The influence of Helicobacter pylori on oesophageal acid exposure in GERD during acid suppressive therapy

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.

Acid suppression and surgical therapy for Barrett's oesophagus

Gastro-oesophageal reflux disease is a common medical problem in developed countries, and is a risk factor for the development of Barrett's oesophagus and oesophageal adenocarcinoma. Both proton pump inhibitor therapy and antireflux surgery are effective at controlling endoscopic signs and symptoms of gastro-oesophageal reflux in patients with Barrett's oesophagus, but often fail to eliminate pathological oesophageal acid exposure. The current available studies strongly suggest that acid suppressive therapy, both pharmacological as well as surgical acid suppression, can reduce the risk the development and progression in patients with Barrett's oesophagus, but are not capable of complete prevention. No significant differences have been found between pharmacological and surgical therapy. For clinical practice, patients should be prescribed a proton pump inhibitor once daily as maintenance therapy, with the dose guided by symptoms. Antireflux surgery can be a good alternative to proton pump inhibitor therapy, but should be primarily offered to patients with symptomatic reflux, and not to asymptomatic patients with the rationale to protect against cancer.

Helicobacter pylori and nonmalignant diseases

Peptic ulcer bleeding and recurrence rate are strongly linked to Helicobacter pylori infection even if nonsteroidal anti-inflammatory drugs (NSAIDs) play a relevant role in this setting. Further studies confirm that H. pylori eradication lowers the risk of recurrent peptic ulcer bleeding. Therefore, a test-and-treat strategy appears to be mandatory for patients with a history of ulcer bleeding and NSAIDs and/or aspirin use. Concerning gastroesophageal reflux disease (GERD), evidence clearly shows that H. pylori status has no effect on symptoms and treatment. Therefore, H. pylori treatment is not contraindicated in patients with GERD. The exact role of H. pylori in functional dyspepsia (FD) remains controversial. Novel possible mechanisms by which H. pylori may elicit dyspeptic symptoms include alterations of gastric motility, as well as endocrine and acid-secretory abnormalities. Hunger sensations, acid secretion, and gastrointestinal motility are regulated by ghrelin, particularly produced by the gastric enteroendocrine cell compartment. The improvement of symptoms correlates with enhanced plasma ghrelin levels. Apart from the need for more trials on this topic, these findings may give insight into the underlying pathophysiology of FD symptoms. Recent reports suggest that the presence of bacterial DNA in the oral cavity may be relevant to its transmission. A potential protective role of H. pylori on inflammatory bowel diseases needs to be better elucidated.

Helicobacter pylori and nonmalignant diseases

Declining Helicobacter pylori prevalence rates have resulted in a decrease of peptic ulcer bleeding incidence. Moreover, eradication reduces peptic ulcer recurrence rate. Newer studies confirm that H. pylori eradication lowers the risk of recurrent peptic ulcer bleeding. Guidelines therefore advocate a test-and-treat strategy for patients with a history of ulcer bleeding and NSAIDs and/or aspirin use. There is mounting evidence that H. pylori status has no effect on symptoms and treatment efficacy in patients with gastroesophageal reflux disease (GERD). Some studies observed an improvement of GERD complaints after H. pylori eradication, which underlines that H. pylori treatment is not contra-indicated in GERD patients. The exact role of H. pylori in functional dyspepsia (FD) remains controversial. However, there is growing consensus that H. pylori-positive FD should be assessed as a separate entity. In these patients, eradication can be beneficial and appropriate. Finally, several studies suggest that H. pylori infection may also be associated with beneficial effects for the host. Epidemiologic studies showed an inverse relation between H. pylori infection and asthma and allergy, although data are conflicting and need to be expanded.

Treatment for Barrett's oesophagus

BACKGROUND

Treatments for Barrett's oesophagus, the precursor lesion of adenocarcinoma, are available but whether these therapies effectively prevent the development of adenocarcinoma, and in some cases eradicate the Barrett's oesophagus segment, remains unclear.

OBJECTIVES

To summarise, quantify and compare the efficacy of pharmacological, surgical and endoscopic treatments for the eradication of dysplastic and non-dysplastic Barrett's oesophagus and prevention of these states from progression to adenocarcinoma.

SEARCH STRATEGY

We searched CENTRAL (The Cochrane Library 2004, issue 4), MEDLINE (1966 to June 2008) and EMBASE (1980 to June 2008).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing medical, endoscopic or non-resectional surgical treatments for Barrett's oesophagus. The primary outcome measures were complete eradication of Barrett's and dysplasia at 12 months, and reduction in the number of patients progressing to cancer at five years or latest time point.

DATA COLLECTION AND ANALYSIS

Three authors independently extracted data and assessed the quality of the trials included in the analysis.

MAIN RESULTS

Sixteen studies, including 1074 patients, were included. The mean number of participants in the studies was small (n = 49; range 8 to 208). Most studies did not report on the primary outcomes. Medical and surgical interventions to reduce symptoms and sequelae of gastro-oesophageal reflux disease (GORD) did not induce significant eradication of Barrett's oesophagus or dysplasia. Endoscopic therapies (photodynamic therapy (PDT with aminolevulinic acid or porfimer sodium), argon plasma coagulation (APC) and radiofrequency ablation (RFA)) all induced regression of Barrett's oesophagus and dysplasia. The data for photodynamic therapy were heterogeneous with a mean eradication rate of 51% for Barrett's oesophagus and between 56% and 100% for dysplasia, depending on the treatment regimens. The variation in photodynamic therapy eradication rates for dysplasia was dependent on the drug, source and dose of light. Radiofrequency ablation resulted in eradication rates of 82% and 94% for Barrett's oesophagus and dysplasia respectively, compared to a sham treatment. Endoscopic treatments were generally well tolerated, however all were associated with some buried glands, particularly following argon plasma coagulation and photodynamic therapy, as well as photosensitivity and strictures induced by porfimer sodium based photodynamic therapy in particular.

AUTHORS' CONCLUSIONS

Despite their failure to eradicate Barrett's oesophagus, the role of medical and surgical interventions to reduce the troubling symptoms and sequelae of GORD is not questioned. Whether therapies for GORD reduce the cancer risk is not yet known. Ablative therapies have an increasing role in the management of dysplasia within Barrett's and current data would favour the use of radiofrequency ablation compared with photodynamic therapy. Radiofrequency ablation has been shown to yield significantly fewer complications than photodynamic therapy and is very efficacious at eradicating both dysplasia and Barrett's itself. However, long-term follow-up data are still needed before radiofrequency ablation can be used in routine clinical care without the need for very careful post-treatment surveillance. More clinical trial data and in particular randomised controlled trials are required to assess whether or not the cancer risk is reduced in routine clinical practice.

Barrett's esophagus: where do we stand?

Barrett's esophagus (BE) is a precursor for esophageal adenocarcinoma, which has an increased incidence rate over the last few decades. Its importance stems from the poor five-year survival of esophageal adenocarcinoma and current data that suggest a survival benefit when surveillance programs are implemented. In this review, we will cover the pathophysiology and natural history of BE and the different endoscopic findings. The prevalence of BE in different geographic areas and the incidence of high-grade dysplasia and adenocarcinoma in this patient population is reviewed. Recent recommendation for screening and surveillance of BE has been covered in this review as well as the efficacy of nonconventional imaging modalities and endoscopic ablation therapies.

Proton pump inhibitor therapy in gastro-oesophageal reflux disease decreases the oesophageal immune response but does not reduce the formation of DNA adducts

BACKGROUND

Chronic oesophageal inflammation and related oxidative stress are important in the pathogenesis of erosive oesophagitis (EO) and its malignant progression.

AIM

To study the effect of proton pump inhibitors (PPIs) on oesophageal cellular immune response and oxidative damage in EO patients.

METHODS

Forty gastro-oesophageal reflux disease (GERD) patients [non-erosive reflux disease (NERD): 15, EO: 25] were included, after 7 days off antisuppressive drugs. EO patients were randomized to 20-mg rabeprazole once daily for either 4 or 8 weeks with baseline and follow-up endoscopy with distal oesophageal biopsies. T lymphocytes, macrophages and mast cells were quantified by immunohistochemistry. DNA adducts were measured by analysis of 8-oxo-deoxyguanosine levels.

RESULTS

Erosive oesophagitis patients had more T lymphocytes and CD8(+) T lymphocytes in squamous epithelium than NERD patients (P = 0.001, P = 0.002, respectively). Levels of DNA adducts between both groups were, however, not different (P = 0.99). Four- and eight-week rabeprazole treatment in EO patients resulted in a significant decrease in number of T lymphocytes and CD8(+) T lymphocytes (all P < 0.05). PPIs did not, however, affect levels of DNA adducts.

CONCLUSIONS

Short-term PPI therapy in EO patients reduces the oesophageal cellular immune response, but does not change oxidative damage. PPI therapy may therefore not be effective in reducing the risk of oesophageal cancer in GERD patients.

Increased prevalence of Helicobacter pylori infection in gastric cardia of patients with reflux esophagitis: a study from Jordan

BACKGROUND

The role of H. pylori infection in GERD is highly controversial. Our aim was to investigate the relationship between reflux esophagitis and H. pylori infection in Jordanian subjects and to examine the gastric site for H. pylori that is most strongly associated with reflux esophagitis.

METHODS

During endoscopy two biopsies from the cardia and another two biopsies from the antrum were taken from 100 consecutive patients with reflux esophagitis (RE group) and from a sex- and age-matched group of 50 patients, who were referred to the endoscopy unit for evaluation of upper gastrointestinal symptoms and whose endoscopic findings were normal (control group). The biopsies were examined histologically for the presence of gastritis and H. pylori.

RESULTS

Antral histological gastritis, Barrett's esophagus and hiatus hernia were significantly more common in the RE group than in the control group. Out of the 100 patients, 68 (68%) in the RE group and 26 of 50 (52%) in the control group were found to have H. pylori infection. The presence of H. pylori in both antral and cardiac biopsies was significantly more frequent in patients of the RE group. Forty-four patients in the RE group had positive H. pylori in both antral and cardiac biopsies (44%), while only 12 out of 50 patients of the control group (24%) had positive H. pylori in both biopsies. In the control group the prevalence of H. pylori in the antrum was similar to that of patients of the RE group (52% vs. 59%), but colonization of H. pylori in the cardia was significantly much lower than that of the RE group (24% vs. 53%; P = 0.0007).

CONCLUSIONS

The increased prevalence of H. pylori colonization in the cardia is associated with reflux esophagitis and further controlled clinical study is required to show the impact of H. pylori eradication in patients with reflux esophagitis.

Safety and symptom improvement with esomeprazole in adolescents with gastroesophageal reflux disease

OBJECTIVES

The primary objective was to assess the safety of esomeprazole 20 or 40 mg once daily in adolescents with clinically diagnosed gastroesophageal reflux disease (GERD). A secondary aim was to assess changes in GERD symptoms after esomeprazole therapy.

PATIENTS AND METHODS

In this multicenter, randomized, double-blind study, adolescents ages 12 to 17 years inclusive received esomeprazole 20 or 40 mg once daily for 8 weeks. Adverse events and changes in clinical parameters (eg, physical examination, laboratory measurements) were evaluated to assess safety. Patients or their parents or guardians scored symptom severity daily, and investigators scored overall GERD symptom severity every 2 weeks using a 4-point scale.

RESULTS

In the 148 adolescents with safety data, treatment-related and non-treatment-related adverse events were reported by 75% and 78% of patients in the esomeprazole 20- and 40-mg groups, respectively. Twenty-two patients (14.9%) experienced adverse events that were considered related to treatment; the most common were headache (8%, 12/148), abdominal pain (3%, 4/148), nausea (2%, 3/148), and diarrhea (2%, 3/148). No serious adverse events or clinically important findings in other safety assessments were observed. At baseline, 68% (100/147) had heartburn, 63% (93/147) had epigastric pain, 57% (84/147) had acid regurgitation, and 15% (22/147) had vomiting symptoms. Symptom scores decreased significantly in both the esomeprazole 20-mg and 40-mg groups by the final study week (P < 0.0001). Investigators rated 63.1% (94/149) of the patients as having moderate or severe symptoms at baseline; at the final visit, this percentage decreased significantly to 9.3% (13/140; P < .0001).

CONCLUSIONS

In adolescent patients with GERD, esomeprazole 20 or 40 mg daily for 8 weeks was well tolerated, and GERD-related symptoms were significantly reduced from baseline values in both groups.

Proton pump inhibitors and Helicobacter pylori gastritis: friends or foes?

H. pylori gastritis and gastric acid closely interact. In H. pylori-positive patients, profound acid suppressive therapy induces a corpus-predominant pangastritis, which is associated with accelerated corpus gland loss and development of atrophic gastritis. Both corpus-predominant and atrophic gastritis have been associated with an increased risk of development of gastric cancer. H. pylori eradication leads to resolution of gastritis and may induce partial regression of pre-existent gland loss. H. pylori eradication does not aggravate GERD nor does it impair the efficacy of proton pump inhibitor maintenance therapy for this condition. This is the background of the advise within the European guidelines for the management of H. pylori infection to offer an H. pylori test and treat policy to patients who require proton pump inhibitor maintenance therapy for GERD. As such a policy fully reverses H. pylori pangastritis even in patients who have been treated for years with proton pump inhibitors, there is no need to eradicate H. pylori before the start of proton pump inhibitors. In fact, the somewhat slower initial response of H. pylori-negative GERD patients to proton pump inhibitor therapy and the fact that many GERD patients will only require short-term therapy suggests to first start the proton pump inhibitor, and only test and treat when maintenance therapy needs to be prescribed. Such considerations prevent the persistent presence of active corpus-predominant gastritis in proton pump inhibitor-treated reflux patients without impairing the clinical efficacy of treatment.

Does Helicobacter pylori infection influence response rate or speed of symptom control in patients with gastroesophageal reflux disease treated with rabeprazole?

OBJECTIVE

The findings of several studies suggest that proton-pump inhibitors (PPIs) suppress gastric acid more effectively in Helicobacter pylori-infected (Hp +) than in non-infected (Hp -) patients, but there has been no evaluation of the short-term clinical response.

MATERIAL AND METHODS

Results of the first week of treatment with rabeprazole in Hp+ and Hp- patients with gastroesophageal reflux disease (GERD) were compared in a large prospective open-label, multicenter, cohort study in general and specialized practices. GERD patients were recruited on the basis of either typical symptoms alone or endoscopic results, assessed for H. pylori infection and treated with rabeprazole (20 mg). Heartburn and regurgitation symptoms were assessed daily during the first 7 days. Outcome parameters were calculated for both symptoms and compared between Hp+ and Hp- patients.

RESULTS

Data on 1548 patients (74.5% Hp-, 25.5% Hp + ) were available. Mean heartburn and regurgitation scores decreased during the first week. For both symptoms, more than 70% of the patients had "adequate" symptom relief at day 5, and more than 80% at day 7. "Complete" symptom relief was reached in more than 70% of patients. Mean onset of adequate symptom control was about 4 days. In Hp+ and Hp- patients there was no difference in response for any of the parameters.

CONCLUSIONS

Among patients treated with rabeprazole in clinical practice, H. pylori infection or its absence has no effect on the speed or degree of GERD symptom relief. Infected patients and non-infected patients can therefore be treated with a similar dose. When treating heartburn with rabeprazole, physicians do not need to consider the patient's H. pylori status and most patients (>80%) have adequate symptom relief after just a few days of treatment.

Antireflux surgery for Barrett's esophagus: comparative results of the Nissen and Collis-Nissen operations

Using a Collis-Nissen repair instead of a standard Nissen fundoplication to treat the reflux disease of Barrett's esophagus is controversial. This paper compares the Nissen and Collis-Nissen operations when treating Barrett's esophagus. Thirty-three patients with documented Barrett's esophagus (male : female, 26 : 7, median age, 48.8 years) had a Nissen fundoplication during 1976-1989. Fifty-one patients (male : female = 41 : 10, median age = 53.2 years) underwent a Collis-Nissen operation between 1990 and 1999. Clinical assessments, esophagogram, radionuclide emptying, manometry, 24-h pH study, and endoscopy were obtained pre- and postoperatively. There was no operative death in either group. Median follow-up was 8.0 years for the Nissen group and 6.5 years for the Collis group. Postoperative reflux symptoms were more frequent in the Nissen group (52%) when compared to the Collis group (7%, P < 0.001). These symptoms correlated with the 24-h pH recordings revealing an increased acid exposure in the Nissen group (3.4%) as opposed to 1% in the Collis group (P = 0.003). Endoscopy revealed mucosal erosions and ulcers in 39% of patients receiving a standard Nissen repair while these damages were seen in 7% of patients who were offered an elongation gastroplasty with a total fundoplication (P = 0.007). The cumulative success rate was 83% for the Nissen group and 100% for the Collis group at 5 years, and 63% versus 90% at 10 years (Log-rank test, P = 0.004). The Collis-Nissen fundoplication provides better reflux protection for Barrett's patients than a standard Nissen repair. It lowers the risk of fundoplication failure.

Indicaciones y consecuencias de la erradicación de Helicobacter pylori en la enfermedad por reflujo gastroesofágico

Several epidemiological data indicate that H. pylori infection prevalence in patients with gastroesophageal reflux disease (GERD) is lower than that reported in respective controls, which would suggest that the organism plays a protective role against this disease. On the other hand, most studies demonstrate that the presence of the infection in patients with GERD does not negatively affect the therapeutic efficacy of proton pump inhibitors (PPIs), and, in case of negatively influencing it, the effects are not clinically relevant and are easily controllable with standard antisecretory treatment. Therefore, the decision to administer H. pylori eradication treatment to a patient should not be influenced by the concomitant presence of GERD. In most cases, H. pylori eradication does not seem to induce GERD development, and it does not seem to worsen GERD when it was already present. Nevertheless, when the gastritis pattern is unknown before the antibiotic administration, the effect of H. pylori eradication on gastric acid secretion and the incidence of GERD is unpredictable. In the exceptional cases in which H. pylori eradication could have negative effects on GERD, its clinical relevance will be limited, and reflux symptoms or endoscopic esophagitis will favourably respond to the standard PPI antisecretory treatment. Therefore, again, when H. pylori eradication is indicated in a particular patient, the concomitant diagnosis of GERD should not change our attitude. Finally, is has recently been recommended to eradicate H. pylori infection in those patients with GERD needing long-term treatment with PPI, as some studies have reported that these drugs induce, in presence of the organism, an atrophic gastritis, with the consequent risk of gastric cancer. However, most of these studies have important methodological defects, and several authors have reported contrary results. In any case, the appearance in the gastric mucosa of clinically relevant lesions, such as intestinal metaplasia, dysplasia or adenocarcinoma, in patients treated with PPI for several years, has not yet been demonstrated, although this could simply be a problem of time. This question seems to be too controversial to be answered with the available data, and we should wait until new studies clarify this topic. In the meantime, as it occurs with any controversial indication, the decision of the doctor facing a patient infected by H. pylori and needing maintenance therapy with PPIs should be assessed on a case by case basis.

Clinical manifestations and complications of gastroesophageal reflux disease (GERD)

Gastroesophageal reflux-induced diseases are among the most common disorders and are associated with classical oesophageal manifestations of gastroesophageal reflux disease (GERD) including a range of symptoms such as heartburn, acid regurgitation and chest pain, and also organic manifestations such as oesophagitis, oesophageal strictures and ulcerations, Barrett's oesophagus and oesophageal adenocarcinoma. Recognition of its impact on other organ systems, extra-oesophageal reflux diseases, such as the ear, nose and throat (ENT) region and the bronchopulmonary system, as well as its contribution to symptoms such as chest pain and sleep disturbances, is also increasing. This paper addresses the symptoms, diseases and complications in which the abnormal reflux of gastric content to the oesophagus and adjacent organ systems is believed to be a frequent contributory factor.

[Reflux esophagitis]

Gastroesophageal reflux disease (GERD) is one of the most prevalent diseases in the industrialized countries. Approximately 15-25% of adults suffer from reflux symptoms, characterized mainly by heartburn and/or regurgitation. Currently, antisecretory medication with proton pump inhibitors (PPI) or antireflux surgery are the established options for GERD-treatment. PPI are the therapeutic gold standard in acute, long-term or on-demand therapy of GERD. Since PPI do not restore the antireflux barrier but merely suppress acid secretion a life-long tablet adherence is required in most cases. In view of limitations of PPI and the potential risks of laparoscopic surgery, several endoscopic antireflux techniques were developed and may evolve as a valuable third option. However, so far objective long-term data are lacking for choosing the appropriate patient who will benefit most from endoluminal antireflux therapy.

Review article: oesophageal complications and consequences of persistent gastro-oesophageal reflux disease

The major oesophageal complications associated with persistent gastro-oesophageal reflux disease (GERD) include erosive oesophagitis, ulceration, strictures and gastrointestinal (GI) bleeding. Although the causes of these complications are uncertain, studies indicate that erosive oesophagitis may progress to the development of ulcers, strictures and GI bleeding. Pharmacological treatment with proton pump inhibitors is favoured over that with H(2)-receptor antagonists for the treatment of strictures. The treatment of strictures is accomplished with dilation and many favour the concomitant use of proton pump inhibitors. Most gastroenterologists are seeing far fewer oesophageal strictures these days since the introduction of proton pump inhibitors. In addition, research has shown that oesophageal complications have a greater impact on patients suffering from night-time GERD than on those suffering from daytime GERD. Barrett's oesophagus is a significant complication associated with persistent GERD and those at risk generally experience a longer duration of symptoms, especially those with a high degree of severity. In addition, there is a strong relationship between Barrett's oesophagus and oesophageal adenocarcinoma. This is in part due to the association of obesity and the development of hiatal hernias. Furthermore, endoscopic screening is being used to detect Barrett's oesophagus and oesophageal adenocarcinoma in persons suffering from chronic GERD, even though screening may not have an impact on outcomes (Sharma P, McQuaid K, Dent J, et al. A critical review of the diagnosis and management of Barrett's esophagus: The AGA Chicago Workshop. Gastroenterology 2004; 127: 310-30.).

Systematic review: the effect of Helicobacter pylori and its eradication on gastro-oesophageal reflux disease in patients with duodenal ulcers or reflux oesophagitis

BACKGROUND

The effect of Helicobacter pylori in provoking or protecting against gastro-oesophageal reflux disease is unclear and studies have given conflicting results. Recent guidelines recommend H. pylori eradication in patients on long-term proton pump inhibitors.

AIM

To ascertain the effect of H. pylori eradication on gastro-oesophageal reflux disease outcomes (reflux oesophagitis and heartburn) in patients with duodenal ulcer disease, and to ascertain the effect of H. pylori infection on reflux oesophagitis concerning heartburn, pH, severity, healing and relapse rates.

METHODS

A systematic review of electronic databases was undertaken to September 2003. Experts in the field, pharmaceutical companies and journals were contacted about unpublished trials. Studies were reviewed according to predefined eligibility and quality criteria. Twenty-seven studies/trials were included in the systematic review.

RESULTS

Study variation rather than therapy-influenced results in relation to the presence or absence of oesophagitis in patients with duodenal ulcer who underwent H. pylori eradication at 6-48 months follow-up. In patients with reflux oesophagitis no obvious differences were discovered in heartburn scores, 24-h pH values, healing and relapse rates between H. pylori-positive and -negative cases.

CONCLUSION

There is no evidence to indicate that H. pylori eradication in duodenal ulcer disease provokes reflux oesophagitis or worsens heartburn; (ii) there are insufficient data to draw firm conclusions about the impact of H. pylori in patients with reflux oesophagitis.

A 1 year follow-up study of the consequences of Helicobacter pylori eradication in duodenal ulcer patients: unchanged frequency of erosive oesophagitis and decreased prevalence of non-erosive gastro-oesophageal reflux disease

BACKGROUND AND AIM

Discussions concerning the increased incidence of gastro-oesophageal reflux disease (GORD) after Helicobacter pylori eradication continue. In this study we aimed to evaluate the presence of co-existing GORD in (1) duodenal ulcer patients after successful H. pylori eradication, (2) patients with persistent H. pylori infection after attempts at eradication, and (3) controls in whom H. pylori eradication had not been attempted.

METHODS

A prospective study of 255 patients with duodenal ulcer who were assigned to H. pylori eradication or to control treatment (omeprazole for 4 weeks) and followed up for 1 year or until peptic ulcer relapse. GORD was determined in the patients who had reflux oesophagitis on endoscopy at the beginning of the study and/or in patients without reflux oesophagitis if they experienced heartburn and/or regurgitation at least twice a week associated with impairment of daily activities.

RESULTS

The study revealed a significant decrease (from 44.6% to 21.7%; P < 0.001) of patients with GORD at the end of the follow-up among those in whom H. pylori eradication had been successful. There was no significant difference in the frequency of reflux oesophagitis before and after the follow-up regardless of H. pylori status.

CONCLUSIONS

H. pylori eradication did not significantly influence the prevalence and incidence of reflux oesophagitis in patients with duodenal ulcer during a 1 year follow-up period, but there was a significantly lower prevalence of GORD after successful H. pylori eradication, as patients with non-erosive GORD had been cured.

New approaches to Helicobacter pylori infection in children

Helicobacter pylori infection is usually acquired during childhood, and evidence-based guidelines regarding diagnosis and treatment of infected children have been recently published. Diseases associated with H. pylori infection are gastritis, duodenal ulcers, mucosal-associated lymphoid-type (MALT) lymphoma, and gastric adenocarcinoma. The association of specific symptoms with H. pylori infection in children and adults (ie, recurrent abdominal pain and nonulcer dyspepsia) remains controversial. Additionally, the role of H. pylori in gastroesophageal reflux disease or in extra-gastrointestinal diseases (ie, coronary artery disease) lacks sufficient evidence to demonstrate causality. The diagnosis of H. pylori-associated diseases in children can reliably be made through gastroduodenal endoscopy with biopsies. Clinical trials are underway for the validation of noninvasive diagnostic tests for the H. pylori-infected child, and current guidelines recommend eradication therapy for infected children with duodenal and gastric ulcer, gastric lymphoma, and atrophic gastritis with intestinal metaplasia. The natural history of childhood H. pylori infection is poorly described. Moreover, rational approaches to the prevention and control of childhood H. pylori infection are critically needed, requiring characterization of the determinants for acquisition and persistence and the disease outcomes following eradication.

Effect of Helicobacter pylori infection in Barrett's esophagus and the genesis of esophageal adenocarcinoma

The relation between Helicobacter pylori and gastroesophageal reflux disease is unclear. Recent reports have suggested a possible protective role for H. pylori, particularly in preventing the complications of gastroesophageal reflux disease (GERD). The purpose of this article is to present a brief overview of the recent literature regarding the role of H. pylori in the genesis of the complications of GERD, focusing on Barrett's esophagus and esophageal adenocarcinoma. The prevalence of H. pylori infection in the population of the West is around 40% and is not different in cohorts of patients with GERD. When the infection induces pangastritis or corpus-predominant gastritis, there may be concomitant reduced gastric acid secretion. Eradication of the bacteria in this subgroup of patients may enhance gastric acid secretion and provoke reflux symptoms. H. pylori organisms do not colonize the specialized intestinal metaplasia characteristic of Barrett's esophagus. H. pylori infection rates in gastric mucosa of patients with Barrett's esophagus occur at a similar or slightly lower frequency than is found in controls. Gastric infection with cagA-positive strains of H. pylori appears to be uncommon in patients with Barrett's esophagus. Furthermore, epidemiologic studies indicate that cagA-positive strains are protective against esophageal adenocarcinoma. Several investigators have proposed that the decreasing prevalence of H. pylori infection might be an important factor in the rising incidence of this tumor.

Influence of Helicobacter pylori infection on severity of oesophagitis and response to therapy in the elderly

BACKGROUND

The prevalence both of Helicobacter pylori infection and oesophagitis is higher in the elderly, than in adult and young populations. However the relationship between Helicobacter pylori infection and the clinical behaviour of oesophagitis has not yet been clarified.

AIM

To evaluate the influence of Helicobacter pylori infection on the severity and clinical outcome after treatment of oesophagitis in elderly patients.

METHODS

A total of 271 elderly patients (134 male, 137 female, mean age = 79.2 years, range 65-96) with grade 1 to 3 oesophagitis were studied. At baseline, the patients were divided into 3 groups according to Helicobacter pylori infection: Group 1 = 88 Helicobacter pylori-negative patients; Group 2 = 59 Helicobacter pylori-positive patients and Group 3 = 124 Helicobacter pylori-positive patients who underwent a one-week proton pump inhibitor-based triple therapy for the eradication of Helicobacter pylori infection. All patients were treated with proton pump inhibitors for two months; patients in Group 3 were also treated for one week with proton pump inhibitors plus two antibiotics. After two months, endoscopy and histology were repeated.

RESULTS

At baseline, 32.5% of patients were Helicobacter pylori-negative and 67.5% were Helicobacter pylori-positive. No baseline differences in severity of oesophagitis were found between Helicobacter pylori negative and positive patients. After proton pump inhibitor therapy, the complete resolution of oesophagitis was observed in 80.7% of Group 1, 76.3% of Group 2 and 75.8% of Group 3 (p=ns). Dividing patients also according to the severity of oesophagitis, no difference in healing rates between the three Groups were observed.

CONCLUSIONS

In this elderly population, Helicobacter pylori infection did not influence the severity of oesophagitis at baseline or the response to short-term treatment with proton pump inhibitors. Furthermore, Helicobacter pylori eradication therapy did not influence the healing rate of oesophagitis.

Current concepts in the management of Helicobacter pylori infection--the Maastricht 2-2000 Consensus Report

Significant progress and new insights have been gained in the 4 years since the first Maastricht Consensus Report, necessitating an update of the original guidelines. To achieve this, the European Helicobacter Pylori Study Group organized a meeting of specialists and experts from around the world, representatives from National Gastroenterology Societies and general practitioners from Europe to establish updated guidelines on the current management of Helicobacter pylori infection. The meeting took place on 21-22 September 2000. A "test and treat" approach is recommended in adult patients under the age of 45 years (the age cut-off may vary locally) presenting in primary care with persistent dyspepsia, having excluded those with predominantly gastro-oesophageal reflux disease symptoms, non-steroidal anti-inflammatory drug users and those with alarm symptoms. Diagnosis of infection should be by urea breath test or stool antigen test. As in the previous guidelines, the eradication of H. pylori is strongly recommended in all patients with peptic ulcer, including those with complications, in those with low-grade gastric mucosa-associated lymphoid tissue lymphoma, in those with atrophic gastritis and following gastric cancer resection. It is also strongly recommended in patients who are first-degree relatives of gastric cancer patients and according to patients' wishes after full consultation. It is advised that H. pylori eradication is considered to be an appropriate option in infected patients with functional dyspepsia, as it leads to long-term symptom improvement in a subset of patients. There was consensus that the eradication of H. pylori is not associated with the development of gastro-oesophageal reflux disease in most cases, and does not exacerbate existing gastro-oesophageal reflux disease. It was agreed that the eradication of H. pylori prior to the use of non-steroidal anti-inflammatory drugs reduces the incidence of peptic ulcer, but does not enhance the healing of gastric or duodenal ulcer in patients receiving antisecretory therapy who continue to take non-steroidal anti-inflammatory drugs. Treatment should be thought of as a package which considers first- and second-line eradication therapies together. First-line therapy should be with triple therapy using a proton pump inhibitor or ranitidine bismuth citrate, combined with clarithromycin and amoxicillin or metronidazole. Second-line therapy should use quadruple therapy with a proton pump inhibitor, bismuth, metronidazole and tetracycline. Where bismuth is not available, second-line therapy should be with proton pump inhibitor-based triple therapy. If second-line quadruple therapy fails in primary care, patients should be referred to a specialist. Subsequent failures should be handled on a case-by-case basis by the specialist. In patients with uncomplicated duodenal ulcer, eradication therapy does not need to be followed by further antisecretory treatment. Successful eradication should always be confirmed by urea breath test or an endoscopy-based test if endoscopy is clinically indicated. Stool antigen test is the alternative if urea breath test is not available.

Helicobacter pylori eradication does not exacerbate reflux symptoms in gastroesophageal reflux disease

BACKGROUND & AIMS

Observational studies have suggested that Helicobacter pylori may protect against gastrointestinal reflux disease (GERD), but these results could be due to bias or confounding factors. We addressed this in a prospective, double blind, randomized, controlled trial.

METHODS

H. pylori-positive patients with at least a 1-year history of heartburn with a normal endoscopy or grade A esophagitis were recruited. Patients were randomized to 20 mg omeprazole, 250 mg clarithromycin, and 500 mg tinidazole twice a day for 1 week or 20 mg omeprazole twice a day and identical placebos. A second concurrently recruited control group of H. pylori-negative patients were given open label 20 mg omeprazole twice a day for 1 week. All patients received 20 mg omeprazole twice a day for the following 3 weeks and 20 mg omeprazole once daily for a further 4 weeks. Omeprazole was discontinued at 8 weeks and patients were followed up for a further 10 months. A relapse was defined as moderate or severe reflux symptoms. H. pylori eradication was determined by 13C-urea breath test.

RESULTS

The H. pylori-positive cases were randomized to antibiotics (n = 93) or placebo (n = 97). Relapse of GERD occurred in 83% of each of the antibiotic, placebo, and H. pylori-negative groups during the 12-month study period. Life tables revealed no statistical difference between the 2 H. pylori-positive groups (log rank test, P = 0.84) or between the 3 groups (log rank test, P = 0.94) in the time to first relapse. Two patients in each group developed grade B esophagitis at 12 months.

CONCLUSIONS

H. pylori eradication therapy does not seem to influence relapse rates in GERD patients.

Helicobacter pylori: a debated factor in gastroesophageal reflux disease

The prevalence of Helicobacter pylori infection is steadily decreasing in developing countries, and this has been paralleled by an increasing incidence of gastroesophageal reflux disease (GERD) and adenocarcinomas of the esophagus and of the esophagogastric junction. The prevalence of H. pylori infection, which is on the decline in Europe and in the United States, is probably related to improvements in sanitary conditions and socioeconomic status. These epidemiological data do not support a role for H. pylori in the pathogenesis of GERD, but at the same time suggest a negative association with the rising incidence in esophageal diseases. While H. pylori infection clearly does not cause GERD, it may protect certain susceptible individuals from the development of GERD and its complications. There are conflicting reports that GERD can develop after H. pylori eradication and that proton pump inhibitors are less effective in suppressing intragastric acidity in H. pylori negative patients--reasons not to eradicate H. pylori in GERD patients. On the contrary, other data suggest an increase in the development of atrophic gastritis in GERD patients (H. pylori positive) on long-term proton pump inhibitor therapy - a reason to eradicate H. pylori. Preexisting lower esophageal sphincter dysfunction, susceptibility to GERD, unmasking of latent GERD, and patterns and severity of gastritis may be important factors contributing to the development of GERD rather than just the presence or absence of infection with H. pylori.

Helicobacter pylori infection in children

A number of scientific breakthroughs since H pylori first became recognized as a human pathogen have increased our understanding of the pathogenesis of gastroduodenal disease. In particular, advances in molecular bacteriology and the complete sequencing of the H pylori genome in 1999, and soon thereafter the human genome, provide tools allowing better delineation of the pathogenesis of disease. These molecular tools for both bacteria and host should now be applied to multicenter pediatric studies that evaluate disease outcome. More recent developments indicate that a better understanding of the microbial-host interaction is critical to furthering knowledge with respect to H pylori-induced diseases. Studies are needed to evaluate either DNA-based or more traditional protein-based vaccines, to evaluate more specific antimicrobials that confer minimal resistance, and to evaluate probiotics for the management of H pylori infection. Multicenter multinational studies of H pylori infection in the pediatric population, which include specific, randomized controlled eradication trials, are essential to extend current knowledge and develop better predictors of disease outcome.

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

BACKGROUND

There is little information on the effects of Helicobacter pylori eradication in patients with a primary diagnosis of gastro-oesophageal reflux disease (GORD). Our aim was to investigate the effect of H pylori eradication in this group of patients.

METHODS

We did a double-blind, randomised, placebo-controlled study in 70 patients with GORD. We assigned individuals to three groups. All patients received lansoprazole 30 mg twice daily for 10 days, followed by 30 mg once daily for 8 weeks. Patients infected with H pylori received either antibiotics (clarithromycin 500 mg and amoxicillin 1000 mg twice daily) or placebo for the first 10 days. Controls were patients not infected with H pylori. Patients were followed up for 6 months at 2-week intervals for GORD symptoms. At the end of the study we repeated endoscopy and oesophageal and gastric 24 h-pH monitoring.

FINDINGS

58 of 70 patients completed our study. At the end of the study 16 of these patients were H pylori-positive (14 placebo and two eradication failures), 13 were negative because of successful H pylori eradication, and 29 were controls. H pylori-positive patients relapsed earlier (54 days) than did those in whom H pylori was eradicated (100 days) (p=0.046). The H pylori-negative control group relapsed after the longest period (110 days). However, time to relapse was also affected by oesophagitis grade (no oesophagitis 127 days, grade III or IV oesophagitis 18 days). When results were corrected for the affect of oesophagitis grade, H pylori-positive patients relapsed earlier (p=0.086) than H pylori-eradiated patients and controls (p=0.001).

INTERPRETATION

H pylori infection positively affects the relapse rate of GORD. Eradication of H pylori could, therefore, help to prolong disease-free interval in patients with GORD.

Helicobacter pylori infection and gastro-oesophageal reflux disease: coincidence or association?

Concerning the relationship between Helicobacter pylori infection and gastro-oesophageal reflux disease (GORD), the debate is ongoing whether the infection confers protection, is harmful or whether both entities are independent. Epidemiological evidence is given for an increased prevalence of GORD and a decreased prevalence of H. pylori infection in the western world. The assumpton derived from it is that H. pylori protects from GORD. Pathophysiological aspects need to consider the type and expression of gastritis which is associated with varying changes of gastric function. Depending on the type of gastritis, acid secretion may either increase or decrease and thereby impact on acid exposure of the oesophagus. Other changes related to the role of H. pylori in pathophysiology of GORD are still hypothetical. Clinical data are controversial whether or not GORD increases after H. pylori eradication. Prospective studies including characterization of strains and gastric physiology will clarify this issue. An accelerated induction of gastric mucosal atrophy in patients on long-term proton pump inhibitors is reported in most available studies. An increase of inflammatory activity in fundic and corpus mucosa is a consistent phenomenon. Therefore, in the authors' opinion, eradication appears advisable.

Review article: is Helicobacter pylori status relevant in the management of GORD?

There is growing interest in the relationship between H. pylori infection and gastro-oesophageal reflux disease (GORD). However, this relationship is complex, as yet not fully elucidated, and probably based on a multiplicity of factors. The prevalence of H. pylori infection in patients with GORD is similar, more often lower than in matched controls. There is a negative correlation between H. pylori infection and the severity of GORD. There are many hypothetical mechanisms by which H. pylori infection may protect from the development of GORD. Conversely, there are many possible mechanisms by which H. pylori infection could theoretically foster the GORD. Patients after H. pylori eradication may develop GORD, and this seems to suggest a protective role of H. pylori infection, but other possible explanations include weight gain after H. pylori eradication, changes in dietary habits and smoking, and pre-existing GORD. H. pylori infected patients treated by various acid-inhibiting therapies such as proton pump inhibitors (PPIs), H2-receptors antagonists (H2-RA) or vagotomy, have an increase of their corpus gastritis severity, both in the activity of inflammation and in the density of organisms. Long-term therapy of GORD in H. pylori infected may lead to rapid progression of atrophic gastritis intestinal metaplasia and dysplasia, and increase the risk of developing gastric cancer. More recently it has been shown that H. pylori infection may interfere with the acid suppressive therapies used for treating GORD. In our opinion the progression of gastritis depends on the threshold of acid output at which H. pylori can 'flourish'. Recently interest is growing on gastric transitional zones and Helicobacter ecology. Any decrease of acid secretion changes the behaviour of H. pylori: the activity of gastritis improves in the antrum, but it deteriorates in the body. During proton pump inhibitor treatment, H. pylori redistribution occurs within the stomach, from an antral to a corpus or fundus prevalent pattern; corpus-fundus gastritis, exacerbated by PPI therapy, may result both in a diminished acid secretion and gastro-oesophageal reflux. The interest in Barrett's oesophagus is growing due to the associated risk of adenocarcinoma. The literature seems to demonstrate that the prevalence of H. pylori infection of the stomach in Barrett's oesophagus patients is not different from that exhibited by controls, roughly one-third of the subjects. Intestinal metaplasia of the gastric cardia seems to be equally frequent in patients with and without GORD. Finally, it appears unlikely that a causal relationship exists between H. pylori infection and Barrett's-associated adenocarcinoma.

A comprehensive review of the natural history of Helicobacter pylori infection in children

Across populations of children, Helicobacter pylori prevalence ranges from under 10% to over 80%. Low prevalence occurs in the U.S., Canada, and northern and western Europe; high prevalence occurs in India, Africa, Latin America, and eastern Europe. Risk factors include socioeconomic status, household crowding, ethnicity, migration from high prevalence regions, and infection status of family members. H. pylori infection is not associated with specific symptoms in children; however, it is consistently associated with antral gastritis, although its clinical significance is unclear. Duodenal ulcers associated with H. pylori are seldom seen in children under 10 years of age. H. pylori-infected children demonstrate a chronic, macrophagic, and monocytic inflammatory cell infiltrate and a lack of neutrophils, as compared with the response observed in adults. The effect of H. pylori infection on acid secretion in children remains poorly defined. The events that occur during H. pylori colonization in children should be studied more thoroughly and should include urease activity, motility, chemotaxis, adherence, and downregulation of the host response. The importance of virulence determinants described as relevant for disease during H. pylori infection has not been extensively studied in children. Highly sensitive and specific methods for the detection of H. pylori in children are needed, especially in younger pediatric populations in which colonization is in its early phases. Criteria for the use of eradication treatment in H. pylori-infected children need to be established. Multicenter pediatric studies should focus on the identification of risk factors, which can be used as prognostic indicators for the development of gastroduodenal disease later in life.

Review article: the clinical influence of Helicobacter pylori in effective acid suppression-implications for the treatment of gastro-oesophageal reflux disease

The relationship between gastro-oesophageal reflux disease (GERD) and Helicobacter pylori is unclear. Recent data indicate that H. pylori probably exerts a protective effect against GERD. In recent years, the interaction between H. pylori, proton pump inhibitors and GERD has been widely studied. Currently available proton pump inhibitors produce significantly higher intragastric pH in H. pylori-positive patients than in those who are H. pylori negative, and this phenomenon may be clinically relevant. The mechanisms responsible for this difference in efficacy are not fully understood, although there are two major theories. Ammonia, produced by H. pylori, is able to neutralize gastric acid, and thus apparently increase the effect of acid suppressive agents (the 'ammonia theory'). The other theory is that decrease in acid output is due to the development of corpus gastritis during treatment with a proton pump inhibitor (the 'gastritis theory'). Treatment strategies to overcome this lowered sensitivity to acid suppression are to increase the frequency/dose of a proton pump inhibitor or to add an H2-receptor antagonist in the evening-but both have pharmaco-economic implications. An agent that could provide adequate pH control regardless of H. pylori status would be highly beneficial in the treatment of GERD, and may also lower treatment costs.

Barrett esophagus

Barrett esophagus continues to intrigue investigators and clinicians alike as the new millennium begins. A large number of publications in the past year have discussed issues of epidemiology, prevalence, detection, and treatment of Barrett esophagus. Chronic symptoms of gastroesophageal reflux were identified as a strong risk for esophageal adenocarcinoma. The relative frequency of short and long Barrett and cardia intestinal metaplasia in patients who undergo upper endoscopy have been better defined. Biomarkers in patients with Barrett may eventually be helpful in identifying those at high risk for the development of neoplasia. High-dose proton pump inhibition to the point of near elimination of esophageal acid exposure remains disappointing in its impact on the surface area of Barrett. Finally, the developments in endoscopic therapy for patients with Barrett esophagus continue to be promising.

Failure of oesophageal acid control in candidates for Barrett's oesophagus reversal on a very high dose of proton pump inhibitor

BACKGROUND

Normalization of oesophageal acid exposure using high dose proton pump inhibitors in patients who are candidates for ablation therapy has been suggested to be essential for successful Barrett's reversal. However, the success rate for achieving pH normalization has not been determined.

METHODS

Patients with Barrett's oesophagus (2-6 cm in length) who were found to be eligible for ablation therapy using multipolar electrocoagulation were included in this prospective study. Patients underwent an upper endoscopy to determine Barrett's length and other anatomic characteristics. Biopsies were obtained to rule out dysplasia. Subsequently, patients were treated with omeprazole 40 mg b.d. Twenty-four hour oesophageal pH monitoring was performed after a mean period of 8.4 +/- 0.6 days of therapy.

RESULTS

Twenty-five patients were enrolled into the study. The pH test was abnormal in four (16%) of the study subjects. An additional two (8%) patients had abnormal supine percentage time with pH less than 4. There was no significant difference in oesophageal acid control between patients with long vs. short segment Barrett's oesophagus. Elderly (> 60 years) patients tended to have less acid control than younger (</= 60 years) patients.

CONCLUSIONS

Failure of oesophageal acid control in candidates for Barrett's oesophagus reversal on very high dose of proton pump inhibitor is not uncommon. Our study suggests that ambulatory 24-h oesophageal pH monitoring should be considered in all candidates for Barrett's reversal who are treated with high dose proton pump inhibitor to ensure normalization of oesophageal acid exposure.