Helicobacter pylori and symptomatic relapse of gastro-oesophageal reflux disease: a randomised controlled trial

Microbiota profiling in esophageal diseases: Novel insights into molecular staining and clinical outcomes

Gut microbiota is recognized nowadays as one of the key players in the development of several gastro-intestinal diseases. The first studies focused mainly on healthy subjects with staining of main bacterial species via culture-based techniques. Subsequently, lots of studies tried to focus on principal esophageal disease enlarged the knowledge on esophageal microbial environment and its role in pathogenesis. Gastro Esophageal Reflux Disease (GERD), the most widespread esophageal condition, seems related to a certain degree of mucosal inflammation, via interleukin (IL) 8 potentially enhanced by bacterial components, lipopolysaccharide (LPS) above all. Gram- bacteria, producing LPS), such as Campylobacter genus, have been found associated with GERD. Barrett esophagus (BE) seems characterized by a Gram- and microaerophils-shaped microbiota. Esophageal cancer (EC) development leads to an overturn in the esophageal environment with the shift from an oral-like microbiome to a prevalently low-abundant and low-diverse Gram--shaped microbiome. Although underinvestigated, also changes in the esophageal microbiome are associated with rare chronic inflammatory or neuropathic disease pathogenesis. The paucity of knowledge about the microbiota-driven mechanisms in esophageal disease pathogenesis is mainly due to the scarce sensitivity of sequencing technology and culture methods applied so far to study commensals in the esophagus. However, the recent advances in molecular techniques, especially with the advent of non-culture-based genomic sequencing tools and the implementation of multi-omics approaches, have revolutionized the microbiome field, with promises of implementing the current knowledge, discovering more mechanisms underneath, and giving insights into the development of novel therapies aimed to re-establish the microbial equilibrium for ameliorating esophageal diseases..

Costs of Cancer Prevention: Physical and Psychosocial Sequelae of Risk-Reducing Total Gastrectomy

PURPOSE

Risk-reducing surgery for cancer prevention in solid tumors is a pressing clinical topic because of the increasing availability of germline genetic testing. We examined the short- and long-term outcomes of risk-reducing total gastrectomy (RRTG) and its lesser-known impacts on health-related quality of life (QOL) in individuals with hereditary diffuse gastric cancer syndrome.

METHODS

Individuals who underwent RRTG as part of a single-institution natural history study of hereditary gastric cancers were examined. Clinicopathologic details, acute and chronic operative morbidity, and health-related QOL were assessed. Validated questionnaires were used to determine QOL scores and psycho-social-spiritual measures of healing.

RESULTS

One hundred twenty-six individuals underwent RRTG because of a pathogenic or likely pathogenic germline CDH1 variant between October 2017 and December 2021. Most patients (87.3%; 110/126) had pT1aN0 gastric carcinoma with signet ring cell features on final pathology. Acute (<30 days) postoperative major morbidity was low (5.6%; 7/126) and nearly all patients (98.4%) lost weight after total gastrectomy. At 2 years after gastrectomy, 94% (64/68) of patients exhibited at least one chronic complication (ie, bile reflux, dysphagia, and micronutrient deficiency). Occupation change (23.5%), divorce (3%), and alcohol dependence (1.5%) were life-altering consequences attributed to total gastrectomy by some patients. In patients with a median follow-up of 24 months, QOL scores decreased at 1 month after gastrectomy and returned to baseline by 6-12 months.

CONCLUSION

RRTG is associated with life-changing adverse events that should be discussed when counseling patients with CDH1 variants about gastric cancer prevention. The risks of cancer-prevention surgery should not only be judged in the context of likelihood of death due to disease if left untreated, but also based on the real consequences of organ removal.

Effect of gastric helicobacter pylori colonization in the development of erosive esophagitis in patients with hiatal hernia

Background/Aims

There may be various factors that determine gastroesophageal reflux disease (GERD) as a result of hiatal hernia (HH) (such as the size of the hernia, age, other host and environmental factors) and the presence of protective factors to explain the absence of reflux disease should not be ignored. Helicobacter pylori (Hp) infection can prevent the development of GERD or cause it. This study aimed to determine whether Hp colonized in the stomach and hernia affects the development of erosive esophagitis (EE) in patients with HH.

Materials and Methods

In this case-controlled study, 111 patients with HH were eligible for the study. Study group with EE (n = 61, 55%) and control group without EE (n = 50, 45%) were formed. Groups were compared for gastric Hp and Hp in the hernia.

Results

While the frequency of Hp in the antrum was 55.7% in the group with EE, it was 30% in the control group (p = 0.01, OR: 2.94 in 95% CI 1.34-6.46). The rates in terms of HP frequency in the corpus were 43.6% and 32.1%, respectively, (p = 0.45). Hp colonization in HH was detected in 18 cases (29.50%) and 14 cases (28%), respectively, (p = 0.86). In regression analysis, antral Hp was found to be effective in the development of EE (p = 0.01).

Conclusion

As a result of this study, we think that antral Hp may have a causative role in the development of reflux esophagitis, but the presence of Hp in HH does not have an effective role in reflux esophagitis formation.

Helicobacter pylori Infection—A Risk Factor for Irritable Bowel Syndrome? An Updated Systematic Review and Meta-Analysis

Nowadays, the relationship between Helicobacter pylori infection (HPI) and irritable bowel syndrome (IBS) remains controversial. Objective: The aim of this study is to investigate the relationship between HPI and IBS through a systematic review and meta-analysis based on the current evidence. Methods: We performed a systematic literature search in electronic databases (PubMed, EMBASE, and the Cochrane library) by computer to identify all reports published before 8 August 2021. The odds ratio (OR) and confidence interval (CI) were calculated to evaluate the association between HPI and IBS. Subgroup analyses were conducted for further assessment and exploration of heterogeneity sources. In addition, we assessed publication bias through funnel plots, Egger’s test, and Begg’s test. Finally, we conducted a sensitivity analysis to evaluate the robustness of the results. Results: Thirteen studies with 13,173 participants were included in the meta-analysis. The pooled OR of the association between HPI and IBS was 1.03 (95% CI [0.80,1.31]; p = 0.84). The adjusted OR of the association between HPI and IBS after excluding the studies with confounding factors defined by our team was 1.29 (95% CI [1.03,1.62]; p = 0.03). We found a positive association between HPI and IBS-D (diarrhea subtype) (OR: 1.54; 95% CI [1.22,1.95]; p = 0.0003). The OR of the relationship between cytotoxin-associated gene A (Cag A) positive HPI and IBS was 4.3 (95% CI [0.51,36.17]; p = 0.18). Conclusions: The likelihood of HPI in IBS patients is relatively higher than that of non-IBS participants but not statistically significant, implying that HPI is not significantly associated with IBS, albeit we may underestimate this association. Moreover, we found a positive association between HPI and IBS-D. We also observed an increased likelihood of Cag-A positive HPI in IBS patients than that of non-IBS participants but not statistically significant.

The association between helicobacter pylori infection and erosive gastroesophageal reflux disease; a cross-sectional study

BACKGROUND

The association between H. pylori (Helicobacter pylori) infection and gastroesophageal reflux disease (GERD) is a complex and confusing subject. The aim of this study was to evaluate the association between helicobacter pylori infection and erosive gastroesophageal reflux disease.

METHOD

In a cross-sectional study, all patients referred for endoscopy due to dyspepsia were enrolled. The diagnosis of erosive GERD was made by endoscopy. Patients with normal esophagus were selected as comparison group. Random gastric biopsies were taken from all participants to diagnose H. pylori infection.

RESULT

In total, 1916 patients were included in this study, of whom 45.6% had GERD. The mean age (SD) was 42.95 (16.32). Overall, 1442 (75.3%) patients were positive for H. pylori infection. The frequency of H. pylori infection in mild GERD patients was higher than the severe GERD, but this difference was not significant (P = 0.214). Except for sociodemographic status (P < 0.001), other variables including gender, age, ethnicity, body mass index (BMI), smoking, and presence of hiatus hernia in patients had no significant association with the frequency of H. pylori infection. According to Robust Poisson regression models analysis, the association of H. pylori (PR 1.026; 95% CI 0.990-1.064; P = 0.158) and sociodemographic status were not significantly different between the two groups. But smoking, increased BMI, older age, presence of hiatus hernia, and peptic ulcer diseases were significantly associated with GERD compared with the non-GERD group.

CONCLUSION

In our results, there was no association between H. pylori infection and erosive GERD. Further studies are recommended.

Management of Helicobacter pylori infection: The Bhubaneswar Consensus Report of the Indian Society of Gastroenterology

The Indian Society of Gastroenterology (ISG) felt the need to organize a consensus on Helicobacter pylori (H. pylori) infection and to update the current management of H. pylori infection; hence, ISG constituted the ISG's Task Force on Helicobacter pylori. The Task Force on H. pylori undertook an exercise to produce consensus statements on H. pylori infection. Twenty-five experts from different parts of India, including gastroenterologists, pathologists, surgeons, epidemiologists, pediatricians, and microbiologists participated in the meeting. The participants were allocated to one of following sections for the meeting: Epidemiology of H. pylori infection in India and H. pylori associated conditions; diagnosis; treatment and retreatment; H. pylori and gastric cancer, and H. pylori prevention/public health. Each group reviewed all published literature on H. pylori infection with special reference to the Indian scenario and prepared appropriate statements on different aspects for voting and consensus development. This consensus, which was produced through a modified Delphi process including two rounds of face-to-face meetings, reflects our current understanding and recommendations for the diagnosis and management of H. pylori infection. These consensus should serve as a reference for not only guiding treatment of H. pylori infection but also to guide future research on the subject.

Risk of Reflux-Related Symptoms and Reflux Esophagitis after Helicobacter pylori Eradication Treatment in the Japanese Population

Backgrounds: A meta-analysis of reports primarily from Western countries showed no association between Helicobacter pylori eradication and reflux esophagitis development. The risk of reflux esophagitis may differ among different populations based on H. pylori virulence factors and acid secretion ability. We evaluated the prevalence rates of reflux esophagitis in H.-pylori-positive Japanese subjects and assessed risk factors for reflux esophagitis after eradication. Methods: Among 148 H.-pylori-positive subjects who underwent H. pylori eradication from August 2015 to December 2019, we evaluated the prevalence of reflux esophagitis on endoscopy at 12 months after eradication success and the severity of reflux-related symptoms by the F-scale questionnaire at 2 months after treatment and 12 months after eradication success. Results: The prevalence of reflux esophagitis in H.-pylori-positive patients at entry was 2.0% (3/148). At 12 months after eradication success, the prevalence was 10.8% (16/148) (p < 0.01). In the F scale, the median total score before treatment was 4 (range: 0–49), which significantly decreased to 2 (range: 0–22) (p < 0.01) at 2 months after treatment and 3 (range: 0–23) (p < 0.01) at 12 months after eradication success. Following multivariate analysis, the pretreatment total F-scale score was a risk factor for the development of reflux esophagitis (odds ratio: 1.069, 95% confidence interval: 1.003–1.139, p < 0.01). Conclusions: In this H.-pylori-positive Japanese population, eradication therapy was associated with reflux esophagitis in around 10% of patients, particularly in those with severe reflux-related symptoms at baseline. Reflux-related symptoms may improve throughout the 12 months after successful eradication therapy, irrespective of the development of reflux esophagitis.

Helicobacter pylori Related Diseases and Osteoporotic Fractures (Narrative Review)

Osteoporosis (OP) and osteoporotic fractures (OFs) are common multifactorial and heterogenic disorders of increasing incidence. Helicobacter pylori (H.p.) colonizes the stomach approximately in half of the world's population, causes gastroduodenal diseases and is prevalent in numerous extra-digestive diseases known to be associated with OP/OF. The studies regarding relationship between H.p. infection (HPI) and OP/OFs are inconsistent. The current review summarizes the relevant literature on the potential role of HPI in OP, falls and OFs and highlights the reasons for controversies in the publications. In the first section, after a brief overview of HPI biological features, we analyze the studies evaluating the association of HPI and bone status. The second part includes data on the prevalence of OP/OFs in HPI-induced gastroduodenal diseases (peptic ulcer, chronic/atrophic gastritis and cancer) and the effects of acid-suppressive drugs. In the next section, we discuss the possible contribution of HPI-associated extra-digestive diseases and medications to OP/OF, focusing on conditions affecting both bone homeostasis and predisposing to falls. In the last section, we describe clinical implications of accumulated data on HPI as a co-factor of OP/OF and present a feasible five-step algorithm for OP/OF risk assessment and management in regard to HPI, emphasizing the importance of an integrative (but differentiated) holistic approach. Increased awareness about the consequences of HPI linked to OP/OF can aid early detection and management. Further research on the HPI-OP/OF relationship is needed to close current knowledge gaps and improve clinical management of both OP/OF and HPI-related disorders.

Endoscopic Reflux Esophagitis and Reflux-Related Symptoms after Helicobacter pylori Eradication Therapy: Meta-Analysis

Backgrounds: The etiology of gastroesophageal reflux disease (GERD) including reflux esophagitis and non-erosive reflux disease is multifactorial and a recent meta-analysis showed no association between the development of GERD and Helicobacter pylori eradication in both Western and East-Asian populations. However, the problem remains that various inclusion criteria are used in these studies, which hinders meta-analysis. With a focus on reflux esophagitis with endoscopic mucosal injury, we meta-analysed to evaluate the association between eradication and reflux esophagitis and symptoms using a clearly defined set of inclusion criteria. Methods: We conducted a meta-analysis of studies published up until March 2020, which compared the incidence of reflux esophagitis and symptoms between patients undergoing H. pylori eradication therapy in a randomized placebo-controlled trial (Category A); between patients with successful and failed eradication (Category B); and between patients with successful vs. failed eradication, receipt of placebo, or no-treatment H. pylori-positives (Category C). Results: A total of 27 studies were included. Significant statistical effects were found for development of endoscopic reflux esophagitis [relative risk (RR): 1.46, 95% confidence interval (CI): 1.16-1.84, p = 0.01] or de novo reflux esophagitis (RR: 1.42, 95% CI: 1.01-2.00, p = 0.03) in the case group that received eradication in all studies, especially in Western populations. There was no significant difference in the incidence of symptoms after eradication between patient and control groups, regardless of category, location of population, or baseline disease. Conclusions: Eradication therapy for H pylori increases the risk of reflux esophagitis, irrespective of past history of esophagitis. In contrast, no effect was seen on reflux-related symptoms.

Localization of Helicobacter pylori gastritis and the relation of existing histopathological features with reflux esophagitis

Background/aims: Interactions between Helicobacter pylori (Hp) and gastroesophageal reflux disease (GERD), which are common diseases worldwide, are confusing. In this study, the aim was to compare and evaluate the relationship between reflux esophagitis (RE) and Hp infection in adult patients with both the gastric localization of Hp and its histopathologic features.Materials and methods: 248 patients with RE were compared with 249 age and sex matched control groups. Biopsy specimens obtained from the gastric antrum and corpus were histologically evaluated.Findings: The incidence of Hp infection was significantly lower in patients with RE than in the control group (Ratio 1.53, 95% CI 1.07-2.20; p = .02, p < .05). Corpus Hp colonization and corpus gastritis scores were notably lower in the study group (p = .01, p < .05), whereas there was no significant difference in Hp colonization and antrum gastritis scores in the antrum. Corpus Hp colonization and gastritis scores were found to be negatively correlated with esophagitis development (r = -0.11; p = .01; (r = -0.14; p = .00 respectively, p < .05). There was no difference between the groups in terms of atrophy development (p > .05).Conclusion: This study showed that the presence of Hp infection in the corpus and corpus gastritis score was significantly lower in patients with erosive reflux esophagitis than in the control group. It also showed that Hp colonization and corpus gastritis scores were negatively correlated with esophagitis development. This inverse relationship was independent of atrophy.

Association of Helicobacter pylori infection with gastroesophageal reflux disease

Objective

Many studies have shown that Helicobacter pylori (Hp) is negatively correlated with gastroesophageal reflux disease (GERD). Moreover, some studies deny that eradication of Hp increases the incidence of GERD. Therefore, we investigated the association of Hp infection with GERD.

Methods

In this retrospective analysis, patients with peptic ulcers were used as a blank control group. We used logistic regression to analyze the relationship between Hp infection and GERD. We analyzed 953 patients with peptic ulcers, 180 patients with both peptic ulcers and GERD, and 298 patients with GERD.

Results

Among the patients with GERD, 75.6% (136/180) and 36.2% (108/298) of those with and without peptic ulcers, respectively, had Hp infection, and the difference was statistically significant. Among patients with peptic ulcers, 75.6% (136/180) and 67.4% (642/953) of those with and without GERD, respectively, had Hp infection. The incidence of GERD in patients with Hp-positive and -negative peptic ulcers was 17.5% (136/778) and 12.4% (44/355), respectively. These differences were also statistically significant.

Conclusion

In the analysis of patients with GERD, the prevalence of Hp infection was higher among patients with than without peptic ulcers.

Potential impact of Helicobacter pylori-related metabolic syndrome on upper and lower gastrointestinal tract oncogenesis

Both Helicobacter pylori infection and metabolic syndrome present significant global public health burdens. Metabolic syndrome is closely related to insulin resistance, the major underlying mechanism responsible for metabolic abnormalities, and Helicobacter pylori infection has been proposed to be a contributing factor. There is growing evidence for a potential association between Helicobacter pylori infection and insulin resistance, metabolic syndrome and related morbidity, including abdominal obesity, type 2 diabetes mellitus, dyslipidemia, hypertension, all of which increase mortality related to cardio-cerebrovascular disease, neurodegenerative disorders, nonalcoholic fatty liver disease and malignancies. More specifically, insulin resistance, metabolic syndrome and hyperinsulinemia have been associated with upper and lower gastrointestinal tract oncogenesis. Apart from cardio-cerebrovascular, degenerative diseases and nonalcoholic fatty liver disease, a number of studies claim that Helicobacter pylori infection is implicated in metabolic syndrome-related Barrett's esophagus and esophageal adenocarcinoma development, gastric and duodenal ulcers and gastric oncogenesis as well as lower gastrointestinal tract oncogenesis. This review summarizes evidence on the potential impact of Helicobacter pylori-related metabolic syndrome on gastroesophageal reflux disease-Barrett's esophagus-esophageal adenocarcinoma, gastric atrophy-intestinal metaplasia-dysplasia-gastric cancer and colorectal adenoma-dysplasia-colorectal cancer sequences. Helicobacter pylori eradication might inhibit these oncogenic processes, and thus further studies are warranted.

Comparison of Esophageal Function Tests to Investigate the Effect of Helicobacter Pylori Infection on Gastroesophageal Reflux Disease (GERD)

Background

The effects of Helicobacter pylori (H. pylori) infection on gastroesophageal reflux disease (GERD) remain unclear. The aim of this study was to compare the results of clinical esophageal function tests and the effect of H. pylori infection on GERD.

Material/Methods

A prospective clinical study included 124 patients diagnosed with GERD (four grades). H. pylori infection was determined by gastroscopy and a rapid urease test (RUT) to divide patients into an HP-positive and an HP-negative group. Esophageal function tests included high-resolution manometry (HRM), peristalsis break (PB), and 24-hour pH monitoring (composite pH DeMeester score). Different grades of GERD, with and without H. pylori infection, esophageal function test results were analyzed.

Results

The HP-positive group, compared with the HP-negative group with GERD, showed a significantly reduced median PB value (3.41±3.65 vs. 6.18±5.27), reduced PBs >5 cm per ten swallows (2.23±3.05 vs. 4.04±3.70) indicating that that H. pylori infection improved esophageal peristalsis. During 24-hour esophageal pH monitoring, the HP-positive group showed a significantly reduced percentage of time for esophageal pH <4.0, number of reflux events >5 min, and number of reflux episodes in 24 hours, compared with the HP-negative group. The DeMeester score was significantly increased in the HP-negative group, indicating a higher esophageal acid exposure (9.11±8.15 vs. 24.30±30.27).

Conclusions

H. pylori infection improved esophageal peristalsis, enhanced lower esophageal sphincter (LES) pressure, and reduced esophageal acid exposure, which might be protective factors for GERD.

Review: Impact of Helicobacter pylori on Alzheimer's disease: What do we know so far?

BACKGROUND

Helicobacter pylori has changed radically gastroenterologic world, offering a new concept in patients' management. Over time, more medical data gave rise to diverse distant, extragastric manifestations and interactions of the "new" discovered bacterium. Special interest appeared within the field of neurodegenerative diseases and particularly Alzheimer's disease, as the latter and Helicobacter pylori infection are associated with a large public health burden and Alzheimer's disease ranks as the leading cause of disability. However, the relationship between Helicobacter pylori infection and Alzheimer's disease remains uncertain.

METHODS

We performed a narrative review regarding a possible connection between Helicobacter pylori and Alzheimer's disease. All accessible relevant (pre)clinical studies written in English were included. Both affected pathologies were briefly analyzed, and relevant studies are discussed, trying to focus on the possible pathogenetic role of this bacterium in Alzheimer's disease.

RESULTS

Data stemming from both epidemiologic studies and animal experiments seem to be rather encouraging, tending to confirm the hypothesis that Helicobacter pylori infection might influence the course of Alzheimer's disease pleiotropically. Possible main mechanisms may include the bacterium's access to the brain via the oral-nasal-olfactory pathway or by circulating monocytes (infected with Helicobacter pylori due to defective autophagy) through disrupted blood-brain barrier, thereby possibly triggering neurodegeneration.

CONCLUSIONS

Current data suggest that Helicobacter pylori infection might influence the pathophysiology of Alzheimer's disease. However, further large-scale randomized controlled trials are mandatory to clarify a possible favorable effect of Helicobacter pylori eradication on Alzheimer's disease pathophysiology, before the recommendation of short-term and cost-effective therapeutic regimens against Helicobacter pylori-related Alzheimer's disease.

Helicobacter pylori infection and esophageal adenocarcinoma: a review and a personal view

Esophageal adenocarcinoma (EAC) is etiologically associated with gastroesophageal reflux disease (GERD). There is evidence to support the sequence GERD, Barrett's esophagus (BE), dysplasia, and finally EAC, with Helicobacter pylori (H. pylori) being implicated in each step to EAC. On the other side of this relation stands the hypothesis of the protective role of H. pylori against EAC. Based on this controversy, our aim was to review the literature, specifically original clinical studies and meta-analyses linking H. pylori infection with EAC, but also to provide our personal and others' relative views on this topic. From a total of 827 articles retrieved, 10 original clinical studies and 6 meta-analyses met the inclusion criteria. Original studies provided inconclusive data on an inverse or a neutral association between H. pylori infection and EAC, whereas meta-analyses of observational studies favor an inverse association. Despite these data, we consider that the positive association between H. pylori infection and GERD or BE, but not EAC, is seemingly a paradox. Likewise, the oncogenic effect of H. pylori infection on gastric and colon cancer, but not on EAC, also seems to be a paradox. In this regard, well-designed prospective cohort studies with a powered sample size are required, in which potential confounders should be taken into consideration since their design.

Helicobacter pylori infection and gastroesophageal reflux in children

Some studies suggest that Helicobacter pylori (H. pylori) infection would be a protective factor for the gastroesophageal reflux. The aim of this study was to explore this fact. A group of 72 children, admitted in a pediatric gastroenterology regional center in Northeast Romania, diagnosed with gastroesophageal reflux by 24-hour continuous esophageal pH monitoring (results were interpreted using the Boix-Ochoa score), underwent upper endoscopy with gastric biopsy to detect the presence of H. pylori by the rapid urease testing and for bacteriological and histologic examination. 19 children (26.39%) had H. pylori infection, while 53 (73.61%) did not. The grade of esophagitis was classified according to the Los Angeles classification system. Out of 47 children with esophagitis A, 16 (34.04%) had H. pylori infection, while out of the 25 children with esophagitis B, only 3 (12%) had H. pylori infection, with statistic significance (χ² = 54.69, P << 0.05, 95% confidence interval [CI]). Regarding the value of the Boix-Ochoa score, it appears that the presence of the H. pylori determines lower pH-metry scores (F = 8.13, P = 0.0015, 95% CI). The presence of the H. pylori was not an important factor in the gastroesophageal reflux. On the other hand its relationship with esophagitis appears to be inverse ratio. The fact that the H. pylori presence is statistically greater in the grade A esophagitis could confirm the hypothesis that the bacteria would slow down the development of the esophagitis.

RELATIONSHIP BETWEEN ESOPHAGITIS GRADES AND HELICOBACTER PYLORI

Background

The Helicobacter pylori infection (HP) is related to the development of gastric lesions and lymphoma; however, it is not known if there is a relation with gastroesophageal reflux disease and reflux esophagitis.

Aim

To evaluate HP's relationship with esophagitis in patients undergoing upper endoscopy.

Methods

Observational, retrospective and cross-sectional study, being evaluated 9576 patients undergoing outpatient endoscopic examination during the period between January and December 2015. Were included patients with any esophageal alteration at the examination; greater than 18; of both genders; independent of the complaint or the reason for the examination, illness or drug use. Were excluded those with active bleeding during the examination and in use of anticoagulants. The variables gender, age, esophagitis and result of the urease test, were studied. For statistical analysis was used the Epi Info software 7.1.5.2.

Results

Most of the samples consisted of women and the overall average age was 46.54±16.32 years. The presence of infection was balanced for gender: 1204 (12.56%) women and 952 (13.92%) men. Relating degree of esophagitis HP- and HP+ was observed that the type A was the most common (58.79%, n=1460); 604 (24.32%) had grade B; 334 (13.45%) grade C, and 85 (3.42%) grade D. In the relation between the grade of esophagitis with gender, esophagitis A was predominant in women and present in 929 (63.33%), followed by type B, 282 (46.68%), 136 C (40.71%) and D 30 (35.29%). In men 531 (36.36%) showed type A, 322 (53.31%) B, 198 (59.28%) C, and 55 (64.70%) D. Among the groups 40-50 and over 60 years there was a significant difference in whether have or not have HP+.

Conclusion

There is no significant difference between HP infection and the different grades of esophagitis.

Volume, distribution and acidity of gastric secretion on and off proton pump inhibitor treatment: a randomized double-blind controlled study in patients with gastro-esophageal reflux disease (GERD) and healthy subjects

Background

Postprandial accumulation of gastric secretions in the proximal stomach above the meal adjacent to the esophagogastric junction (EGJ), referred to as the ‘acid pocket’, has been proposed as a pathophysiological factor in gastro-esophageal reflux disease (GERD) and as a target for GERD treatment. This study assessed the effect of proton pump inhibitor (PPI) therapy on the volume, distribution and acidity of gastric secretions in GERD and healthy subjects (HS).

Methods

A randomized, double blind, cross-over study in 12 HS and 12 GERD patients pre-treated with 40 mg pantoprazole (PPI) or placebo b.i.d. was performed. Postprandial secretion volume (SV), formation of a secretion layer and contact between the layer and the EGJ were quantified by Magnetic Resonance Imaging (MRI). Multi-channel pH-monitoring assessed intragastric pH.

Results

A distinct layer of undiluted acid secretion was present on top of gastric contents in almost all participants on and off high-dose acid suppression. PPI reduced SV (193 ml to 100 ml, in HS, 227 ml to 94 ml in GERD; p < 0.01) and thickness of the acid layer (26 mm to 7 mm, 36 mm to 9 mm respectively, p < 0.01). No differences in secretion volume or layer thickness were observed between groups; however, off treatment, contact time between the secretion layer and EGJ was 2.6 times longer in GERD compared to HS (p = 0.012). This was not the case on PPI.

Conclusions

MRI can visualize and quantify the volume and distribution dynamics of gastric secretions that form a layer in the proximal stomach after ingestion of a liquid meal. The secretion volume and the secretion layer on top of gastric contents is similar in GERD patients and HS; however contact between the layer of undiluted secretion and the EGJ is prolonged in patients. High dose PPI reduced secretion volume by about 50 % and reduced contact time between secretion and EGJ towards normal levels.

Trial registration

NCT01212614.

Electronic supplementary material

The online version of this article (doi:10.1186/s12876-015-0343-x) contains supplementary material, which is available to authorized users.

The effect of Helicobacter pylori eradication therapy on the development of gastroesophageal reflux disease

BACKGROUND

It is uncertain whether the Helicobacter pylori eradication therapy makes a role in the progression of gastroesophageal reflux disease (GERD).

METHODS

A meta-analysis was undertaken to investigate the effect of H pylori eradication therapy on the development of GERD.

RESULTS

Overall, 16 cohort studies were included. The authors demonstrated that H pylori eradication had no significant effect on the occurrence of GERD in these cohort studies (odds ratio = 0.87, 95% confidence interval = 0.66-1.14, I = 32.4%, P = 0.103).

CONCLUSIONS

In general, H pylori eradication has no significant effect on the development of GERD in the long term. However, eradication therapy should be taken once there is H pylori infection, because H pylori infection is acknowledged to be a major cause of acute and chronic gastritis and peptic ulcer diseases and has been established as a definite etiologic factor for gastric cancer.

Does a relationship still exist between gastroesophageal reflux and Helicobacter pylori in patients with reflux symptoms?

Background

The nature of the relationship between Helicobacter pylori and reflux esophagitis (RE) is not fully understood. In addition, the effect of H. pylori eradication on RE and gastroesophageal reflux disease (GERD) is unclear. This study was designed to investigate the relationship between H. pylori infection and the grade of GERD in patients with reflux symptoms.

Methods

Between January 2010 and July 2013, 184 consecutive patients with daily reflux symptoms for at least one year were evaluated at the ambulatory for functional esophageal disease, Tor Vergata University Hospital, Rome, Italy. All patients underwent a pretreatment evaluation, which included anamnesis, clinical examination, Esophagogastroduodenoscopy (EGDS) with biopsy, esophageal manometry and 24-hour pH-metry. All statistical elaborations were obtained using Statigraphies 5 plus for Window XP.

Results

There was no statistical difference regarding Lower Esophageal Sphincter (LES) pressure between patients who were H. pylori-positive and H. Pylori-negative (19.2 ± 9.5 (range: 3.7 to 46.2) and 19.7 ± 11.0 (range: 2.6 to 61), respectively). Further, no significant difference was evidenced in esophageal wave length (mean value: 3.1 seconds in H. pylori-negative patients versus 3.2 seconds in H. pylori-positive patients) or in esophageal wave height (mean value: 72.2 ± 39.3 in H. pylori-negative patients versus 67.7 ± 28.4 in H. pylori-positive patients). We observed that hiatal hernia (P = 0.01), LES opening (P = 0.05), esophageal wave length (P = 0.01) and pathological reflux number (P = 0.05) were significantly related to the presence of esophagitis. However, H. pylori infection was not significantly related to the presence of reflux esophagitis.

Conclusions

Our clinical, endoscopic, manometric and pH-metric data shows no significant role of H. pylori infection in the development of GERD or in the pathogenesis of reflux esophagitis. However, current data do not provide sufficient evidence to define this relationship and further prospective large studies are needed.

The effect of Helicobacter pylori infection and eradication in patients with gastro-oesophageal reflux disease: A parallel-group, double-blind, placebo-controlled multicentre study

OBJECTIVES

This study aimed to resolve controversy regarding the effects of Helicobacter pylori eradication therapy and H. pylori infection in gastro-oesophageal reflux disease.

DESIGN

A randomized, double-blind, multicentre trial was performed in patients presenting with reflux symptoms. H. pylori-positive patients were randomized to receive either antibiotics or placebo for 7 days. H. pylori-negative patient controls received placebo. All received esomeprazole 20 mg b.d. for 7 days, followed by 40 mg o.d. to complete an 8-week course, and were followed up for 32 weeks by telephone.

RESULTS

In this study, 198/589 (34%) patients were H. pylori-positive and 113 H. pylori-negative patients served as controls. Baseline endoscopy revealed 63% Los Angeles grade 0A and 37% Los Angeles grade BCD oesophagitis with no difference between patient groups. Symptom improvement on esomeprazole was seen in 89%. H. pylori eradication was successful in 82%. H. pylori eradication had no effect on symptomatic relapse (hazard ratio 1.15, 95% CI 0.74-1.8; p = 0.5). Overall, H. pylori-positive patients had a lower probability of relapse compared to H. pylori-negative controls (hazard ratio 0.6, 95% CI 0.43-0.85; p = 0.004). Relapse hazard was modulated also by oesophagitis grade (BCD vs. 0A, hazard ratio 2.1, 95% CI 1.5-3.0).

CONCLUSION

Relapse of gastro-oesophageal reflux disease symptoms after a course of high dose acid suppression took longer for H. pylori-positive patients than H. pylori-negative controls; however eradication therapy had no effect on the risk of relapse; ClincialTrials.gov number, NCT00574925.

Acid peptic diseases: pharmacological approach to treatment

Acid peptic disorders are the result of distinctive, but overlapping pathogenic mechanisms leading to either excessive acid secretion or diminished mucosal defense. They are common entities present in daily clinical practice that, owing to their chronicity, represent a significant cost to healthcare. Key elements in the success of controlling these entities have been the development of potent and safe drugs based on physiological targets. The histamine-2 receptor antagonists revolutionized the treatment of acid peptic disorders owing to their safety and efficacy profile. The proton-pump inhibitors (PPIs) represent a further therapeutic advance due to more potent inhibition of acid secretion. Ample data from clinical trials and observational experience have confirmed the utility of these agents in the treatment of acid peptic diseases, with differential efficacy and safety characteristics between and within drug classes. Paradigms in their speed and duration of action have underscored the need for new chemical entities that, from a single dose, would provide reliable duration of acid control, particularly at night. Moreover, PPIs reduce, but do not eliminate, the risk of ulcers in patients taking NSAIDs, reflecting untargeted physiopathologic pathways and a breach in the ability to sustain an intragastric pH of more than 4. This review provides an assessment of the current understanding of the physiology of acid production, a discussion of medications targeting gastric acid production and a review of efficacy in specific acid peptic diseases, as well as current challenges and future directions in the treatment of acid-mediated diseases.

Feasibility of esophagogastric junction distensibility measurement during Nissen fundoplication

Increased esophagogastric junction distensibility has been implicated in the development of gastroesophageal reflux disease (GERD). Previous authors have demonstrated a reduction in distensibility following anti-reflux surgery, but the changes during the operation are not clear. Our study aimed to ascertain the feasibility of measuring intraoperative distensibility changes and to assess if this would have potential to modify the operation. Seventeen patients with GERD were managed in a standardized manner consisting of preoperative assessment with symptom scoring, endoscopy, 24 hours pH studies, and manometry. Patients then underwent laparoscopic Nissen fundoplication with intraoperative distensibility measurement using an EndoFLIP EF-325 functional luminal imaging probe (Crospon Ltd, Galway, Ireland). This device utilizes impedance planimetry technology to measure cross-sectional area and distensibility within a balloon-tipped catheter. This is inflated at the esophagogastric junction to fixed distension volumes. Thirty-second median cross-sectional area and intraballoon pressure measurements were recorded at 30 and 40 mL balloon distensions. Measurement time points were initially after induction of anesthesia, after pneumoperitoneum, after hiatal mobilization, after hiatal repair, after fundoplication, and finally pre-extubation. Postoperatively, patients continued on protocol and were discharged after a two-night stay tolerating a sloppy diet. Patients with a hiatus hernia on high-resolution manometry had a significantly higher initial esophagogastric junction distensibility index (DI) than those without. Hiatus repair and fundoplication resulted in a significant overall reduction in the median DI from the initial to final recordings (30 mL balloon distension reduction of 3.26 mm(2) /mmHg (P = 0.0087), 40 mL balloon distension reduction of 2.39 mm(2) /mmHg [P = 0.0039]). There was also a significant reduction in the DI after pneumoperitoneum, hiatus repair, and fundoplication at 40 mL balloon distension. Two individual cases in the series highlight the utility of the system in potentially changing the operation. After fundoplication, patient 7 recorded a DI of 0.47 mm(2) /mmHg, the lowest in our series, and subsequently required reoperation because of significant symptoms of dysphagia. Patient 12 had a fundoplication that appeared visually too tight and was converted intraoperatively to a Lind 270° wrap resulting in a change in the DI from 0.65 to 0.89 mm(2) /mmHg. Laparoscopic Nissen fundoplication results in a significant reduction in the distensibility of the esophagogastric junction. The EndoFLIP system is able to demonstrate significant changes during the operation and may help guide intraoperative modification. Larger multicenter studies with long-term follow up would be beneficial to develop a target range of distensibility associated with good outcome.

Population-based assessment of heartburn in urban Black Americans

Prevalence data for heartburn in the urban Black American community is lacking. In order to estimate prevalence for this community, we analyzed data from an ongoing cohort study in progress at our hospital. Comprehensive interviews allowed for exploration of factors associated with heartburn. Complex, stratified sampling design was the method used. Survey invitations are hand-delivered to random blocks in a single zip code tabulation area. One member per eligible household is invited to complete a computer-based survey. Heartburn was defined as ≥ 3 days/week of symptoms as defined by the Montreal Definition and Classification of gastroesophageal reflux disease. Scaling and weighting factors were utilized to estimate population level prevalence. Multivariate logistic regression was used to identify independent predictor variables for heartburn. Enrolled 379 participants corresponding to a weighted sample size of 22,409 (20,888-23,930) citizens. Demographic characteristics of the sample closely matched those of the entire targeted population. Overall, the weighted prevalence of heartburn ≥ 3 times per week was 17.6% (16.4-18.8%). Variables independently associated with heartburn were body mass index, daily caloric and fat intake, diabetes mellitus (odds ratio = 2.95; 2.59-3.36), cigarette smoking, and alcohol consumption (odds ratio = 2.55; 2.25-2.89). Factors inversely associated included illicit drug use and increased physical activity. Waist : hip ratio showed no relationship. The prevalence of heartburn ≥ 3 times per week is high in the Black American community. Adverse lifestyle behaviors showed particularly important associations. Our study needs to be replicated in other communities with similar demographics.

Effect of Helicobacter pylori treatment on gastroesophageal reflux disease (GERD): meta-analysis of randomized controlled trials

OBJECTIVE

Gastroesophageal reflux disease (GERD) is a multifactorial disorder characterized by reflux of acidic gastric contents into the esophagus leading to tissue damage and symptoms. The role of H. pylori in the pathogenesis of GERD is controversial. Therefore, we performed a meta-analysis on the effect of H. pylori treatment on symptomatic as well as endoscopic changes associated with GERD.

MATERIAL AND METHODS

Multiple medical databases were searched (4/2011). Randomized controlled trials (RCTs) comparing H. pylori treatment with no treatment on symptomatic adults with GERD were included. The effects of H. pylori eradication were analyzed by calculating pooled estimates for new onset or changes in the symptoms of GERD or endoscopic reflux esophagitis. Separate analyses were performed for each outcome by using odds ratio (OR) or weighted mean difference (WMD) by fixed and random effects models. Publication bias was assessed by funnel plots. Heterogeneity among studies was assessed by calculating I² measure of inconsistency.

RESULTS

Ten trials met the inclusion criteria. No statistically significant effect was found for symptomatic GERD (OR 0.81, 95% CI 0.56-1.17, p = 0.27) or endoscopic evidence of reflux esophagitis (OR 1.13; 95% CI: 0.72-1.78, p = 0.59) between the two groups. A subgroup analysis of eradication data revealed a statistically significant lower incidence of GERD symptoms in the eradicated group (13.8%) compared with the non-eradicated group (24.9%) (OR 0.55; 95% CI: 0.35-0.87, p = 0.01). Funnel plot revealed no publication bias.

CONCLUSIONS

Treatment of H. pylori does not seem to increase GERD symptoms or reflux esophagitis. However, documented eradication of H. pylori appears to significantly improve GERD symptoms.

Effect of Helicobacter pylori Eradication on the Development of Reflux Esophagitis and Gastroesophageal Reflux Symptoms: A Nationwide Multi-Center Prospective Study

Background/Aims

A two-year, prospective, nationwide multicenter study was undertaken to evaluate the effect of Helicobacter pylori eradication on the development of reflux esophagitis (RE) and gastroesophageal reflux disease (GERD) symptoms in the Korean population.

Methods

In total, 1,489 subjects without RE were enrolled at the outpatient clinics of 12 tertiary hospitals nationwide, and 452 subjects underwent follow-up (F/U) for 2 years to evaluate the development of RE and GERD symptoms.

Results

RE was found in 33 subjects (7.3% of 452 subjects) and 14 subjects (7.3% of 192 subjects) during the first and second year of F/U, respectively. H. pylori status was not associated with the development of RE. RE was found in six (9.0%) of 67 H. pylori-negative patients, in 26 (11.2%) of 233 eradicated subjects and in eight (7.0%) of 114 noneradicated subjects (p=0.532). Multivariate analysis showed that age ≥60 years (odds ratio [OR], 7.11; 95% confidence interval [CI], 1.92 to 26.41), alcohol consumption (OR, 4.43; 95% CI, 1.03 to 19.19) and F/U cholesterol levels ≥200 mg/dL (OR, 5.03; 95% CI, 1.32 to 19.17) were significant risk factors for the development of RE. There was no significant difference in the development of GERD symptoms or weight according to H. pylori status during the 2-year F/U.

Conclusions

Eradication of H. pylori did not affect the development of reflux esophagitis or GERD symptoms among patients in outpatient gastroenterology clinics in South Korea.

Effects of Helicobacter pylori eradication on gastroesophageal reflux disease

BACKGROUND AND AIMS

Helicobacter pylori infection appears to be a protective factor for gastroesophageal reflux disease (GERD). However, H. pylori is associated with the subtype of esophageal carcinoma, and long-term proton-pump inhibition usage would cause gastric atrophy in patients with persistent H. pylori infection, which is a precancerous lesion. The relationship between H. pylori infection and GERD is still unclear. We aimed to confirm whether the eradication of H. pylori would worsen or improve symptomatic or endoscopic GERD.

METHODS

A systematic review of the published data was undertaken, and a meta-analysis was performed to determine the effect of H. pylori eradication on the occurrence of symptomatic (heartburn, acid regurgitation) and endoscopically proven erosive (esophagitis) GERD in patients with or without pre-existing GERD.

RESULTS

A total of 11 articles met the inclusion criteria and thus were included in the meta-analysis. There was no significant difference in the frequency of symptomatic or endoscopically proven erosive GERD after the eradication between patients with H. pylori eradicated and those with persistent infection, regardless of follow-up period, location, or the baseline disease.

CONCLUSION

H. pylori eradication does not aggravate the clinical outcomes in terms of short-term and long-term posteradication occurrence of GERD. There is no association between H. pylori eradication and the development of GERD in the patients with different diseases, even those with GERD.

[Clinical analysis of recurrence rate and symptom improvement in gastro-esophageal reflux disease patients]

BACKGROUND/AIMS

Gastro-esophageal reflux disease (GERD) is a chronic condition, with 50-80% of patients experiencing recurrence within one year following completion of initial treatment. The present study aimed to estimate recurrence rate and treatment response in GERD patients treated with proton pump inhibitor.

METHODS

A total of 207 symptomatic GERD patients, which were confirmed by endoscopy from July 2008 till January 2009, were enrolled. They were divided into non-erosive reflux disease (NERD) group and erosive reflux disease (ERD) group by endoscopic findings. Patients were treated with lansoprazole 15 mg (NERD group) or 30 mg (ERD group) once daily for 8 weeks. The presence of symptoms was assessed in each patient at baseline and post-treatment using a questionnaire. Subsequent symptomatic recurrence on the cessation of therapy in each improved patients was checked by telephone survey or outpatient interview.

RESULTS

Ninety-four patients and 113 patients were first diagnosed with NERD and ERD, respectively. The mean post-treatment follow-up period was 24.4+/-8.5 weeks. Recurrence rate was 40.0% (NERD, 43.8%; ERD, 37.1% (p=0.224)). Recurrence time was 10.1+/-5.8 weeks (NERD 9.6 weeks; ERD, 10.6 weeks (p=0.444)). Regarding the symptom improvement after 8 week therapy with lansoprazole, 89.4% (NERD, 85.1%; ERD, 92.9% (p=0.056)) of total patients were symptomatically improved.

CONCLUSIONS

Forty percentage of GERD patients recurred within 6 months following the completion of 8 week therapy with lansoprazole. Recurrence rate, recurrence time, and rate of symptom improvement were not significantly different between NERD group treated with half dose and ERD group treated with full dose lansoprazole.

WITHDRAWN: Eradication of Helicobacter pylori for non-ulcer dyspepsia

BACKGROUND

Helicobacter pylori (H pylori) is the main cause of peptic ulcer disease. The role of H pylori in non-ulcer dyspepsia is less clear.

OBJECTIVES

To determine the effect of H pylori eradication on dyspepsia symptoms in patients with non-ulcer dyspepsia.

SEARCH STRATEGY

Trials were identified through electronic searches of the Cochrane Controlled Trials Register (CCTR), MEDLINE, EMBASE, CINAHL and SIGLE, using appropriate subject headings and keywords, searching bibliographies of retrieved articles, and through contacts with experts in the fields of dyspepsia and with pharmaceutical companies.

SELECTION CRITERIA

All parallel group randomised controlled trials (RCTs) comparing drugs to eradicate H pylori with placebo or other drugs known not to eradicate H pylori for patients with non-ulcer dyspepsia.

DATA COLLECTION AND ANALYSIS

Data were collected on individual and global dyspeptic symptom scores, quality of life measures and adverse effects. Dyspepsia outcomes were dichotomised into minimal/resolved versus same/worse symptoms.

MAIN RESULTS

Twenty one randomised controlled trials were included in the systematic review. Eighteen trials compared antisecretory dual or triple therapy with placebo antibiotics +/- antisecretory therapy, and evaluated dyspepsia at 3-12 months. Seventeen of these trials gave results as dichotomous outcomes evaluating 3566 patients and there was no significant heterogeneity between the studies. There was a 10% relative risk reduction in the H pylori eradication group (95% CI = 6% to 14%) compared to placebo. The number needed to treat to cure one case of dyspepsia = 14 (95% CI = 10 to 25). A further three trials compared Bismuth based H pylori eradication with an alternative pharmacological agent. These trials were smaller and had a shorter follow-up but suggested H pylori eradication was more effective than either H2 receptor antagonists or sucralfate in treating non-ulcer dyspepsia.

AUTHORS' CONCLUSIONS

H pylori eradication therapy has a small but statistically significant effect in H pylori positive non-ulcer dyspepsia. An economic model suggests this modest benefit may still be cost-effective but more research is needed.

Consequences of Helicobacter pylori infection in children

Although evidence is emerging that the prevalence of Helicobacter pylori (H. pylori) is declining in all age groups, the understanding of its disease spectrum continues to evolve. If untreated, H. pylori infection is lifelong. Although H. pylori typically colonizes the human stomach for many decades without adverse consequences, children infected with H. pylori can manifest gastrointestinal diseases. Controversy persists regarding testing (and treating) for H. pylori infection in children with recurrent abdominal pain, chronic idiopathic thrombocytopenia, and poor growth. There is evidence of the role of H. pylori in childhood iron deficiency anemia, but the results are not conclusive. The possibility of an inverse relationship between H. pylori and gastroesophageal reflux disease, as well as childhood asthma, remains a controversial question. A better understanding of the H. pylori disease spectrum in childhood should lead to clearer recommendations about testing for and treating H. pylori infection in children who are more likely to develop clinical sequelae.

Guidelines for the management of Helicobacter pylori infection in Japan: 2009 revised edition

BACKGROUND

Over the past few years, the profile of Helicobacter pylori infection has changed in Japan. In particular, the relationship between H. pylori and gastric cancer has been demonstrated more clearly. Accordingly, the committee of the Japanese Society for Helicobacter Research has revised the guidelines for diagnosis and treatment of H. pylori infection in Japan.

MATERIALS AND METHODS

Four meetings of guidelines preparation committee were held from July 2007 to December 2008. In the new guidelines, recommendations for treatment have been classified into five grades according to the Minds Recommendation Grades, while the level of evidence has been classified into six grades. The Japanese national health insurance system was not taken into consideration when preparing these guidelines.

RESULTS

Helicobacter pylori eradication therapy achieved a Grade A recommendation, being useful for the treatment of gastric or duodenal ulcer, for the treatment and prevention of H. pylori-associated diseases such as gastric cancer, and for inhibiting the spread of H. pylori infection. Levels of evidence were determined for each disease associated with H. pylori infection. For the diagnosis of H. pylori infection, measurement of H. pylori antigen in the feces was added to the tests not requiring biopsy. One week of proton-pump inhibitor-based triple therapy (including amoxicillin and metronidazole) was recommended as second-line therapy after failure of first-line eradication therapy.

CONCLUSION

The revised Japanese guidelines for H. pylori are based on scientific evidence and avoid the administrative restraints that applied to earlier versions.

Second Asia-Pacific Consensus Guidelines for Helicobacter pylori infection

The Asia-Pacific Consensus Conference was convened to review and synthesize the most current information on Helicobacter pylori management so as to update the previously published regional guidelines. The group recognized that in addition to long-established indications, such as peptic ulcer disease, early mucosa-associated lymphoid tissue (MALT) type lymphoma and family history of gastric cancer, H. pylori eradication was also indicated for H. pylori infected patients with functional dyspepsia, in those receiving long-term maintenance proton pump inhibitor (PPI) for gastroesophageal reflux disease, and in cases of unexplained iron deficiency anemia or idiopathic thrombocytopenic purpura. In addition, a population 'test and treat' strategy for H. pylori infection in communities with high incidence of gastric cancer was considered to be an effective strategy for gastric cancer prevention. It was recommended that H. pylori infection should be tested for and eradicated prior to long-term aspirin or non-steroidal anti-inflammatory drug therapy in patients at high risk for ulcers and ulcer-related complications. In Asia, the currently recommended first-line therapy for H. pylori infection is PPI-based triple therapy with amoxicillin/metronidazole and clarithromycin for 7 days, while bismuth-based quadruple therapy is an effective alternative. There appears to be an increasing rate of resistance to clarithromycin and metronidazole in parts of Asia, leading to reduced efficacy of PPI-based triple therapy. There are insufficient data to recommend sequential therapy as an alternative first-line therapy in Asia. Salvage therapies that can be used include: (i) standard triple therapy that has not been previously used; (ii) bismuth-based quadruple therapy; (iii) levofloxacin-based triple therapy; and (iv) rifabutin-based triple therapy. Both CYP2C19 genetic polymorphisms and cigarette smoking can influence future H. pylori eradication rates.

Positive association between Helicobacter pylori and gastroesophageal reflux disease in children

OBJECTIVES

The role of Helicobacter pylori (H pylori) in gastroesophageal reflux disease (GERD) remains controversial, particularly in children, because there are limited published data. Adult studies suggested that H pylori infection may protect against GERD by causing atrophic gastritis, which leads to reduced gastric acid secretion. The objective of our study was to determine the role of H pylori infection in the development of GERD in a pediatric population.

PATIENTS AND METHODS

A retrospective analysis of 420 patients (M:F = 214:206) who underwent esophagogastroduodenoscopy (EGD) with biopsies between January 2000 and April 2006 was conducted. Patient demographics, clinical indications for EGD and the prevalence of reflux esophagitis (RE), the biomarker for GERD, in 2 groups, H pylori positive and H pylori negative, were reviewed. The prevalence of RE in the H pylori-positive and H pylori-negative groups was further analyzed on the basis of sex and age (<1 year, 1-10 years, >10 years). The mean age of the study population was 8.2 years (range 0-20 years). The clinical indications for EGD were as follows: recurrent abdominal pain (n = 186, 44%), malabsorption (n = 80, 19%), persistent vomiting (n = 80, 19%), suspected eosinophilic gastrointestinal disorders (n = 63, 15%), and others such as upper gastrointestinal bleeding or inflammatory bowel disease surveillance (n = 11, 3%). Statistical analysis was performed by using chi test, Fisher exact test, and multivariate logistical regression analysis.

RESULTS

Among the 420 patients, 16 patients (3.8%) were positive for H pylori and 167 patients (39.8%) were found to have RE. Thirteen patients with H pylori were found to have histologic evidence of RE. The prevalence of RE in the H pylori-positive population was 81.3% compared with 38.1% in the H pylori-negative population (P < or = 0.05). There were no patients with H pylori in the youngest age group. In the second age group (1-10 years), 100% of the H pylori-positive patients had RE, whereas 44.6% of the H pylori-negative patients had RE (P < or = 0.05). Both male and female patients with H pylori had a higher prevalence of RE, 77.8% and 85.7%, respectively. On a multivariate logistical regression, for the overall study cohort, H pylori-positive patients had an odds ratio of 5.79 of developing RE compared with H pylori-negative patients (P < or = 0.05).

CONCLUSIONS

Our study results indicate that there is a significantly higher prevalence of RE in an H pylori-infected cohort independent of age or sex. The findings suggest that H pylori infection in children is positively associated with RE.

Helicobacter pylori eradication may induce de novo, but transient and mild, reflux esophagitis: Prospective endoscopic evaluation

BACKGROUNDS AND AIM

The effect on reflux esophagitis of eradicating Helicobacter pylori is variable and not fully defined. We previously reported that in patients who have reflux esophagitis associated with duodenal ulcer, a significant improvement in the pre-existing reflux esophagitis occurred after H. pylori was eradicated. In the present study, we asked whether H. pylori eradication leads to de novo development of reflux esophagitis in peptic ulcer patients.

METHODS

Prospective post-eradication evaluations were conducted in 1195 H. pylori-positive patients with peptic ulcer diseases who were confirmed not to have reflux esophagitis by endoscopic examination before eradication therapy. After eradication therapy, endoscopy and a urea breath test were performed yearly.

RESULTS

A total of 1187 patients were followed for up to 10.0 years (a mean of 3.6 years). Reflux esophagitis developed in 279 of 1000 patients cured of infection and in 26 of 187 patients who had persistent infection (P < 0.0001, Fisher's exact test). The esophagitis was mild (Los Angeles grade A) in most patients, transient in approximately one-half, and rarely necessitated long-term medication for the condition. Cure of infection, alcohol consumption, younger age, and high body mass index were identified as significant factors for the risk of developing non-transient reflux esophagitis.

CONCLUSIONS

Cure of H. pylori infection may increase the risk of developing reflux esophagitis in patients with peptic ulcer, but the esophagitis is mostly mild and transient, and long-term medication is rarely required. Thus, H. pylori eradication therapy need not be withheld for fear of provoking reflux esophagitis.

The pathophysiologic basis for epidemiologic trends in gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is defined by either subjective complaints indicative of problematic gastroesophageal reflux or objective complications directly attributable to reflux. Studies focused on GERD-related symptoms suggest a worldwide increase in prevalence of approximately 4% per year. Epidemiologic data indicate that possible contributing factors include increasing longevity, rising obesity rates, greater consumption of medications affecting esophageal function, and potentially changing prevalence rates of Helicobacter pylori infection. This article explores the interplay between pathophysiology and epidemiology by focusing on these risk factors and their potential effect on GERD pathogenesis.

Gastroesophageal reflux disease: an Asian perspective

The prevalence of gastroesophageal reflux disease (GERD) ranges from 2.5% to 7.1% in most population-based studies in Asia. There is evidence that GERD and its complications are rising, coinciding with a decline in Helicobacter pylori (H. pylori) infection. Asian GERD patients share similar risk factors and pathophysiological mechanisms with their Western counterparts. Possible causes for the lower prevalence of GERD include less obesity and hiatus hernia, a lesser degree of esophageal dysmotility, a high prevalence of virulent strains of H. pylori, and low awareness. Owing to the lack of precise translation for 'heartburn' in most Asian languages, reflux symptoms are often overlooked or misinterpreted as dyspepsia or chest pain. Furthermore, a symptom-based diagnosis with a therapeutic trial of the proton pump inhibitor (PPI) may be hampered by the high prevalence of H. pylori-related disease. The risk stratification for prompt endoscopy, use of a locally-validated, diagnostic symptom questionnaire, and response to H. pylori'test and treat' help improve the accuracy of the PPI test for diagnoses. PPI remain the gold standard treatment, and 'on-demand' PPI have been shown to be a cost-effective, long-term treatment. The clinical course of GERD is benign in most patients in Asia. The risk of progression from non-erosive reflux disease to erosive esophagitis is low, and treatment response to a conventional dose of PPI is generally higher. Although H. pylori eradication may lead to more resilient GERD in a subset of patients, the benefits of H. pylori eradication outweigh the risks, especially in Asian populations with a high incidence of gastric cancer.

Characteristics of the esophageal low-pressure zone in healthy volunteers and patients with esophageal symptoms: assessment by high-resolution manometry

BACKGROUND

Esophageal motility studies in humans have documented a low-pressure zone (LPZ) in the area of transition from striated to smooth muscle. While preliminary studies indicate that a bolus might be retained in this area, the clinical relevance of the LPZ remains unclear.

AIM

To investigate a possible relationship between esophageal symptoms and the size of the esophageal LPZ.

METHODS

We reviewed high-resolution manometry (HRM) data from patients with esophageal symptoms (dysphagia, chest pain, and heartburn/regurgitation) and asymptomatic volunteers. The proximal border of the LPZ was defined as the point where the amplitude of the proximal contraction wave declined below 30 mmHg, and the distal border as the point where the distal contraction wave first increased above 30 mmHg.

RESULTS

The average (+/- standard error of mean [SEM]) length of the LPZ in 44 asymptomatic individuals was 5.4 +/- 0.6 cm and did not differ (P= 0.222) from the LPZ in 64 patients with dysphagia (6.8 +/- 0.4 cm), 34 patients with chest pain (6.4 +/- 0.6 cm), and 42 patients with gastroesophageal reflux disease (GERD) symptoms (7.0 +/- 0.6 cm). These results did not change when the length of the LPZ was corrected for total esophageal length. The time width of the LPZ in asymptomatic individuals (1.6 +/- 0.2 s) was shorter than in patients with dysphagia and GERD symptoms (dysphagia 2.4 +/- 0.2 s, GERD symptoms 2.8 +/- 0.3 s).

CONCLUSION

A time delay between the proximal and distal esophageal contraction waves might be a meaningful variable in GERD and dysphagia.

Helicobacter pylori and gastroesophageal reflux disease

BACKGROUND

The nature of the relationship between Helicobacter pylori and reflux oesophagitis is still not clear. To investigate the correlation between Helicobacter pylori infection and GERD taking into account endoscopic, pH-metric and histopathological data.

METHODS

Between January 2001 and January 2003 a prospective study was performed in 146 patients with GERD in order to determine the prevalence of Helicobacter pylori infection at gastric mucosa; further the value of the De Meester score endoscopic, manometric and pH-metric parameters, i.e. reflux episodes, pathological reflux episodes and extent of oesophageal acid exposure, of the patients with and without Helicobacter pylori infection were studied and statistically compared. Finally, univariate analysis of the above mentioned data were performed in order to evaluate the statistical correlation with reflux esophagitis.

RESULTS

There were no statistically significant differences between the two groups, HP infected and HP negative patients, regarding age, gender and type of symptoms. There was no statistical difference between the two groups regarding severity of symptoms and manometric parameters. The value of the De Meester score and the ph-metric parameters were similar in both groups. On univariate analysis, we observed that hiatal hernia (p = 0,01), LES size (p = 0,05), oesophageal wave length (p = 0,01) and pathological reflux number (p = 0,05) were significantly related to the presence of reflux oesophagitis.

CONCLUSION

Based on these findings, it seems that there is no significant evidence for an important role for H. pylori infection in the development of GERD and erosive esophagitis. Nevertheless, current data do not provide sufficient evidence to define the relationship between HP and GERD. Further assessments in prospective large studies are warranted.

Influence of bolus consistency and position on esophageal high-resolution manometry findings

BACKGROUND

Conventional esophageal manometry evaluating liquid swallows in the recumbent position measures pressure changes at a limited number of sites and does not assess motility during solid swallows in the physiologic upright position.

AIM

To evaluate esophageal motility abnormalities during water and bread swallows in the upright and recumbent positions using high-resolution manometry (HRM).

METHODS

Thirty-two-channel HRM testing was performed using water (10 ml each) and bread swallows in the upright and recumbent positions. The swallows were considered normal if the distal peristaltic segment >30 mmHg was >5 cm, ineffective if the 30-mmHg pressure band was <5 cm, and simultaneous if the onset velocity of the 30 mmHg pressure band was >8 cm/s. Abnormal esophageal manometry was defined as the presence of > or =30% ineffective and/or > or =20% simultaneous contractions.

RESULTS

The data from 96 patients (48 F; mean age 51 years, range 17-79) evaluated for dysphagia (56%), chest pain (22%), and gastroesophageal reflux disease (GERD) symptoms (22%) were reviewed. During recumbent water swallows, patients with dysphagia, chest pain, and GERD had a similar prevalence of motility abnormalities. During upright bread swallows, motility abnormalities were more frequent (p = 0.01) in patients with chest pain (71%) and GERD (67%) compared to patients with dysphagia (37%).

CONCLUSIONS

Evaluating bread swallows in the upright position reveals differences in motility abnormalities overlooked by liquid swallows alone.

Clinical and endoscopic features of Chinese reflux esophagitis patients

AIM: To analyze the clinical and endoscopic features of Chinese patients with reflux esophagitis (RE).

METHODS: A total of 1405 RE patients were analyzed retrospectively. Data on gender, age, presence/absence of H pylori infection and associated esophageal hiatal hernia were collected. Esophagitis was divided into different grades according to Los Angeles Classification.

RESULTS: Of 18823 patients, 1405 were diagnosed as RE. The ratio of male to female patients was 1.75:1 (P < 0.01). The mean age of male and female patients was significantly different (P = 0.01). The peak age at onset of the disease was 40-60 years. According to Los Angeles Classification, there were significant differences in the age of patients with grades A and B compared to patients with grades C and D (P < 0.01). Two hundred and seventy-seven patients were infected with H pylori, the infection rate was low (P < 0.01). Complication of esophageal hiatal hernia was found to be significantly associated with the severity of esophagitis and age in 195 patients (P < 0.01). Esophageal mucosa damages were mainly located at the right esophageal wall.

CONCLUSION: The peak age of onset of RE is 40-60 years and higher in males than in females. The mean age of onset of RE is lower in males than in females. The infection rate of H pylori is significantly decreased in patients with esophagitis. Old age and esophageal hiatal hernia are associated with more severe esophagitis. Right esophageal mucosal damage can occur more often in RE patients.

Asia-Pacific consensus guidelines on gastric cancer prevention

BACKGROUND AND AIM

Gastric cancer is a major health burden in the Asia-Pacific region but consensus on prevention strategies has been lacking. We aimed to critically evaluate strategies for preventing gastric cancer.

METHODS

A multidisciplinary group developed consensus statements using a Delphi approach. Relevant data were presented, and the quality of evidence, strength of recommendation, and level of consensus were graded.

RESULTS

Helicobacter pylori infection is a necessary but not sufficient causal factor for non-cardia gastric adenocarcinoma. A high intake of salt is strongly associated with gastric cancer. Fresh fruits and vegetables are protective but the use of vitamins and other dietary supplements does not prevent gastric cancer. Host-bacterial interaction in H. pylori infection results in different patterns of gastritis and differences in gastric acid secretion which determine disease outcome. A positive family history of gastric cancer is an important risk factor. Low serum pepsinogens reflect gastric atrophy and may be useful as a marker to identify populations at high risk for gastric cancer. H. pylori screening and treatment is a recommended gastric cancer risk reduction strategy in high-risk populations. H. pylori screening and treatment is most effective before atrophic gastritis has developed. It does not exclude the existing practice of gastric cancer surveillance in high-risk populations. In populations at low risk for gastric cancer, H. pylori screening is not recommended. First-line treatment of H. pylori infection should be in accordance with national treatment guidelines.

CONCLUSION

A strategy of H. pylori screening and eradication in high-risk populations will probably reduce gastric cancer incidence, and based on current evidence is recommended by consensus.

Secretion of epidermal growth factor in saliva of duodenal ulcer patients; an association with Helicobacter pylori eradication and erosive esophagitis

PURPOSE

Erosive esophagitis frequently develops after successful Helicobacter pylori eradication. Since salivary secretion of epidermal growth factor (EGF) plays a crucial role in the pathogenesis of gastroesophageal reflux disease, the current study objective was to find out whether erosive esophagitis development after Helicobacter pylori eradication is associated with the secretion of EGF in saliva.

MATERIALS AND METHODS

A total of 115 H. pylori infected patients (positive results of CLO-test, histology and serology) with a duodenal ulcer were recruited for the study. Gastroscopic examinations and saliva collections were performed twice, prior to H. pylori eradication and one year after its cessation. The salivary EGF was determined using a radioimmunological method.

RESULTS

Salivary EGF secretion was lower in H. pylori infected subjects with erosive esophagitis than without (0.82+/-0.66 vs 1.70+/-3.49 ng/min, p=0.021). However, a year after successful H. pylori eradication, salivary EGF did not differ between the groups (2.17+/-2.06 vs 1.79+/-2.06 ng/min); the lack of difference was due to high peptide secretion in patients who developed erosive esophagitis after eradication.

CONCLUSION

Erosive esophagitis development following H. pylori eradication is not the result of decreased salivary EGF secretion.