What do we do after failed Hp eradication?
2016-03-01 Gastroenterology Channel in Medicine
We are not God who came to save the earth, we are angels who accompany our patients, even when it seems to be a desperate time, there is still always something we can do ……
Source: Medical Gastroenterology Channel
Author: Yin Him
I remember a few years ago at a provincial HP treatment group meeting, after the speaker introduced the quadruple eradication therapy for HP, one of the attendees sincerely asked, “What else can we do after encountering failed quadruple eradication therapy in the clinic?” The speaker did hesitate a bit at that time to face this tricky question, not knowing how to answer it appropriately in a public setting …… because this is a clinical dilemma that every doctor who has treated people with HP infection encounters. –Continuing the medication will have a series of side effects caused by prolonged, high-dose antibiotic use, while changing the medication or extending the dosing cycle based on experience will definitely kill HP? Temporary interruption of treatment can be confusing for the patient: this is also a time when the patient is very nervous and has many questions: Will my HP infection just go away? Will I get stomach cancer? I remember that after a moment of contemplation, the speaker replied very calmly: “I would advise the patient to stop treatment for the time being, and we will do regular follow-up observations under gastroscopy first ……”
On the surface, the speaker’s answer seemed very weak, but I almost applauded his honesty. Because he didn’t choose a more “perfect” answer – for example, suggesting a second-line treatment option, choosing a more precise treatment based on drug sensitivity tests – because he knew that the answer the questioner was looking for was that when there is nothing we can do, we should Go back and see what role HP actually plays in a person’s body ……
Of course, there must be a standard answer to this question as well.
First we have to know why the treatment failed? It’s because HP is evolving! The fact that this tiny bacterium can live in a highly acidic environment shows that it must have something to offer. For example, studies have shown that the mechanism of metronidazole resistance is related to mutations in the rdxA and FrxA genes; the mechanism of clarithromycin resistance is related to point mutations in the V region of the 23SrRNA of Hp; the mechanism of amoxicillin resistance is related to mutations in penicillin-binding proteins (PBPs); the mechanism of quinolone resistance is related to DNA rotamase subunits (gyrA,gyrB) quinolone drug resistance Decision region (QRDR) gene mutations; tetracycline resistance mechanisms are associated with mutations in Hp 16SrRNA sequences ……
Honestly, I look dizzy too! Not to mention that it also deforms – from rod-shaped to spherical; it also escapes – some studies have shown that Hp that enters the epithelial vacuole of the gastric mucosa has a half-life of about 24 h and may return to recolonize the cell; it also swarms — Different genotypic Hp strains can mix and infect the same patient …… They are really tricky! Add to this the polymorphism of the infected patient’s genes, different immune status, different dental plaque (because the plaque microorganism has a unique “biofilm” structure, and HP can colonize the oral cavity, so systemic drug treatment can not eradicate oral Hp or has very little effect) – so even if Hua Tuo comes to the rescue, the patient will not be able to get rid of Hp. -So even if Hua Tuo comes, he may still be unable to do anything about this little bug other than schistosomiasis.
So what is the standard answer? –Individualized and precise treatment, of course! This is the focus of many studies in recent years. For example, the H. pylori individualized treatment test gene chip to predict the patient’s HP infection before treatment and guide the rational use of drugs – with such a thing, the treatment process becomes perfect! Of course it does, but perfection is necessarily not easy to come by, so what do we do in most hospitals that don’t have such conditions? I heard someone whisper, “Get transferred there!” Yes, that’s the responsible attitude. If I can’t handle the problem well, I should refer the patient to a doctor who can solve the problem better, which is certainly a good attitude. But the patient may not have the energy and financial resources to do so.
So what else can be done? This is where we need to go back and think: what was the original reason we killed HP? Oh, to prevent HP-related cancers! So are HP-infected people destined to develop cancer? Of course not! Since the purpose of sterilization is to reduce the risk of cancer in the future, which is one of the preventive measures, can we make up for it in other ways? For example, first of all, change the habits of life, eat more fresh vegetables, less spicy and stimulating food, quit smoking and drinking, reduce the pressure of life; then for example, regular physical examination, including gastroscopy, tumor marker examination, and then for example, before anti-HP treatment, preliminary mastering of the local HP drug resistance characteristics (the characteristics of each region’s flora and antibiotic use habits will not be the same, need to sum up and accumulate more in clinical work), patients There are many reasons for the occurrence of cancer, and when we are blocked in a certain path of preventive measures, we should not be stuck in the same place, but should try to make up for it from other angles ……
As Dr. Trudeau, who rests on the shores of Saranac Lake in northeastern New York, summarized his life in 1915 on his tombstone: -To Cure Sometimes, To Relieve Often, To Comfort Always. “To cure sometimes; to help often; to comfort always.”
I hope we can all step down from the altar of those who practice medicine – we are not Gods who have come to save the earth, we are angels who are there for our patients, and even when it seems that we are at the end of our rope, there is still always something we can do ……