method of chronic gastritis and duodenitis;
② Clinical differentiation between dyspepsia and functional dyspepsia caused by H. pylori;
③The rational diagnosis of gastritis;
④Treatment timing, method and indication population of H.pylori gastritis, 22 clinical issues were raised, and the consensus reached is summarized as follows.
Classification of chronic gastritis in the ICD-11 classification
The current widely used ICD-10 classification of chronic gastritis is considered outdated because it does not include H. pylori as a causative factor in the classification system. The consensus recommends a new, etiologically based ICD-11 classification. The classification for gastritis should be differentiated according to the site of gastritis, the severity of histological changes and or endoscopic changes, and gastric mucosal erosions should be separated from gastritis and described separately in the report.
In addition, the Kyoto consensus is that H. pylori gastritis should be considered as an infectious disease, even if the patient is asymptomatic or has no complications (e.g., ulcer or gastric cancer).
Dyspepsia associated with H. pylori infection
The Kyoto Consensus states that dyspepsia associated with H. pylori infection is a specific type of dyspepsia, and that H. pylori eradication therapy is the first-line treatment for such patients. If dyspepsia symptoms disappear after 6 to 12 months of successful H.pylori eradication, it suggests that dyspepsia is related to H.pylori infection; if symptoms persist after 6 to 12 months of successful eradication, the possibility of functional dyspepsia should be considered.
Diagnosis of gastritis
The Kyoto Consensus states that a properly trained physician can accurately determine gastric mucosal atrophy and intestinalization by image-enhanced high-definition endoscopy.
Diagnosis by gastric histological biopsy is recommended by the latest Sydney criteria and requires evaluation of specimens from multiple points at the gastric body and sinus. The severity and extent of atrophy and intestinalization are associated with the risk of gastric cancer, and the Kyoto consensus recommends the use of histologic grading methods such as the OLGA and OLGIM grading systems for the assessment of gastric cancer risk. In addition, serological tests (pepsinogen I, II, I/II, and H.pylori antibodies) are also clinically relevant for assessing people at high risk for gastric cancer.
For the screening of H. pylori gastritis, the Kyoto consensus suggests that it should be based on the epidemiological status of this disease in each region, and the timing of screening should be before the onset of gastric mucosal atrophy and intestinalization.
Treatment of gastritis
H.pylori eradication should be performed in all H.pylori-positive patients (unless there are anti-balance considerations); in asymptomatic positive patients, the best time for eradication is before the onset of gastric mucosal atrophy; H.pylori eradication prevents the development of gastric cancer, and the degree of risk reduction depends on the severity and extent of gastric mucosal atrophy at the time of eradication. It should be emphasized that H.pylori eradication does not completely eliminate the risk of gastric cancer, and patients who are still at risk for gastric cancer (mucosal atrophy) should be followed up with endoscopy and histology.
H.pylori eradication protocols should be selected based on the results of drug sensitivity tests, antibiotic use and data on clinical outcomes in each region. after H.pylori eradication treatment, H.pylori should be routinely tested, and non-invasive testing is preferred.
Combining national conditions, emphasizing and standardizing the diagnosis and treatment of H.pylori gastritis in China
This Kyoto Consensus provides a pertinent discussion on the classification, diagnosis and treatment of gastritis, which is worthy of our study and reference. China is a country with a high incidence of gastric cancer, and H. pylori infection has been confirmed as a specific cause of gastric cancer development. Epidemiological data show that the prevalence of H.pylori infection in our mainland population is as high as 40%-60%, with a large number of infected individuals. Therefore, the majority of clinicians should pay attention to and standardize the diagnosis and treatment of H.pylori gastritis and make it an important part of primary prevention of gastric cancer in China.
For the Kyoto consensus to consider H.pylori gastritis as an infectious disease and to single out H.pylori infection-associated dyspepsia as a special type of dyspepsia, it should be said to be objective and reasonable. The eradication of H. pylori as the first-line treatment for H. pylori infection-associated dyspepsia can maximize the benefit of such patients.
In the diagnosis of gastritis, the Kyoto Consensus emphasizes histological assessment, and the degree and extent of gastric mucosal lesions are closely related to the risk of gastric cancer development. The Kyoto Consensus encourages clinicians to use image-enhanced high-definition endoscopy to identify enterosis and atrophy of the gastric mucosa, which places higher demands on the skills of clinical endoscopists. In this regard, we should strengthen the systematic training of endoscopists to enhance their ability to identify endoscopic gastric mucosal lesions.
Should we implement a “H.pylori detection and treatment” strategy in clinical practice?
In view of the potential hazards of H.pylori infection, the Kyoto consensus recommends screening for H.pylori infection in the general population. In this regard, should we implement a “H.pylori detection and treatment” strategy in China? In other words, patients with recent dyspepsia who are <40 years old (adjusted for local incidence of upper gastrointestinal tumors) and who do not have alarming symptoms (including gastrointestinal bleeding, persistent vomiting, recent significant weight loss, dysphagia, painful swallowing, or abdominal masses) can be tested for h.pylori by non-invasive methods (urea breath test or stool antigen test) and treated with eradication if positive. The benefit of this strategy is that it reduces the risk of digestive problems.
The benefit of this strategy is that it reduces endoscopy in the management of dyspepsia, but there is a risk of missing tumors. Therefore, this strategy has been commonly implemented in countries and regions with high cost of endoscopy and low incidence of upper gastrointestinal tumors. In contrast, in our country, the cost of endoscopy is low and the incidence of upper GI tumors is high, so it was not recommended in the Fourth National Consensus Report on the Management of Helicobacter pylori Infection.
The publication of the Kyoto Consensus and the views therein made us rethink and re-examine this strategy. Overall, China is a country with a high incidence of gastric cancer, but the regional distribution is uneven. The safety of implementing the “H.pylori detection and treatment” strategy in areas with a low incidence of gastric cancer (<100,000 per 100,000) has long been established. It should also be relatively safe in areas with a high incidence of gastric cancer if the age threshold is lowered (<30 years). In fact, our consensus h.pylori eradication indication "individual request for treatment" includes some individuals who have undergone the "h.pylori detection and treatment" strategy. < p="">
The implementation of the “H.pylori detection and treatment” strategy must emphasize: (1) exclusion of individuals with alarm symptoms and a family history of gastric cancer; (2) gastroscopy for those willing to undergo gastroscopy; and (3) gastroscopy for those whose symptoms have not resolved after eradication therapy.
How to standardize H.pylori eradication in patients with H.pylori gastritis?
The Kyoto Consensus suggests that H.pylori infected patients should be given eradication therapy unless there are counteracting considerations. Counterbalancing factors include the patient’s coexisting disease, high reinfection rate in the community, and prioritization of health resources. Potential benefits of H. pylori eradication include halting the progression of gastric mucosal damage, reducing the source of infection, and stopping the development of H. pylori-associated disease.
However, while seeing the benefits of H.pylori eradication, one should also be sober about the realities facing our country: the prevalence of H.pylori infection in the population is still high (40-60%) and the population base of infection is quite large; the rate of H.pylori resistance is high and the eradication rate is decreasing or significantly decreasing; there may be a high rate of reinfection; and the problem of irregular application of antibiotics, including H.pylori eradication, is prominent . These factors largely constrain us from comprehensive screening and eradication of H.pylori.
Based on the views of the Kyoto Consensus and the current situation in China, for clinicians, the standardized treatment of H.pylori-infected patients is the key at the moment. Although the Kyoto Consensus does not explicitly recommend specific eradication protocols, it emphasizes that eradication protocols should ideally be based on locally effective protocols, ideally using individual drug sensitivity tests or community antibiotic susceptibility or antibiotic consumption data and clinical outcome data. In other words, the emphasis is on “local adaptation”.
Bismuth quadruple therapy is the recommended regimen in China Based on the results of randomized controlled studies in evidence-based medicine and the national situation in China: the resistance rate of clarithromycin, metronidazole and quinolone antibiotics in H. pylori eradication regimen is high, while the resistance rate of amoxicillin, furazolidone and tetracycline is low, and bismuth can be obtained. Therefore, our fourth consensus recommends a quadruple regimen containing bismuth [bismuth + proton pump inhibitor (PPI) + 2 antibacterial drugs] with a combination of antibiotics with low resistance rate (amoxicillin, furazolidone, tetracycline) for 10/14 days. The success of the first H. pylori eradication should be emphasized.
The main role of PPI is to interfere with the survival environment of H. pylori and to enhance the antibiotic activity through various pathways. PPI works by inhibiting gastric acid secretion, therefore, the selection of PPI with strong acid-suppressive effect will help to improve the eradication rate of H. pylori. Our consensus report also clearly indicates that selecting PPI with stable action, high efficacy and less affected by CYP2C19 gene polymorphism can improve the eradication rate of H.pylori.
Post-eradication review Post-eradication review and follow-up are equally important The Kyoto consensus states that post-eradication review not only confirms the efficacy of eradication, but also provides timely and early warning of the increasing antibiotic resistance in the population year by year (manifested as increased eradication failure rate). Therefore, clinicians should take this seriously.
In addition, since eradication of H. pylori does not completely eliminate the risk of gastric cancer, physicians should assess the risk of gastric cancer in patients treated with eradication and provide long-term follow-up for patients at risk of developing gastric cancer.