Current European concepts in the management of Helicobacter pylori infection--the Maastricht Consensus Report. The European Helicobacter Pylori Study Group (EHPSG)

Recurrent peptic ulcers in patients following successful Helicobacter pylori eradication: a multicenter study of 4940 patients

OBJECTIVE

Although curative treatment of Helicobacter pylori infection markedly reduces the relapse of peptic ulcers, the details of the ulcers that do recur is not well characterized. The aim of this study is to describe the recurrence rate and specific features of peptic ulcers after cure of H. pylori infection.

METHODS

This was a multicenter study involving 4940 peptic ulcer patients who were H. pylori negative after successful eradication treatment and were followed for up to 48 months. The annual incidence of ulcer relapse in H. pylori-cured patients, background of patients with relapsed ulcers, time to relapse, ulcer size, and site of relapsed ulcers were investigated.

RESULTS

Crude peptic ulcer recurrence rate was 3.02% (149/4940). The annual recurrence rates of gastric, duodenal and gastroduodenal ulcer were 2.3%, 1.6%, and 1.6%, respectively. Exclusion of patients who took NSAIDs led annual recurrence rates to 1.9%, 1.5% and 1.3%, respectively. The recurrence rate was significantly higher in gastric ulcer. Recurrence rates of patients who smoked, consumed alcohol, and used NSAIDs were significantly higher in those with gastric ulcer recurrence compared to duodenal ulcer recurrence (e.g. 125 of 149 [83.9%] relapsed ulcers recurred at the same or adjacent sites as the previous ulcers).

CONCLUSIONS

Curative treatment of H. pylori infection is useful in preventing ulcer recurrence. Gastric ulcer is more likely to relapse than duodenal ulcer. Recurrent ulcer tended to recur at the site of the original ulcers.

Gastric juice, gastric tissue and blood antibiotic concentrations following omeprazole, amoxicillin and clarithromycin triple therapy

BACKGROUND

Amoxicillin and clarithromycin are key antibiotics in proton pump inhibitor-based Helicobacter pylori eradication therapies.

AIMS

To study gastric mucus and tissue concentrations and collect basic data about optimal antibacterial doses.

METHODS

Plasma, gastric mucosa and gastric juice antibiotic concentrations were measured following either low- or high-dose amoxicillin (750 or 1000 mg b.i.d.) and clarithromycin (400 or 500 mg b.i.d.) given in combination with omeprazole 20 mg bid to 12 male volunteers in an open crossover design. Gastric juice and mucosal biopsy collection was performed either 2 (n=6) or 6 hours (n=6) after dosing.

RESULTS

Amoxicillin concentrations 2 hours after high dosage were gastric juice > gastric body > antral mucosa > plasma. At 6 hours, plasma and gastric juice concentrations were still above the MIC for amoxicillin-susceptible bacteria but no antibiotic was detectable in mucosa samples. Clarithromycin concentrations after high dosage were gastric juice > mucosa > serum; all above the MIC for clarithromycin-susceptible bacteria at both 2 and 6 hours.

CONCLUSIONS

Both dosage regimens provided effective antibiotic concentrations in gastric juice at 2 hours. After dosing, both antibiotics demonstrated high gastric tissue concentrations via local diffusion while clarithromycin also provided sustained delivery (6 hours) via gastric mucosa penetration.

Burden of Helicobacter pylori and H. pylori-related diseases in developed countries: recent developments and future implications

Helicobacter pylori colonizes the gastric mucosa. H. pylori infection is the main cause of peptic ulcer and gastric malignancy. This review gives an overview on the epidemiology of H. pylori infection and H. pylori-associated diseases in the developed world, mainly Europe, and it discusses very recent developments with regard to the prevalence and its future implications for H. pylori-associated diseases.

Rabeprazole in a one-week eradication therapy of Helicobacter pylori: comparison of different dosages

AIM

Many data regarding omeprazole-, lanzoprazole- and pantoprazole-based triple therapy for Helicobacter pylori (H. pylori) eradication have been reported, but there is few data present regarding rabeprazole (R). We report the efficacy and tolerability of rabeprazole in different dosages in association with clarithromycin (C)and tinidazole (T) in H. pylori eradication.

DESIGN AND METHODS

Ninety-four H. pylori-positive patients with dyspeptic symptoms were enrolled and randomly allocated to eradication therapy in two different one-week regimens. In regimen A, 47 patients received R 20 mg b.i.d, C 500 mg b.i.d and T 500 mg b.i.d, while in regimen B, 47 patients received R 10 mg b.i.d, C 500 mg b.i.d and T 500 mg b.i.d. Eradication of H. pylori was evaluated by a 13C urea breath test (UBT) two months after the end of the therapy.

RESULTS

Four patients (two in each regimen) did not complete treatment. The H. pylori eradication rate was 91.4% in group A compared to 89.3% in group B (P-value not significant). Minor side-effects were reported in 4.2% of group A and 6.4% of group B patients.

CONCLUSION

Rabeprazole showed good efficacy and tolerability in one-week H. pylori therapy at 20 mg b.i.d and 10 mg b.i.d, suggesting the use of the lower dosage.

Triple vs. quadruple therapy for treating Helicobacter pylori infection: a meta-analysis

BACKGROUND

Triple therapy (proton pump inhibitor, clarithromycin and amoxicillin or an imidazole) is the first-line treatment for Helicobacter pylori infection. However, the effectiveness of triple therapy is decreasing due to the increase in antibiotic resistance. Quadruple therapy (proton pump inhibitor, tetracycline, metronidazole and a bismuth salt) is a very effective regimen even in areas of high prevalence of antibiotic resistance, and may be an alternative first-line treatment.

AIM

To compare triple vs. quadruple therapy for the first-line treatment of H. pylori infection.

METHODS

An extensive literature search was performed to identify randomized trials comparing triple vs. quadruple therapy. Selected trials were included in a meta-analysis using Review Manager 4.1.

RESULTS

Four studies met the inclusion criteria. Eradication rates with quadruple therapy were slightly higher in both the intention-to-treat (81% vs. 78%; odds ratio, 0.83; 95% confidence interval, 0.61-1.14) and per protocol (88% vs. 85%; odds ratio, 0.81; 95% confidence interval, 0.55-1.20) analysis, although the differences were not statistically significant. Nor were there significant differences in compliance or adverse effects between the therapies.

CONCLUSION

Triple and quadruple therapies seem to be roughly equivalent in terms of effectiveness, compliance and side-effects profile when administered as first-line treatment for H. pylori infection.

The gastritis connection: prevention and early detection of gastric neoplasms

Most gastric polyps, adenocarcinomas, carcinoids, and B cell lymphomas arise on a gastric mucosa damaged by long-standing chronic gastritis. The most common form of chronic gastritis is caused by infection with Helicobacter pylori. All patients with H. pylori infection develop lymphoid aggregates with germinal centers that interact intimally with the gastric mucosa (mucosa-associated lymphoid tissue [MALT]); these follicles are the condition sine qua non for the development of primary B cell mantle lymphomas, also known as MALT lymphomas. As the infection progresses, atrophy of the gastric mucosa develops in a subset of patients, which is replaced by an intestinal-type epithelium (intestinal metaplasia). On this background, dysplasia and adenocarcinomas of the intestinal type may develop. When atrophy is sufficiently severe to impair acid production, the gastrin-producing cells of the antrum increase their secretion of gastrin and stimulate endocrine cells in the corpus, which may eventually proliferate, become dysplastic, and give raise to carcinoids. This development is more frequent in advanced cases of autoimmune gastritis associated with pernicious anemia. On this background, there is also extensive epithelial hyperplasia and the formation of hyperplastic or inflammatory polyps, a small percentage of which may become dysplastic and progress to adenocarcinoma. Chronic exposure of the corpus mucosa to pancreaticoduodenal secretions ("bile reflux") causes reactive mucosal changes that may predispose to neoplasia. Thus, the progression of inflammation to atrophy to metaplasia, and in some cases chronic chemical injury, may give rise, at different times and under the influence of other, unknown stimuli, to most types of gastric tumors. Other types of gastritis, including lymphocytic and granulomatous gastritis, are rare and have not been associated with gastric neoplasia. Awareness of these associations, appropriate treatment policies, and implementation of endoscopic surveillance programs would dramatically reduce the incidence of most types of gastric neoplasms and would allow the detection of many tumors at a stage when endoscopic resection or conservative treatment would still be possible.

The use of proton pump inhibitors in children: a comprehensive review

Proton pump inhibitors (PPIs) belong to a group of chemically related compounds whose primary function is the inhibition of acid production in the final common metabolic pathway of gastric parietal cells. PPIs are highly selective and effective in their action and have few short- or long-term adverse effects. These pharmacologic features have made the development of PPIs the most significant advancement in the management of acid peptic related disorders in the last two decades. There are numerous published adult studies that describe the pharmacology, efficacy and safety of these anti-secretory agents; however, in the pediatric population, there are very few comparable studies, particularly multicenter studies with significant patient enrollment. In preparing this article, our aim was to perform a comprehensive review of the literature on the clinical pharmacology and use of PPIs in the pediatric population, and to briefly review some recent articles. Relevant literature was identified by performing MEDLINE/Pubmed searches from January 1990 to December 2001. Combinations of the following search terms were use to analyze these databases: proton pump inhibitor, children, pediatrics, gastroesophageal reflux disease (GERD), esophagitis, intestinal metaplasia, Helicobacter pylori, omeprazole, lansoprazole, pantoprazole, rabeprazole, esomeprazole, and safety. Abstracts from the 14th annual conference of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) 2001, and the Disease and Digestive Week 2001, were also included in the review. All pediatric studies reviewed were limited to either omeprazole or lansoprazole. The dosage range used for the management of GERD and related disorders with lansoprazole was 0.73-1.66 mg/kg/day (maximum 30 mg/day). The dosage range for GERD management using omeprazole was 0.3-3.5 mg/kg (maximum 80 mg/day). The dosage range for omeprazole used for H. pylori was 0.5-1.5 mg/kg/day, with a maximum dosage of 40 mg/day, and lansoprazole-containing regimens for H. pylori eradication used dosages ranging from 0.6-1.2 mg/kg/day, with a maximum dosage of 30 mg/day. Few severe adverse events were reported with the use of either drug. Eradication rates for H. pylori were 56-87% for lansoprazole-based triple therapy, and 75-94% for omeprazole-based eradication regimens. To date, there are no published controlled trials of sufficient power comparing the efficacy of the five commercially available PPIs in children, for a variety of acid peptic diseases. Studies suggest that PPIs are highly effective for the management of GERD and related disorders, and are a critically needed component of triple therapy to eradicate H. pylori. PPIs have a very good tolerability profile in adults and children, but long-term tolerability studies are needed, particularly in the pediatric population. Multicenter studies are critically needed to evaluate the second-generation PPIs, to compare PPI efficacy to each other, and to assess the importance of developmental and genetic pharmacology of these drugs in children with acid-peptic disease.

Recent use of proton pump inhibitor-based triple therapies for the eradication of H pylori: a broad data review

INTRODUCTION

For the eradication of Helicobacter pylori a 1-week triple therapy combining proton pump inhibitors with two antibiotics has been recommended as a gold standard therapy. However, a recent broad data review on the efficacy of the different regimens is missing. Therefore, the aim of this study was to systematically review the recent literature.

METHODS

We undertook a broad data review of the efficacy of nine different 7-day triple therapies consisting of a proton pump inhibitor (lansoprazole, pantoprazole, omeprazole) in its standard dosage and two antibiotics. Relevant original papers on H. pylori eradication in adults, published in English or German between 1995 and 2000, were identified from MEDLINE searches. Studies were reviewed and selected according to predefined criteria.

RESULTS

Our predefined criteria were fulfilled by 79 full paper articles including 112 study arms with 8383 patients on intention-to-treat, or 6787 patients on per-protocol basis, respectively. The mean eradication rates unweighted or weighted by the number of patients in the study arm vary from 71.9% to 83.8% for intention-to-treat analysis and from 78.5% to 91.2% for per-protocol analysis.

CONCLUSIONS

All nine PPI based triple therapy regimens are very effective in H. pylori eradication. The current literature review underlines that the use of either lansoprazole, omeprazole, or pantoprazole combined with two antibiotics yield similar high eradication rates.

Are dyspeptic symptoms linked to Helicobacter pylori? A prospective cohort study among medical students

OBJECTIVE AND DESIGN

In Austria, the prevalence of Helicobacter pylori (Hp) infection in healthy people with or without symptoms of dyspepsia has not yet been assessed systematically. We conducted a prospective cohort study among medical students during their rotation in internal medicine to determine whether or not dyspeptic symptoms are linked to Hp infection. Symptoms were assessed before testing for Hp so that knowledge of Hp status could not influence symptom-reporting behavior.

METHODS

From February 2000 to February 2001 we invited 242 medical students to participate in this trial. Abdominal symptoms were assessed by a questionnaire. Dyspeptic symptoms were defined according to the Rome II criteria: heartburn was not considered a dyspeptic symptom. Severity of symptoms was assessed using the Glasgow dyspepsia severity score (GDSS). After determination of symptoms, students underwent a 13C-urea breath test for Hp.

RESULTS

Of 242 students (103 male, 139 female, mean age 26 years, range 21-39 years), 23 tested positive for Hp (10%). Of 34 participants reporting dyspeptic symptoms (14%, GDSS-range 1-11), four were Hp positive (12%). Of the 208 asymptomatic students, 19 were Hp positive (9%). Statistical analysis did not show a significant difference in the frequency of Hp infection between asymptomatic students and students reporting dyspeptic symptoms.

CONCLUSION

Hp prevalence in Austrian medical students is similar to that in other western countries. There was no significant difference in Hp prevalence between dyspeptic students and asymptomatic students.

Family history of gastric cancer: should we test and treat for Helicobacter pylori?

A close link has been established between infection and gastric cancer. In this article, we suggest that using a risk stratification technique (like that for colorectal cancer), the high-risk group of first-degree relatives of patients with gastric cancer can be separated out for testing and treatment. This would be more manageable and more cost-effective than screening the whole population, in which the mortality from distal gastric cancer has declined concomitant with the eradication of infection. Support for the feasibility of this approach is derived from studies showing that the family is the core unit of transmission and that childhood colonization, especially with a virulent strain, is apparently a major risk factor for disease progression to the neoplastic stage. When there is a case of gastric cancer in the family, first-degree relatives, who might be infected by a bacterium with an identical genetic fingerprint, are at higher risk than normal for developing gastric cancer. Furthermore, genetic and epidemiologic studies based on the Correa model have shown that both primary and secondary prevention of gastric cancer is possible. Calculations done in high-risk populations, such as Japanese-Americans, confirm the savings in cost and the safety of the test-and-treat strategy. Considering that eradication should be done as early as possible, at a point in the cascade when the changes are still reversible, and that gastric cancer is associated with a high mortality rate, we suggest that this strategy be applied to this high-risk population.

Association of metronidazole resistance and natural competence in Helicobacter pylori

To study whether the capability of horizontal DNA transfer is associated with metronidazole resistance in Helicobacter pylori, a total of 81 clinical isolates were tested for MICs of metronidazole (MTZ). The MIC assays were performed by using the E-test and reconfirmed by the agar dilution method. Natural competence assays were performed by transferring a chloramphenicol acetyltransferase cassette and a 23S rRNA gene from a clarithromycin-resistant strain (with an A-to-G mutation at nucleotide 2143) by using natural transformation. Of the 81 isolates, 65 (80.2%) were naturally competent while 16 were not. Among the 65 naturally competent strains, 39 (60%) were highly resistant to MTZ (MICs, >32 microg/ml) while only 2 of 16 (12.5%) noncompetent strains were highly MTZ resistant (P, <0.001). Therefore, there is an association between natural competence and MTZ resistance.

Eradication of Helicobacter pylori and risk of peptic ulcers in patients starting long-term treatment with non-steroidal anti-inflammatory drugs: a randomised trial

BACKGROUND

Whether Helicobacter pylori increases the risk of ulcers in patients taking non-steroidal anti-inflammatory drugs (NSAIDs) is controversial. We hypothesised that eradication of H pylori infection would reduce the risk of ulcers for patients starting long-term NSAID treatment.

METHODS

Patients were enrolled if they were NSAID naïve, had a positive urea breath test, had dyspepsia or an ulcer history, and required long-term NSAID treatment. They were randomly assigned omeprazole triple therapy (eradication group) or omeprazole with placebo antibiotics (placebo group) for 1 week. All patients were given diclofenac slow release 100 mg daily for 6 months from randomisation. Endoscopy was done at 6 months or if severe dyspepsia or gastrointestinal bleeding occurred. The primary endpoint was the probability of ulcers within 6 months. Analyses were by intention to treat.

FINDINGS

Of 210 arthritis patients screened, 128 (61%) were positive for H pylori. 102 patients were enrolled, and 100 were included in the intention-to-treat analysis. H pylori was eradicated in 90% of the eradication group and 6% of the placebo group. Five of 51 eradication-group patients and 15 of 49 placebo-group patients had ulcers. The 6-month probability of ulcers was 12.1% (95% CI 3.1-21.1) in the eradication group and 34.4% (21.1-47.7) in the placebo group (p=0.0085). The corresponding 6-month probabilities of complicated ulcers were 4.2% (1.3-9.7) and 27.1% (14.7-39.5; p=0.0026).

INTERPRETATION

Screening and treatment for H pylori infection significantly reduces the risk of ulcers for patients starting long-term NSAID treatment.

Evaluation of two commercial enzyme immunoassays, testing immunoglobulin G (IgG) and IgA responses, for diagnosis of Helicobacter pylori infection in children

Serological testing to diagnose Helicobacter pylori infection in children is still controversial, although commonly used in clinical practice. We compared the immunoglobulin G (IgG) and IgA results of two commercially available enzyme immunoassays (EIAs) (Pyloriset IgG and IgA and Enzygnost II IgG and IgA) for 175 children with abdominal symptoms divided into three age groups (0 to < or =6 years, n = 47; >6 to < or =12 years, n = 77; >12 years, n = 51). A child was considered H. pylori infected if at least two of three tests (histology, rapid urease test, 13C-urea breath test) or culture were positive and noninfected if all results were concordantly negative. Of 175 children, 93 (53%) were H. pylori negative and 82 were H. pylori positive. With the recommended cutoff values, the overall specificity was excellent for all four EIAs (95.7 to 97.8%) regardless of age. Sensitivity varied markedly between tests and was 92.7, 70.7, 47.5, and 24.4% for Enzygnost II IgG, Pyloriset IgG, Enzygnost II IgA, and Pyloriset IgA, respectively. Sensitivity was low in the youngest age group (25 to 33.3%), except for Enzygnost II IgG (91.6%). Receiver-operating curve analyses revealed that lower cutoff values would improve the accuracy of all of the tests except Enzygnost II IgG. Measurement of specific IgA, in addition to IgG, antibodies hardly improved the sensitivity. The specificity of commercial serological tests is high in children when the cutoff values obtained from adults are used. In contrast, sensitivity is variable, with a strong age dependence in some, but not all, tests. We speculate that young children may have a different immune response to H. pylori, with preferable responses to certain antigens, as well as lower titers than adults. The Pyloriset test may fail to recognize these specific antibodies.

Comparison of 1-week vs. 2- or 4-week therapy regimens with ranitidine bismuth citrate plus two antibiotics for Helicobacter pylori eradication

BACKGROUND

Helicobacter pylori eradication therapies based on ranitidine bismuth citrate have recently been introduced in clinical practice.

AIM

To compare the efficacy of three regimens containing ranitidine bismuth citrate given for 1, 2 and 4 weeks, combined with two antibiotics for the first week, in the eradication of H. pylori.

METHODS

Eighty-six consecutive patients (50 duodenal ulcer disease, 36 non-ulcer dyspepsia) with H. pylori infection were offered three eradication regimens: (a) 1-week group (n=28), ranitidine bismuth citrate 400 mg b.d. for 7 days; (b) 2-week group (n=29), ranitidine bismuth citrate 400 mg b.d. for 14 days; and (c) 4-week group (n=29), ranitidine bismuth citrate 400 mg b.d. for 28 days. In all patients, clarithromycin 500 mg b.d. and metronidazole 500 mg b.d. were given for the first week. Endoscopy was repeated 1 month after the end of treatment and eradication was considered to be successful if both rapid urease test and histology were negative.

RESULTS

Overall, H. pylori was eradicated in 84% (72/86) patients on intention-to-treat analysis, whereas the per protocol cure rate was 89% (72/81). Eradication rates were 23/27 (85%) (95% confidence interval (CI): 66-96%), 25/27 (92%) (95% CI: 76-99%) and 24/27 (89%) (95% CI: 71-98%) in the 1-, 2- and 4-week groups, respectively, on per protocol analysis, and 25/28 (82%) (95% CI: 63-94%), 25/29 (86%) (95% CI: 68-96%) and 24/29 (83%) (95% CI: 64-94%), respectively, on intention-to-treat analysis (P > 0.05, N.S.). No significant differences were observed between groups concerning duodenal ulcer healing, resolution of symptoms and adverse effects.

CONCLUSIONS

The 1-week regimen with ranitidine bismuth citrate, clarithromycin and metronidazole is effective in H. pylori eradication. Prolongation of treatment with ranitidine bismuth citrate for 2 or 4 weeks does not achieve a statistically significant more favourable outcome.

There are some benefits for eradicating Helicobacter pylori in patients with non-ulcer dyspepsia

BACKGROUND

The relationship between Helicobacter pylori infection and non-ulcer dyspepsia is not established.

AIM

To determine whether eradication of H. pylori might be of benefit in non-ulcer dyspepsia patients.

METHODS

We randomly assigned 129 H. pylori infected patients with severe epigastric pain, without gastro-oesophageal reflux symptoms, to receive twice daily treatment with 300 mg of ranitidine, 1000 mg of amoxicillin, and 500 mg of clarithromycin for 7 days and 124 such patients to receive identical-appearing placebos.

RESULTS

Treatment was successful (decrease of symptoms at 12 months) in 62% of patients in the active-treatment group and in 60% of the placebo group (N.S.). At 12 months, the rate of eradication of H. pylori was 69% in the active-treatment group and 18% in the placebo group (P < 0.001). Complete relief of symptoms occurred significantly more frequently in patients on the active treatment (43%) than in placebo-treated patients (31%, P=0.048). Within the active-treatment group, therapeutic success was significantly more frequent in the non-infected patients (84% vs. 64%, P=0.04).

CONCLUSIONS

Although eradicating H. pylori is not likely to relieve symptoms in the majority of patients with non-ulcer dyspepsia, a small proportion of H. pylori-infected patients may benefit from eradication treatment.

What is the optimal length of proton pump inhibitor-based triple therapies for H. pylori? A cost-effectiveness analysis

BACKGROUND

Triple therapy with a proton pump inhibitor, clarithromycin and amoxicillin is widely used for H. pylori infection. The appropriate length of treatment remains controversial.

AIM

To determine whether length of treatment has an impact on the cost-effectiveness of triple therapy.

METHODS

The study took the form of a cost-effectiveness analysis spanning 2 years. The perspective was societal and the setting, ambulatory care. Subjects were Helicobacter pylori-positive patients with a duodenal ulcer. The triple therapy trials spanned 7, 10 or 14 days and the main outcome measures were cost per patient and marginal cost for additional cured patient calculated for a low cost-of-care setting (Spain), for a high-cost setting (USA), and for two follow-up strategies: (i) systematic 13C-urea breath test after eradication; (ii) clinical follow-up, breath-test if symptoms recurred.

RESULTS

Base-case analysis showed that for both the 13C-UBT and the clinical follow-up branches, lowest costs were obtained with 7-day schedules both in Spain and the USA. Sensitivity analysis showed that in Spain, 10-day therapies would have to increase 7-day cure rates by 10-12% to become cost-effective. In contrast, in the USA only a 3-5% increase was needed. The corresponding figures for 14-day therapy were 25-35% and 8-11%, respectively.

CONCLUSIONS

Seven-day therapies seem the most cost-effective strategy. However, in high-cost areas the differences were less evident.

The effect of Helicobacter pylori eradication therapy on dyspepsia symptoms in industrial workers in Japan

BACKGROUND

The relationship between Helicobacter pylori infection and non-ulcer dyspepsia is still controversial. The potential benefits and risks of the treatment could depend on local conditions, such as the prevalence of the infection and the local rates of gastric cancer.

AIM

To evaluate the effects of H. pylori eradication therapy on non-ulcer dyspepsia symptoms in industrial workers in Japan.

METHODS

A total of 615 employees of an industrial corporation were examined for H. pylori infection and symptom scores; 215 H. pylori-positive non-ulcer dyspepsia cases underwent eradication therapy. Symptom scores were also analysed 12 months after the eradication therapy. Serum pepsinogen A and pepsinogen C levels were analysed and chronic atrophic gastritis was serologically diagnosed on the basis of the criteria of a pepsinogen A < 70 ng/mL and pepsinogen A : pepsinogen C ratio < 3.0.

RESULTS

The symptom score improved significantly in the cured cases, but not in the non-cured cases. The effect of the cure of H. pylori infection on symptoms was analysed according to the serological diagnosis of chronic atrophic gastritis. In both groups, cases with atrophic gastritis and cases with chronic gastritis only, the cure of infection was effective in improving symptoms.

CONCLUSION

The cure of H. pylori infection was effective in reducing non-ulcer dyspepsia symptoms in industrial workers in Japan.

Peptic ulcer occurrence in follow-up of chronic gastritis in patients with treated and not eradicated CagA-positive Helicobacter pylori infection

The aim of the present prospective investigation was to study 49 dyspeptic Helicobacter pylori (HP)-positive (HP+) or -negative (HP), CagA+ and CagA- patients with a normal pattern or pure chronic gastritis at initial histology as well as normal features or hyperemic gastropathy at initial endoscopy in a two-year follow up. All the HP+ patients were treated with omeprazole 20 mg twice a day plus amoxicillin 1 g twice a day for two weeks. No substantial change was seen in gastritis in CagA+ patients in whom the infection was not eradicated, and, in contrast, a progressive improvement in 13/14 successfully treated patients was found. At endoscopy, a progressive change to a normal picture was seen in 8 and no change in 6 of 14 patients whose HP infection was eradicated, in contrast a worsening in the 9 HP+ patients who were still infected was observed. In particular, peptic lesions arose in 6 of 21 CagA+ patients in whom the infection was not eradicated. In conclusions, the lack of change in chronic gastritis at histology and the progressive worsening of endoscopic hyperemic gastropathy (with peptic lesions arising in 28,6%) when HP+ CagA+ infection is not eradicated, unlike the progressive improvement of the anatomoclinical condition in the patients whose infection was eradicated, draws attention to the relevance of eradicating HP in CagA+ patients even when no peptic lesion is found at initial endoscopy.

Absence of abdominal pain in older persons with endoscopic ulcers: a prospective study

OBJECTIVE

In a retrospective study we reported absence of abdominal pain in 35% of elderly patients with peptic ulcer disease. We now report a prospective study on this question.

METHODS

Patients undergoing upper GI endoscopy were systematically questioned before endoscopy. A reproducible method for identifying the location of symptoms was used. Among patients referred for upper endoscopy, there was no selection of patients for study purposes as all had strong indications, such as pain, dyspepsia, GI bleeding, weight loss, or anemia. Patients were divided into two groups according to age: A younger group consisting of patients <50 yr (mean, 33.6 yr) and an older group >60 yr (mean, 70.9 yr).

RESULTS

A total of 277 patients were included in the study. There was no significant difference in reported use of medications, alcohol, or cigarette use between the groups. Of the 106 patients with peptic ulcer, 15 (14.2%) had not experienced pain. Abdominal pain was absent in 5 (6.9%) of the younger patients and 10 (29.4%) of the older patients. The difference was significant using the chi2 method (p = 0.004). A trend toward an even higher proportion of pain-free peptic ulcer disease was noted in the elderly female group (37.5%), but it did not reach statistical significance.

CONCLUSIONS

Absence of abdominal pain is confirmed in approximately 30% of elderly patients with peptic ulcer disease.

Genetic factors in the development of gastric precancerous lesions--a role of Helicobacter pylori ?

Helicobacter pylori is believed to predispose to gastric cancer by inducing gastric precancerous alterations. There is a well known predisposition to gastric cancer and the risk of developing it is greater in relatives of patients with familial cases of this malignancy. The aim of this study was to determine the prevalence of gastric precancerous lesions (atrophy and intestinal metaplasia) and their association with Hp infection in first-degree relatives in patients with noncardia gastric cancer.

METHODS

Hp status and gastric histology assessed by upper gastrointestinal endoscopy, biopsies from the antral and body region, the rapid urease test and staining for Hp, inflammation, activity, atrophy and intestinal metaplasia (prevalence and grading) were studied in 108 first-degree relatives of patients with noncardia gastric cancer and compared with 73 controls with mild non-ulcer dyspepsia who had no cancer relatives and were examined in the same way.

RESULTS

subjects with and without cancer relatives had a similar prevalence of Hp infection (49 vs. 47%). Endoscopy revealed a few asymptomatic duodenal ulcers and small hiatus hernias in Hp positive subjects of both groups. Hp positive relatives of gastric cancer had a markedly higher prevalence of atrophy than those with Hp negativity without cancer relatives (29 vs. 9%) and those with Hp negativity and cancer relatives (29 vs. 3%. Prevalence of intestinal metaplasia was also higher in those with Hp positivity and cancer relatives than in those without cancer relatives (15 vs. 5% and was not present in Hp negative subjects with cancer relatives. Inflammation and activity showed similar scores in subjects with and without cancer relatives with higher scores in both Hp positive groups. The prevalence of precancerous lesions in the relatives of gastric cancer was nearly always confined to those with Hp positivity. One year after eradication the prevalence of atrophy in cancer relatives decreased from 29 to 14%; prevalence of intestinal metaplasia remained without substantial changes. Scores for inflammation and activity were also lower after eradication.

CONCLUSIONS

First-degree relatives of patients with gastric cancer have an increased prevalence of gastric precancerous abnormalities which are strongly confined to those with Hp infection. Eradication of Hp in these subjects with cancer relatives reduces the prevalence of precancerous lesions (atrophy) and grades of inflammation and activity. In view of these results, eradication of Hp should be offered to such subjects.

One year follow-up of patients after successful helicobacter pylori eradication therapy

The aim of this study was to investigate the Helicobacter pylori (Hp) status of patients who underwent successful eradication therapy 1 year prior to the study and to evaluate their current symptoms.

METHODS

all of the patients were initially evaluated by oesophago-gastro-bulboscopy and the Hp status was determined by at least two different methods [rapid urease test, histology or urea breath test (UBT)]. The Hp infection was treated with a 1-week triple therapy protocol, and the UBT was repeated 4-6 weeks later. We invited back 110 patients who had negative post-eradication UBT results 12+/-3 months prior to the study period. UBT was repeated and a questionnaire was completed about the previous and present complaints and medication.

RESULTS

80 of the 110 patients (73%) came back for the follow-up. Twenty five patients had peptic ulcer disease, 36 patients had gastritis or duodenitis without erosive lesions, and 19 patients had erosive form of gastritis or duodenitis initially. All of the patients except one in the erosive gastritis group had negative control UBT 1 year after the eradication, which means 1.25% recurrence rate within 1 year. The eradication therapy completely revealed the symptoms of 16 patients in the ulcer group (64%), 13 patients in the gastroduodenitis group (36%, P=0.03 vs. ulcer patients), 10 patients with erosive gastroduodenitis (52%), but this was only temporary. One year after the eradication therapy seven of the ulcer patients (28%), 11 patients with gastroduodenitis (31%) and seven patients with erosive gastroduodenitis (37%) were symptom-free. Most of the patients had epigastric pain (44%), heartburn (43%) and/or abdominal distension (33%). Nine ulcer patients (36%), 10 patients with gastroduodenitis (28%) and five patients with erosive gastroduodenitis (26%) were taking H(2)-blockers regularly.

CONCLUSION

the 1-month post-eradication UBT was probable true negative in all of the evaluated cases, since 79 patients (98.75%) were also negative after 1 year. The Hp recurrence rate is very low (1.25%) in a 1-year period. The symptoms were relieved shortly after eradication therapy in the majority of patients with ulcer disease or erosive lesions. However, significantly smaller portion of the patients with gastroduodenitis became symptom-free. Only about one third of the treated patients remained symptom-free 1 year after the eradication.

[High eradication rates in Helicobacter pylori infection in patients with duodenal ulcer who failed previous eradication therapy]

BACKGROUND

To analyze the effectiveness of a second-line treatment of Helicobacter pylori infection in patients with duodenal ulcer based on previous antibiotic regimen.

PATIENTS AND METHODS

Open, prospective, uncontrolled study, but guided by protocol including 30 consecutive patients with endoscopic diagnosis of active duodenal ulcer and failure of a first-line H. pylori eradication treatment diagnosed by urea breath test or a new endoscopy with histology and positive urease test. Treatment consisted in 10 days with omeprazole (20 mg/12 h), bismuth subcitrate (120 mg/6 h), tetracycline (500 mg/6 h) and metronidazole (500 mg/8 h) (OBTM) if previous regimen was with clarithromycin; or 10 days with omeprazole (20 mg/12 h), clarithromycin (500 mg/12 h) and amoxycillin (1g/12 h) (OCA) if previous regimen did not include clarithromycin; using metronidazole (500 mg/8 h) instead of amoxycillin (OCM) in case of allergy. Eradication was defined as a negative 13C-urea breath test 2 months after the end of therapy.

RESULTS

One patient had to stop treatment due to the side effects and in 2 patients urea breath test was not performed (3 patients due to the OBTM group). Per protocol eradication was achieved in 25 out of 27 patients (92.6%) and by intention-to-treat eradication was attained in 25 out of 30 cases (83.3%). When both groups analyzed separately, the OCA combination was successful in 5 from 6 patients (83.3%; 95% CI 35.9-99.6); while the OBTM combination was successful in 20 from 21 valuable patients (95. 2%; 95% CI 76.2-99.9). In this second case we make an intention to treat analysis and eradication was achieved in 20 from 24 (83.3%; 95% CI 62.6-95.3).

CONCLUSION

The eradicative treatment for H. pylori based in different antibiotics used in subsequent attempts get high eradication rates in patients with duodenal ulcer.

[Helicobacter pylori and stomach cancer]

A number of epidemiological studies and summaries of such studies in the form of meta-analyses have shown a significant relationship between Helicobacter pylori infections of the gastric mucosa and the incidence of gastric cancer. The risk of developing stomach cancer is on average six times higher in the presence of H.p. In countries such as Austria, some 1% of H.p. positives develop gastric cancer in the course of their lives, while only one per 750 noninfected individuals do so. The molecular basis is unclear, but a defect in the tumor-suppressor gene p53 seems to play an important role. As H.p. infection is common (some 30% of the total population in Austria is infected) and gastric cancer without H.p. eradication has become less common (in 1997 there were 24 new cases per 100,000 population), H.p. eradication is not advised as prophylaxis for gastric cancer. Patients who have a positive family history of gastric cancer and those who have had surgery for gastric cancer should, however, according to the Maastricht recommendations, undergo eradication. An example is given to show that in comparison with other measures for cancer screening or prevention, the cost of 120,000 ATS per prevented gastric cancer would be a very good investment with general eradication of H.p. in all individuals over 50 years of age.

Latin American open-label study with rabeprazole in patients with functional dyspepsia. Mexican Rabeprazole Investigators Group

This multicenter, open-label study assessed the clinical efficacy and tolerability of the proton-pump inhibitor rabeprazole 20 mg once daily in 189 patients with functional dyspepsia and normal findings on upper endoscopy. The clinical efficacy rate was 86% after only 4 weeks of treatment, and symptoms remained under control at the end of 4 weeks without treatment. Rabeprazole was well tolerated and was associated with a low incidence (8%) of mild, transient adverse events.

A meta-analysis of short versus long therapy with a proton pump inhibitor, clarithromycin and either metronidazole or amoxycillin for treating Helicobacter pylori infection

BACKGROUND

Although triple therapies with a proton pump inhibitor, clarithromycin and either amoxycillin or metronidazole are the most widely accepted treatment for Helicobacter pylori infection, there is no consensus on how long treatment should be maintained for.

AIM

To evaluate whether increasing the length of triple therapies beyond 7 days improves treatment efficacy.

METHODS

An extensive search of the literature was performed. Reports of randomized trials comparing different lengths of therapy were selected. Short (7-day) vs. long (10/14-day) therapies were compared, and three-way comparison of 7-day vs. 10-day, 10-day vs. 14-day and 7-day vs. 14-day therapies was performed. Meta-analysis was conducted using conventional shareware (Review Manager 4.0). The Peto Odds Ratio using a fixed model analysis was calculated for each comparison.

RESULTS

Thirteen studies were identified. Pooled 10- to 14-day therapies achieved better results than 7-day schedules. In head-to-head comparisons, only 14-day therapies were significantly better than 7-day treatments. Improvement in cure rates ranged from 7 to 9%. Comparisons of 7-day vs. 10-day and 10-day vs. 14-day also showed a non-significant trend towards better cure rates with longer therapies.

CONCLUSIONS

Fourteen-day, proton pump inhibitor-based triple therapy achieves better results than 7-day schedules. Additional data are necessary to evaluate 10-day therapies.

Pharmacokinetic interaction between proton pump inhibitors and roxithromycin in volunteers

BACKGROUND

Triple therapy including two antibiotics and a proton pump inhibitor is a rational approach to the treatment of Helicobacter pylori induced peptic ulcer disease. The interaction of antimicrobial therapy and acid suppression is not yet well elucidated.

AIMS

To investigate the effects of proton pump inhibitors on roxithromycin levels in plasma and gastric tissue under steady-state conditions in volunteers.

METHODS

In two crossover studies omeprazole 20 mg b.d., lansoprazole 30 mg b.d., roxithromycin 300 mg b.d., and the combination of roxithromycin with either omeprazole or lansoprazole were administered to 12 healthy volunteers over 6 days. Blood plasma levels of the drugs were measured. In addition, roxithromycin concentrations were also determined in gastric juice and gastric tissue obtained during endoscopy.

RESULTS

The proton pump inhibitors and roxithromycin did not alter the blood plasma pharmacokinetics of each other. When compared to roxithromycin administered alone, its combination with a proton pump inhibitor significantly increased the roxithromycin concentrations in gastric juice (3.0-5.0 microg/mL vs. 0.3-0.4 microg/mL) and gastric tissue (antrum: 3.8-4.0 vs. 2.8 microg/g, fundus: 5.9-7.4 vs. 4.2-4.4 microg/g).

CONCLUSIONS

Proton pump inhibitors and roxithromycin do not alter the systemic bioavailability of each other. However, proton pump inhibitors increase the local concentration of roxithromycin in the stomach which may contribute to the clinically proven synergic beneficial action in eradication therapy of H. pylori.

Matrix metalloproteinase expression in cultured human gastric wall fibroblasts--interactions with Helicobacter pylori isolated from patients with ulcers

BACKGROUND

Matrix metalloproteinases (MMPs), enzymes capable of degrading collagens and other extracellular matrix components, have been implicated in gastric ulcer formation. However, the effect on MMP expression of Helicobacter pylori, also implicated in these lesions, has not been studied to our knowledge.

AIM

To seek links between H. pylori and MMP expression likely to affect gastric ulcer formation. After fibroblasts from human gastric wall were cocultured with H. pylori. concentrations of MMP-1 and -2 in the medium were determined by enzyme-linked immunosorbent assays.

RESULTS

Whereas MMP-1 was not detected in media from fibroblasts or H. pylori culture alone, MMP-1 was detected in cocultures (P<0.01). Similar amounts of MMP-2 were detected in medium from fibroblasts cultured alone and with H. pylori. No MMP-2 production by H. pylori cultured alone was detected.

CONCLUSIONS

MMP-1 appears to be important in gastric ulcer pathogenesis, and MMP-1 induction by H. pylori may impede gastric ulcer healing.

Effect of ornidazole and clarithromycin resistance on eradication of Helicobacter pylori in peptic ulcer disease

BACKGROUND

Clarithromycin and nitroimidazoles such as metronidazole and ornidazole are among the most frequently used antibiotics for curing Helicobacter pylori infection. However, controversial data exist on whether their in vitro resistance has a negative impact on treatment outcome.

METHODS

Patients with H. pylori positive active peptic ulcer disease were randomly assigned to receive lansoprazole 30 mg o.d., amoxycillin 1 g b.d. and ornidazole 500 mg b.d. (LAO) or lansoprazole 30 mg o.d., amoxycillin 1 g b.d. and clarithromycin 500 mg b.d. (LAC) for 2 weeks. Pre-treatment resistance to ornidazole and clarithromycin was assessed by Epsilometer (E-) test. Four weeks after completion of treatment, patients underwent a 13C urea breath test to assess H. pylori status.

RESULTS

Data from 80 patients with active peptic ulcer disease and positive H. pylori status were analysed. The prevalence of primary drug resistance was 25% for metronidazole and 7.5% for clarithromycin. In patients treated with LAO, effective treatment was achieved in 87% of metronidazole-susceptible, but only 30% of metronidazole-resistant strains (P < 0.01). In the LAC group, therapy was successful in 81% of clarithromycin-susceptible strains, whereas treatment failed in all patients with primary clarithromycin resistance (n = 3).

CONCLUSION

Resistance against nitroimidazoles significantly affects treatment outcome in H. pylori eradication therapy.

Four-day, twice daily, quadruple therapy with amoxicillin, clarithromycin, tinidazole and omeprazole to cure Helicobacter pylori infection: a pilot study

BACKGROUND

The best regimen for the treatment of Helicobacter pylori infection has yet to be defined. Four-day quadruple therapy with tetracycline, metronidazole, bismuth, and a proton pump inhibitor has been shown to obtain a very high cure rate. However, the fact that it must be taken four times daily may interfere with compliance. The objective of the study was to test the efficacy and tolerability of a new 4-day therapy with 4 drugs taken every 12 hours to cure H. pylori infection. Patients and Methods. Fifty-six consecutive patients with peptic ulcer disease and H. pylori infection were treated with an oral 4-day course with omeprazole (20 mg/12 hours), clarithromycin (500 mg/12 hours), amoxicillin (1 g/12 hours) and tinidazole (500 mg/12 hours). Efficacy of the treatment was determined at least 2 months after therapy either by biopsy (in the case of gastric ulcer) or by 13C-urea breath test. A second breath test was performed at least 6 months after therapy.

RESULTS

Two patients were lost to follow-up. Forty-nine of the remaining 54 patients were cured at the first control [intention-to-treat cure rate: 87.5% (CI 95% 75-94%); per protocol cure rate: 90.7% (CI 95% 81-98%)]. Forty-three of these 49 cured patients returned for a second 13C urea breath-test at 6-12 months. Two of them were not cured, giving a long-term cure rate of 85.5% per protocol and 73.2% by intention-to-treat. Compliance was good, although 25 patients had mild side effects.

CONCLUSION

This particular four-day therapy is well tolerated, easy to follow, and achieves an acceptably high cure rate.

Absence of benefit of eradicating Helicobacter pylori in patients with nonulcer dyspepsia

BACKGROUND

The relation between Helicobacter pylori infection and nonulcer dyspepsia is uncertain. We tested the hypothesis that curing the infection will relieve symptoms of dyspepsia.

METHODS

We randomly assigned 170 H. pylori-infected patients with nonulcer dyspepsia to receive twice-daily treatment with 20 mg of omeprazole, 1000 mg of amoxicillin, and 500 mg of clarithromycin for 14 days and 167 such patients to receive identical-appearing placebos; all patients were then followed through regular visits for 12 months. Symptoms were scored on diary cards for seven days before each visit. A carbon-13 urea breath test was performed at base line and repeated at 1 and 12 months, and endoscopic biopsy was performed at 12 months to determine H. pylori status. Treatment was considered successful if the patient had only mild pain or discomfort or none at all.

RESULTS

The rate of eradication of H. pylori infection was 90 percent in the active-treatment group and 2 percent in the placebo group at four to six weeks (P<0.001). At 12 months, there was no significant difference between groups in the rate of successful treatment (46 percent in the active-treatment group and 50 percent in the placebo group; relative likelihood of success with active treatment, 0.93; 95 percent confidence interval, 0.73 to 1.18; P=0.56). There was also no significant difference in the rate of successful treatment at 12 months between patients who were H. pylori-negative and those who were H. pylori-positive (48 percent vs. 49 percent). The rates of successful treatment were also similar when patients were analyzed according to the type of dyspepsia (ulcer-like, reflux-like, or dysmotility-like) and changes in the quality of life. There was no significant association between treatment success and histologic improvement in chronic gastritis at 12 months (P=0.68).

CONCLUSIONS

We found no evidence that curing H. pylori infection in patients with nonulcer dyspepsia leads to relief of symptoms.

Seven-day 'rescue' therapy after Helicobacter pylori treatment failure: omeprazole, bismuth, tetracycline and metronidazole vs. ranitidine bismuth citrate, tetracycline and metronidazole

BACKGROUND

Eradication therapy with omeprazole (O), amoxycillin (A) and clarithromycin (C) is used extensively, although it often fails. A 'rescue' therapy with a quadruple combination of O, bismuth (B), tetracycline (T) and metronidazole (M) has been recommended.

AIM

: To assess ranitidine bismuth citrate (Rbc) instead of O and B for treatment failure.

METHODS

Sixty consecutive patients (13 duodenal ulcer, 47 non-ulcer dyspepsia) in whom a previous eradication trial with O, A and C had failed were randomized to receive one of two regimens for 7 days: O (20 mg b.d.), B (120 mg q. d.s.), T (500 mg q.d.s.) and M (250 mg q.d.s.) (group OBTM, n=30); or Rbc (400 mg b.d.), T (500 mg q.d.s.) and M (250 mg q.d.s.) (group RbcTM, n=30). Eradication was defined as a negative 13C-urea breath test 1 month after completing therapy.

RESULTS

Mean age +/- s.d. was 45 +/- 12 years, 47% were males. Distribution of studied variables (age, sex, smoking, duodenal ulcer/non-ulcer dyspepsia) was similar in both therapeutic groups. Per protocol eradication was achieved in 17 out of 29 patients (59%) in group OBTM and in 25 out of 29 patients (86%) in group RbcTM (P < 0.05). Intention-to-treat eradication was achieved, respectively, in 17 out of 30 (57%) and in 25 out of 30 (83%) (P < 0.05). In the multivariate analysis the variables which influenced on H. pylori eradication were the type of therapy (odds ratio, OR=3.9; 95%CI: 1.02-15; P < 0.05) and diagnosis (duodenal ulcer/non-ulcer dyspepsia) (OR=0.1; CI: 0.02-0.4). Adverse effects were infrequent and mild with both regimens.

CONCLUSION

Therapy with RbcTM is a promising option after H. pylori eradication failure with OCA, achieving a higher efficacy than quadruple therapy with OBTM.

Efficacy of omeprazole plus two antimicrobials for the eradication of Helicobacter pylori in a Turkish population

Omeprazole combined with 2 antimicrobials has been suggested as a first-line option for Helicobacter pylori eradication in recent years. However, controversy exists regarding the efficacy of this protocol. This open-label, prospective clinical study investigated the efficacy of omeprazole-based triple therapy for H pylori eradication in 518 patients with H pylori-positive functional dyspepsia with or without duodenal ulcer. Amoxicillin, macrolides (clarithromycin or roxithromycin), and nitroimidazoles (metronidazole, ornidazole, or tinidazole) were the antibiotics used in the study. Nonulcer patients were randomly assigned to 1 of 8 different treatment protocols and duodenal ulcer patients were randomly assigned to 1 of 4 different treatment protocols consisting of omeprazole (20 mg once daily for nonulcer patients, 20 mg twice daily for ulcer patients for 14 days) with a combination of 2 of the above antimicrobials (for 10 days). H pylori infection was assessed by histologic findings and a rapid urease test before therapy and 4 weeks after therapy ended. Four hundred fifty-nine patients completed their regimens; 327 had functional dyspepsia (180 men, 147 women; median age, 39 years; range, 18 to 70 years) and 132 had ulcers (81 men, 51 women; median age, 40 years; range, 18 to 70 years). Eradication of H pylori was achieved in 58.8% (270 of 459) of all patients, 58.1% (190 of 327) of nonulcer dyspeptic patients, and 60.6% (80 of 132) of duodenal ulcer patients. The eradication rate varied from 47.2% to 69.4% in different treatment protocols. There were no statistically significant differences in eradication rates in any treatment group. All drugs were generally well tolerated in all groups, and no patient discontinued treatment because of side effects. Therapy with omeprazole and 2 antimicrobials for H pylori had limited efficacy in a Turkish population. The reason for these results, which conflict with those of other studies, is not clear. Further investigations of regimens for the eradication of H pylori in our population are necessary.

Management of uninvestigated and functional dyspepsia: a Working Party report for the World Congresses of Gastroenterology 1998

BACKGROUND

The management of dyspepsia is controversial.

METHODS

An international Working Party was convened in 1998 to review management strategies for dyspepsia and functional dyspepsia, based on a review of the literature and best clinical practice.

RESULTS

Dyspepsia, defined as pain or discomfort centred in the upper abdomen, can be managed with reassurance and over-the-counter therapy if its duration is less than 4 weeks on initial presentation. For patients with chronic symptoms, clinical evaluation depends on alarm features including patient age. The age cut off selected should depend on the age specific incidence when gastric cancer begins to increase, but in Western nations 50 years is generally an acceptable age threshold. In younger patients without alarm features, Helicobacter pylori test and treatment is the approach recommended because of its value in eliminating the peptic ulcer disease diathesis. If, after eradication of H. pylori, symptoms either are not relieved or rapidly recur, then an empirical trial of therapy is recommended. Similarly, in H. pylori-negative patients without alarm features, an empirical trial (with antisecretory or prokinetic therapy depending on the predominant symptom) for up to 8 weeks is recommended. If drugs fail, endoscopy should be considered because of its reassurance value although the yield will be low. In older patients or those with alarm features, prompt endoscopy is recommended. If endoscopy is non-diagnostic, gastric biopsies are recommended to document H. pylori status unless already known. While treatment of H. pylori is unlikely to relieve the symptoms of functional dyspepsia, the long-term benefits probably outweigh the risks and treatment can be considered on a case-by-case basis. In H. pylori-negative patients with documented functional dyspepsia, antisecretory or prokinetic therapy, depending on the predominant symptom, is reasonable, assuming reassurance and explanation are insufficient, unless patients have already failed this approach. Other treatment options include antidepressants, antispasmodics, visceral analgesics such as serotonin type 3 receptor antagonists, and behavioural or psychotherapy although these are all of uncertain efficacy. Long-term drug treatment in functional dyspepsia should be avoided; intermittent short courses of treatment as needed is preferred.

CONCLUSION

The management of dyspepsia recommended is based on current best evidence but must be tailored to local factors such as practice setting, the background prevalence of H. pylori and structural disease, and costs.

Familial clustering of Helicobacter pylori infection: population based study

OBJECTIVES

To assess the rate of intrafamilial transmission of Helicobacter pylori infection in the general population and the role of a family's social background.

DESIGN

Population survey.

SETTING

Campogalliano, a town in northern Italy with about 5000 residents.

PARTICIPANTS

3289 residents, accounting for 416 families.

MAIN OUTCOME MEASURES

Prevalence of H pylori infection assessed by presence of IgG antibodies to H pylori.

RESULTS

The overall prevalence of H pylori infection was 58%. Children belonging to families with both parents infected had a significantly higher prevalence of H pylori infection (44%) than children from families with only one (30%) or no parents (21%) infected (P<0.001). Multivariate analyses confirmed that children with both parents positive had double the risk of being infected by H pylori than those from families in which both parents were negative. Family social status was independently related to infection in children, with those from blue collar or farming families showing an increased risk of infection compared with children of white collars workers (odds ratio 2.02, 95% confidence interval 1.16 to 3.49).

CONCLUSIONS

H pylori infection clusters within families belonging to the same population. Social status may also be a risk factor. This suggests either a person to person transmission or a common source of exposure for H pylori infection.

A practical approach to patients with refractory Helicobacter pylori infection, or who are re-infected after standard therapy

The vast majority of recurrences of Helicobacter pylori infection after apparent eradication are observed during the first year. Almost all of these early recurrences are due to recrudescence rather than reinfection by a new strain. After the first year, the recurrence rates approximate to the rate of natural acquisition of H. pylori infection. By contrast, in developing countries, higher rates of recurrence suggest a major role of real reinfection. Important predictive factors of H. pylori treatment success are compliance and bacterial susceptibility to antibiotics. The new 1-week triple therapies, based on a proton pump inhibitor (PPI) and 2 antibiotics, lead to treatment discontinuation but rarely. If containing a nitroimidazole, their efficacy is reduced to 60 to 80% by pretreatment in vitro resistance. The prevalence of nitroimidazole resistance varies dependent on the geographical area, with rates over 50% in tropical regions. Resistance against macrolides hinders treatment success in 50 to 80% of patients. In the US, south-western Europe and Japan the prevalence of macrolide resistance amounts to about 10%, in other countries about 3%. After failed treatment, acquired resistance is frequent. Testing for resistance is recommended to facilitate the decision for an alternative triple therapy or for quadruple therapy comprising bismuth, metronidazole, tetracycline and a PPI. It seems reasonable to increase the dose of PPI in a retreatment regimen containing amoxicillin. Post-treatment double resistance against nitroimidazoles and macrolides reduces the success of most of the currently evaluated retreatment regimens. To overcome double resistance, high dose PPI plus amoxicillin is one approach, beside other experimental multidrug treatments.

Susceptibility in vitro of Helicobacter pylori to cetylpyridinium chloride

The antimicrobial agent cetylpyridinium chloride (CPC) which is used in therapy of oro-pharyngeal infections and for antiseptic treatment of the oral cavity is active against different bacterial species. Determination of the minimal inhibitory concentration (MIC) using the agar dilution technique revealed that the gastric pathogen Helicobacter pylori in vitro is highly susceptible to CPC as indicated by an MIC of 10 microM (3.4 microg ml(-1)) which was significantly lower than the MIC of CPC against other bacterial species, which were analyzed in comparison to H. pylori. Bacteria of the genus Campylobacter, various Streptococcus spp., Staphylococcus aureus and Escherichia coli showed higher MICs ranging from 100 microM to 2 mM. In summary, this finding renders CPC-containing drugs candidates possibly useful for eradication or for the prevention of transmission of the gastric pathogen.

The optimal antibiotic combination in a 5-day Helicobacter pylori eradication regimen

BACKGROUND

Current guidelines for Helicobacter pylori eradication recommend 7 days of a proton-pump inhibitor, clarithromycin (C), and either metronidazole (M) or amoxycillin (A). A shorter course would be cheaper and could be as effective.

AIM

This study was designed to investigate the efficacy of three 5-day regimens based on lansoprazole (L).

METHODS

168 dyspepsia patients with H. pylori infection were randomized to receive a 5-day course of either LCM, LAC or CALM, and a 13C-urea breath test was performed after 4 weeks to assess eradication.

RESULTS

160 patients completed the study. Intention-to-treat eradication rates were as follows: LCM 81%, LAC 59%, CALM 88%. LCM and CALM gave significantly better eradication rates than LAC. There was no significant difference in adverse events across the three groups. Logistical regression analysis showed that the specific regimen used and the age of the patient were the only factors influencing eradication outcome.

CONCLUSIONS

Five days of CALM yields acceptable eradication rates, and is cheaper than conventional 7-day proton pump inhibitor-triple therapy. It appears to offer good results in metronidazole-resistant strains of H. pylori. A randomized trial comparing 5-day CALM with conventional 7-day therapy is needed before this regimen can be recommended for routine use.

Safety and efficacy of one-week triple therapy for eradicating Helicobacter pylori in children

BACKGROUND

Proton pump inhibitor-based eradication therapy of Helicobacter pylori has been widely studied in adults, but there have been only a few reports about this therapy in children. The purpose of this study was to investigate the safety and efficacy of 1-week triple therapy for eradication of H. pylori and ulcer healing in children.

PATIENTS AND METHODS

We prospectively studied 15 patients aged 2-17 years (5 with gastric ulcers, 8 with duodenal ulcers, and 2 with nodular gastritis alone). Three patients had H2 blocker-resistant duodenal ulcers. Patients received 0.75 mg/kg of lansoprazole b.i.d., 25 mg/kg of amoxicillin b.i.d., and 10 mg/kg of clarithromycin b.i.d. for 7 days. No additional therapy (including antisecretory drugs) was administered to any patients following eradication therapy. Patients underwent endoscopy to obtain antral biopsies (culture, urease test and histology) and to evaluate the mucosal status, and underwent a 13C-urea breath test before and 4-8 weeks after the completion of a 1-week course of therapy.

RESULTS

All patients received the full drug regimen. Endoscopy showed complete healing of ulcers in 12 of 13 patients with peptic ulcer disease (92%). H. pylori was eradicated in 13 of 15 patients (87%). Diarrhea and/or an altered taste sensation occurred in 5 patients (33%). There were no hematological or biochemical abnormalities related to therapy.

CONCLUSION

The 1-week triple therapy was safe and effective for eradicating H. pylori. The present study showed that ulcer healing in juveniles is closely associated with eradication of H. pylori, and that no additional therapy is required when H. pylori is eradicated. A shorter course of eradication therapy than 2 weeks may be suitable for children with H. pylori infection.

Helicobacter pylori reinfection rates in children after eradication therapy

BACKGROUND

There are few studies of Helicobacter pylori reinfection in childhood. In the current study the reinfection rate of H. pylori and ulcer recurrence were investigated during a follow-up period of 12 months or more in children who had undergone eradication therapy.

METHODS

Twenty-seven patients aged 5 to 16 years (6 with gastric ulcer, 13 with duodenal ulcer, and 8 with nodular gastritis) were studied. Biopsy-based H. pylori tests performed 1 to 2 months after eradication therapy demonstrated that eradication was successful in 23 patients (5 with gastric ulcer, 11 with duodenal ulcer, and 7 with nodular gastritis) and unsuccessful in 4 (1 with gastric ulcer, 2 with duodenal ulcer, and 1 with nodular gastritis). Twenty-three successfully treated patients were observed for a mean of 22 months (a total of 42.2 patient years of follow-up). To assess H. pylori status, all 23 patients underwent a 13C-urea breath test 1 year after eradication therapy. If the test result was negative, the patients underwent the follow-up test once every year thereafter. In successfully and unsuccessfully treated patients, endoscopy was performed if a patient reported symptoms suggesting ulcer recurrence.

RESULTS

The initial follow-up 13C-urea breath tests showed that all 23 patients remained free of infection at 12 to 19 months. Among 17 patients, the second test confirmed reinfection in 1 at 28 months. In two patients studied, the third test showed a negative result. The reinfection rate was 2.4% per patient year. Over the follow-up period, ulcer recurrence was found in 2 of 3 ulcer patients with eradication failure but in none of the 16 ulcer patients with successful eradication. The recurrence rate was significantly lower in successfully treated patients than in unsuccessfully treated patients (p < 0.05).

CONCLUSIONS

Reinfection with H. pylori is rare in children aged more than 5 years, and successful eradication significantly reduces ulcer recurrence. This study supports the benefit of eradication therapy in older children.

One-week treatment with omeprazole, clarithromycin, and metronidazole in children with Helicobacter pylori infection

BACKGROUND

The efficacy of a 1-week "triple therapy" in children with Helicobacter pylori gastritis and recurrent abdominal pain was studied. The effect of treatment was also studied in correlation to recurrent abdominal pain.

METHODS

Thirty-two children with recurrent abdominal pain were investigated with H. pylori serology, 13C-urea breath test, and endoscopy. Gastric biopsy specimens were analyzed with a rapid urease test and histopathology. H. pylori-positive children were treated with omeprazole, clarithromycin, and metronidazole for 7 days. The same treatment was repeated for 2 weeks if a urea breath test produced positive results 1 month after the treatment period. If the test results were still positive after treatment, a second endoscopy was performed with culture.

RESULTS

Twenty-eight (87.5%) children were urea breath test-negative at follow-up 4 weeks (range, 4-15) after treatment. Another child became H. pylori-negative after a second treatment course. Two of the three children who were still positive after the two treatment periods, showed resistance to metronidazole and clarithromycin.

CONCLUSIONS

One-week therapy with omeprazole, clarithromycin and metronidazole is an effective treatment in children with H. pylori infection. Bacterial resistance to clarithromycin and metronidazole must be monitored if treatment fails.

Low Grade MALToma and Early Cancer of the Stomach in a Patient with Helicobacter pylori Infection: A Case Report

A causal relationship has been suggested between Helicobacter pylori infection and gastric malignancy, including both gastric cancer and low grade lymphoma of mucosa-associated lymphoid tissue (MALToma). We describe a rare case of simultaneous occurrence of low grade MALToma and early cancer of the stomach in a 72-year-old woman. In this patient, low grade MALToma not only had preceded gastric cancer by 5 years, but had also disappeared, and subsequently reappeared coexisting with early cancer of the stomach and Helicobacter pylori infection. Eradication therapy for Helicobacter pylori was performed immediately prior to subtotal gastrectomy for early gastric cancer of the pyloric area. Thereafter, regression of MALToma was observed. These results, taken together with a previously reported case of low grade MALToma, suggest that low grade MALToma of the stomach may fluctuate, at least in the initial stages, even in the presence of constant Helicobacter pylori infection.

How should new-onset dyspepsia be managed in general and specialist practice?

Managing patients with new-onset dyspeptic symptoms represents a real challenge in clinical decision-making. The major controversy has been over the optimal management strategy of patients with new-onset dyspeptic symptoms who do not present with alarm symptoms. Since unaided clinical diagnosis is unreliable, proposed management strategies have included empirical treatment algorithms, computer-assisted predictive score models and Helicobacter pylori-based strategies such as test-and-scope or test-and-treat algorithms. Endoscopy remains the diagnostic 'gold standard', and the management should ideally be based on endoscopic diagnosis. Because of economic constraints and increasing waiting lists, this is not possible. When precise and comprehensive guidelines have been formulated, future patients will probably be managed in primary care by a Helicobacter test-and-treat policy, leaving only empirical treatment failures for specialist evaluation.