Helicobacter pylori eradication is beneficial in the treatment of functional dyspepsia

Factors Predicting Effectiveness of Eradication Therapy for Helicobacter pylori-Associated Dyspepsia Symptoms

Functional dyspepsia is distinguishable from Helicobacter pylori-associated dyspepsia. However, distinguishing H. pylori-associated dyspepsia from functional dyspepsia before H. pylori eradication is difficult. Therefore, in the present study, we aimed to investigate whether serum pepsinogen levels before H. pylori eradication are associated with the amelioration of dyspepsia after successful H. pylori eradication. Additionally, we examined the usefulness of serum pepsinogen levels and other factors in predicting dyspepsia outcomes. H. pylori eradication was effective in 14 patients (Responders) and ineffective in 19 patients (Non-responders). The pepsinogen I/II ratio in Responders (3.4 ± 1.2) and Non-responders (2.3 ± 1.0) differed significantly (p = 0.006). The optimal cut-off pepsinogen I/II value was 2.3. Multivariate logistic regression analysis showed that the adjusted odds ratio for Non-responders was 26.1 (95% confidence interval: 2.0-338.0, p = 0.012) for a pepsinogen I/II ratio ≤ 2.3 and 8.10 (95% confidence interval: 1.1-57.6, p = 0.037) for smoking habits. The pepsinogen I/II ratio and smoking habits were associated with the effects of H. pylori eradication on dyspeptic symptoms. Thus, the pepsinogen I/II ratio cut-off value can be used to identify patients likely to respond to H. pylori eradication after the resolution of dyspeptic symptoms.

Helicobacter pylori Diagnosis and Treatment in Africa: The First Lagos Consensus Statement of the African Helicobacter and Microbiota Study Group

BACKGROUND

Helicobacter pylori (H. pylori) infection is the most prevalent type of bacterial infection. Current guidelines from different regions of the world neglect specific African conditions and requirements. The African Helicobacter and Microbiota Study Group (AHMSG), founded in 2022, aimed to create an Africa-specific consensus report reflecting Africa-specific issues.

SUMMARY

Eighteen experts from nine African countries and two European delegates supported by nine African collaborators from eight other countries prepared statements on the most important African issues in four working groups: (1) epidemiology, (2) diagnosis, (3) indications and prevention, and (4) treatment. Limited resources, restricted access to medical systems, and underdeveloped diagnostic facilities differ from those of other regions. The results of the individual working groups were presented for the final consensus voting, which included all board members.

KEY MESSAGES

There is a need for further studies on H. pylori prevalence in Africa, with diagnosis hinged on specific African situation. Treatment of H. pylori in the African setting should be based on accessibility and reimbursement, while indication and prevention should be defined in specific African countries.

Curcumin and proton pump inhibitors for functional dyspepsia: a randomised, double blind controlled trial

OBJECTIVE

To compare the efficacy of curcumin versus omeprazole in improving patient reported outcomes in people with dyspepsia.

DESIGN

Randomised, double blind controlled trial, with central randomisation.

SETTING

Thai traditional medicine hospital, district hospital, and university hospitals in Thailand.

PARTICIPANTS

Participants with a diagnosis of functional dyspepsia.

INTERVENTIONS

The interventions were curcumin alone (C), omeprazole alone (O), or curcumin plus omeprazole (C+O). Patients in the combination group received two capsules of 250 mg curcumin, four times daily, and one capsule of 20 mg omeprazole once daily for 28 days.

MAIN OUTCOME MEASURES

Functional dyspepsia symptoms on days 28 and 56 were assessed using the Severity of Dyspepsia Assessment (SODA) score. Secondary outcomes were the occurrence of adverse events and serious adverse events.

RESULTS

206 patients were enrolled in the study and randomly assigned to one of the three groups; 151 patients completed the study. Demographic data (age 49.7±11.9 years; women 73.4%), clinical characteristics and baseline dyspepsia scores were comparable between the three groups. Significant improvements were observed in SODA scores on day 28 in the pain (-4.83, -5.46 and -6.22), non-pain (-2.22, -2.32 and -2.31) and satisfaction (0.39, 0.79 and 0.60) categories for the C+O, C, and O groups, respectively. These improvements were enhanced on day 56 in the pain (-7.19, -8.07 and -8.85), non-pain (-4.09, -4.12 and -3.71) and satisfaction (0.78, 1.07, and 0.81) categories in the C+O, C, and O groups, respectively. No significant differences were observed among the three groups and no serious adverse events occurred.

CONCLUSION

Curcumin and omeprazole had comparable efficacy for functional dyspepsia with no obvious synergistic effect.

TRIAL REGISTRATION NUMBER

TCTR20221208003.

Guidelines on optimizing the use of proton pump inhibitors: PPI stewardship

Proton pump inhibitors (PPIs) have been available for over three decades and are among the most commonly prescribed medications. They are effective in treating a variety of gastric acid-related disorders. They are freely available and based on current evidence, use of PPIs for inappropriate indications and duration appears to be common. Over the years, concerns have been raised on the safety of PPIs as they have been associated with several adverse effects. Hence, there is a need for PPI stewardship to promote the use of PPIs for appropriate indication and duration. With this objective, the Indian Society of Gastroenterology has formulated guidelines on the rational use of PPIs. The guidelines were developed using a modified Delphi process. This paper presents these guidelines in detail, including the statements, review of literature, level of evidence and recommendations. This would help the clinicians in optimizing the use of PPIs in their practice and promote PPI stewardship.

Helicobacter pylori infection

Helicobacter pylori infection causes chronic gastritis, which can progress to severe gastroduodenal pathologies, including peptic ulcer, gastric cancer and gastric mucosa-associated lymphoid tissue lymphoma. H. pylori is usually transmitted in childhood and persists for life if untreated. The infection affects around half of the population in the world but prevalence varies according to location and sanitation standards. H. pylori has unique properties to colonize gastric epithelium in an acidic environment. The pathophysiology of H. pylori infection is dependent on complex bacterial virulence mechanisms and their interaction with the host immune system and environmental factors, resulting in distinct gastritis phenotypes that determine possible progression to different gastroduodenal pathologies. The causative role of H. pylori infection in gastric cancer development presents the opportunity for preventive screen-and-treat strategies. Invasive, endoscopy-based and non-invasive methods, including breath, stool and serological tests, are used in the diagnosis of H. pylori infection. Their use depends on the specific individual patient history and local availability. H. pylori treatment consists of a strong acid suppressant in various combinations with antibiotics and/or bismuth. The dramatic increase in resistance to key antibiotics used in H. pylori eradication demands antibiotic susceptibility testing, surveillance of resistance and antibiotic stewardship.

Management of Helicobacter pylori infection: the Maastricht VI/Florence consensus report

Helicobacter pyloriInfection is formally recognised as an infectious disease, an entity that is now included in the International Classification of Diseases 11th Revision. This in principle leads to the recommendation that all infected patients should receive treatment. In the context of the wide clinical spectrum associated with Helicobacter pylori gastritis, specific issues persist and require regular updates for optimised management.The identification of distinct clinical scenarios, proper testing and adoption of effective strategies for prevention of gastric cancer and other complications are addressed. H. pylori treatment is challenged by the continuously rising antibiotic resistance and demands for susceptibility testing with consideration of novel molecular technologies and careful selection of first line and rescue therapies. The role of H. pylori and antibiotic therapies and their impact on the gut microbiota are also considered.Progress made in the management of H. pylori infection is covered in the present sixth edition of the Maastricht/Florence 2021 Consensus Report, key aspects related to the clinical role of H. pylori infection were re-evaluated and updated. Forty-one experts from 29 countries representing a global community, examined the new data related to H. pylori infection in five working groups: (1) indications/associations, (2) diagnosis, (3) treatment, (4) prevention/gastric cancer and (5) H. pylori and the gut microbiota. The results of the individual working groups were presented for a final consensus voting that included all participants. Recommendations are provided on the basis of the best available evidence and relevance to the management of H. pylori infection in various clinical fields.

Altered Vagal Signaling and Its Pathophysiological Roles in Functional Dyspepsia

The vagus nerve is crucial in the bidirectional communication between the gut and the brain. It is involved in the modulation of a variety of gut and brain functions. Human studies indicate that the descending vagal signaling from the brain is impaired in functional dyspepsia. Growing evidence indicate that the vagal signaling from gut to brain may also be altered, due to the alteration of a variety of gut signals identified in this disorder. The pathophysiological roles of vagal signaling in functional dyspepsia is still largely unknown, although some studies suggested it may contribute to reduced food intake and gastric motility, increased psychological disorders and pain sensation, nausea and vomiting. Understanding the alteration in vagal signaling and its pathophysiological roles in functional dyspepsia may provide information for new potential therapeutic treatments of this disorder. In this review, we summarize and speculate possible alterations in vagal gut-to-brain and brain-to-gut signaling and the potential pathophysiological roles in functional dyspepsia.

Current Treatment Options and Therapeutic Insights for Gastrointestinal Dysmotility and Functional Gastrointestinal Disorders

Functional gastrointestinal disorders (FGIDs) have been re-named as disorders of gut-brain interactions. These conditions are not only common in clinical practice, but also in the community. In reference to the Rome IV criteria, the most common FGIDs, include functional dyspepsia (FD) and irritable bowel syndrome (IBS). Additionally, there is substantial overlap of these disorders and other specific gastrointestinal motility disorders, such as gastroparesis. These disorders are heterogeneous and are intertwined with several proposed pathophysiological mechanisms, such as altered gut motility, intestinal barrier dysfunction, gut immune dysfunction, visceral hypersensitivity, altered GI secretion, presence and degree of bile acid malabsorption, microbial dysbiosis, and alterations to the gut-brain axis. The treatment options currently available include lifestyle modifications, dietary and gut microbiota manipulation interventions including fecal microbiota transplantation, prokinetics, antispasmodics, laxatives, and centrally and peripherally acting neuromodulators. However, treatment that targets the pathophysiological mechanisms underlying the symptoms are scanty. Pharmacological agents that are developed based on the cellular and molecular mechanisms underlying pathologies of these disorders might provide the best avenue for future pharmaceutical development. The currently available therapies lack long-term effectiveness and safety for their use to treat motility disorders and FGIDs. Furthermore, the fundamental challenges in treating these disorders should be defined; for instance, 1. Cause and effect cannot be disentangled between symptoms and pathophysiological mechanisms due to current therapies that entail the off-label use of medications to treat symptoms. 2. Despite the knowledge that the microbiota in our gut plays an essential part in maintaining gut health, their exact functions in gut homeostasis are still unclear. What constitutes a healthy microbiome and further, the precise definition of gut microbial dysbiosis is lacking. More comprehensive, large-scale, and longitudinal studies utilizing multi-omics data are needed to dissect the exact contribution of gut microbial alterations in disease pathogenesis. Accordingly, we review the current treatment options, clinical insight on pathophysiology, therapeutic modalities, current challenges, and therapeutic clues for the clinical care and management of functional dyspepsia, gastroparesis, irritable bowel syndrome, functional constipation, and functional diarrhea.

Efficacy of Helicobacter pylori eradication therapy for functional dyspepsia: updated systematic review and meta-analysis

OBJECTIVE

Functional dyspepsia (FD) is a chronic disorder that is difficult to treat. Helicobacter pylori may contribute to its pathophysiology. A Cochrane review from 2006 suggested that eradication therapy was beneficial, but there have been numerous randomised controlled trials (RCTs) published since. We evaluated impact of eradication therapy on both cure and improvement of FD, as well as whether any benefit was likely to arise from eradication of H. pylori.

DESIGN

We searched the medical literature through October 2021 to identify RCTs examining efficacy of eradication therapy in H. pylori-positive adults with FD. The control arm received antisecretory therapy or prokinetics, with or without placebo antibiotics, or placebo alone. Follow-up was for ≥3 months. We pooled dichotomous data to obtain a relative risk (RR) of symptoms not being cured or symptoms not improving with a 95% CI. We estimated the number needed to treat (NNT).

RESULTS

Twenty-nine RCTs recruited 6781 H. pylori-positive patients with FD. Eradication therapy was superior to control for symptom cure (RR of symptoms not being cured=0.91; 95% CI 0.88 to 0.94, NNT=14; 95% CI 11 to 21) and improvement (RR of symptoms not improving=0.84; 95% CI 0.78 to 0.91, NNT=9; 95% CI 7 to 17). There was no significant correlation between eradication rate and RR of FD improving or being cured (Pearson correlation coefficient=-0.23, p=0.907), but the effect was larger in patients with successful eradication of H. pylori than with unsuccessful eradication (RR=0.65; 95% CI 0.52 to 0.82, NNT=4.5, 95% CI 3 to 9). Adverse events (RR=2.19; 95% 1.10 to 4.37) and adverse events leading to withdrawal (RR=2.60; 95% CI 1.47 to 4.58) were more common with eradication therapy.

CONCLUSION

There is high quality evidence to suggest that H. pylori eradication therapy leads to both cure and improvement in FD symptoms, although the benefit is modest.

The Fear of Gastric Cancer in Patients with Dyspepsia: Challenge in Specialist Care Gastroenterology

BACKGROUND

Dyspepsia is one of the most common complaints in gastroenterology. While its etiology is usually benign, rare cases of malignancy have to be identified. Individualized risk stratification is essential for cost-effective management of dyspepsia. Here, we discuss the challenges of investigating dyspepsia at the specialist level and provide a framework for rational workup and surveillance strategies.

SUMMARY

Causes of dyspepsia can be functional or organic, including gastritis, peptic ulcers, or malignancy. H. pylori gastritis represents a specific entity of dyspepsia and increases the risk of gastric cancer. H. pylori eradication can improve symptoms in a subset of patients and reduce gastric cancer risk. In young patients without alarm features, malignancy is rare, and noninvasive testing for H. pylori is appropriate. In elder patients and those with alarm features, high-quality endoscopy is the method of choice to rule out malignancy. Advanced corpus-predominant atrophic gastritis with or without intestinal metaplasia represent precancerous lesions.

KEY MESSAGES

Symptom assessment requires to distinguish dyspepsia of functional or organic origin. Risk stratification in dyspeptic patients is based on age, alarm features, and H. pylori status. Noninvasive test-and-treat is recommended in patients with low gastric cancer risk, while endoscopy is recommended in individuals at increased risk. H. pylori infection should be eradicated in order to obtain a symptomatic benefit and reduce gastric cancer risk. Advanced preneoplastic lesions require endoscopic surveillance.

Evidence based guidelines for the treatment of Helicobacter pylori infection in Korea 2020

Helicobacter pylori infection is one of the most common infectious diseases worldwide. H. pylori is responsible for substantial gastrointestinal morbidity with a high disease burden. Since the revision of the H. pylori Clinical Practice Guidelines in 2013 in Korea, the eradication rate of H. pylori has gradually decreased with the use of a clarithromycin based triple therapy. According to a nationwide randomized controlled study by the Korean College of Helicobacter and Upper Gastrointestinal Research released in 2018, the intention-to-treat eradication rate was only 63.9%, which was mostly due to increased antimicrobial resistance to clarithromycin. The clinical practice guidelines for treatment of H. pylori were updated based on evidence-based medicine from a meta-analysis conducted on a target group receiving the latest level of eradication therapy. The draft recommendations developed based on the meta-analysis were finalized after expert consensus on three recommendations regarding the indication for treatment and eight recommendations on the treatment itself. These guidelines were designed to provide clinical evidence for the treatment of H. pylori to patients, nurses, medical school students, policymakers, and clinicians. These may differ from current medical insurance standards, and will be revised if more evidence emerges in the future.

Molecular detection of Helicobacter pylori and clarithromycin resistance in gastric biopsies: a prospective evaluation of RIDA®GENE Helicobacter pylori assay

Background: Empirical treatment of Helicobacter pylori (HP) depends on the local prevalence of clarithromycin resistance but data are lacking and culturing of HP is time-consuming. We evaluated RIDA®GENE Helicobacter pylori assay (r-biopharm), a quantitative PCR assay for detecting HP and clarithromycin resistance mutations in gastric biopsies.Material/methods: Gastric biopsies were obtained from each of 436 consecutive patients referred for gastroscopic investigation and results of qPCR were compared to culture and immunohistochemical staining (IHCS).Results: Of 436 samples, 47 were positive for HP by PCR (11%), 42 by culture (9.7%) and 44 by IHCS (10%). Compared to culture, sensitivity and specificity of the qPCR were 100% and 99%, respectively, and 96% and 99% compared to IHCS. The sensitivity and specificity for clarithromycin resistance detection were 92% and 97%, respectively.Conclusions: RIDA®GENE Helicobacter pylori assay reliably and rapidly detects HP and its resistance to clarithromycin in human gastric biopsies.

Evidence-Based Guidelines for the Treatment of Helicobacter pylori Infection in Korea 2020

Helicobacter pylori infection is one of the most common infectious diseases worldwide. Although the prevalence of H. pylori is gradually decreasing, approximately half of the world's population still becomes infected with this disease. H. pylori is responsible for substantial gastrointestinal morbidity worldwide, with a high disease burden. It is the most common cause of gastric and duodenal ulcers and gastric cancer. Since the revision of the H. pylori clinical practice guidelines in 2013 in Korea, the eradication rate of H. pylori has gradually decreased with the use of a clarithromycin-based triple therapy for 7 days. According to a nationwide randomized controlled study conducted by the Korean College of Helicobacter and Upper Gastrointestinal Research released in 2018, the intention-to-treat eradication rate was only 63.9%, which was mostly due to increased antimicrobial resistance, especially from clarithromycin. The clinical practice guidelines for the treatment of H. pylori were updated according to evidence-based medicine from a meta-analysis conducted on a target group receiving the latest level of eradication therapy. The draft recommendations developed based on the meta-analysis were finalized after an expert consensus on three recommendations regarding the indication for treatment and eight recommendations for the treatment itself. These guidelines were designed to provide clinical evidence for the treatment (including primary care treatment) of H. pylori infection to patients, nurses, medical school students, policymakers, and clinicians. These may differ from current medical insurance standards and will be revised if more evidence emerges in the future.

Evidence-based Guidelines for the Treatment of Helicobacter pylori Infection in Korea: 2020 Revised Edition

Helicobacter pylori (H. pylori) infection is one of the most common infectious diseases worldwide. Although its incidence is gradually decreasing, about half of the world's population still get infected. H. pylori infection is responsible for substantial gastrointestinal morbidity worldwide. It is the most common cause of gastric and duodenal ulcers as well as gastric cancer. Since the revision of the H. pylori Clinical Practice Guidelines in 2013, the eradication rate of H. pylori has gradually decreased with the use of classical triple therapy, wherein amoxicillin, clarithromycin, and proton pump inhibitors are administered, for 7 days. According to a nationwide randomized controlled study conducted by the Korean College of Helicobacter and Upper Gastrointestinal Research released in 2018, the intention-to-treat eradication rate was only 63.9%, which was due to increased antimicrobial resistance induced by the use of antibiotics, especially clarithromycin. The update of clinical practice guideline for treatment of H. pylori was developed based on evidence-based medicine by conducting a meta-analysis. The draft recommendations were finalized after expert consensus on three recommendations regarding the indication for treatment and eight recommendations on the treatment itself. These guidelines are designed to provide patients, nurses, medical school students, policymakers, and clinicians with clinical evidence to guide primary care and treatment of H. pylori infection. These may differ from current medical insurance standards and will be revised further, if necessary, based on research-based evidence.

Clinical Practice Guidelines for Functional Dyspepsia in Korea

Functional dyspepsia (FD) is a chronic upper gastrointestinal (GI) symptom complex that routine diagnostic work-up, such as endoscopy, blood laboratory analysis, or radiological examination, fails to identify a cause. It is highly prevalent in the World population, and its response to the various available therapeutic strategies is only modest because of the heterogenous nature of its pathogenesis. Therefore, FD represents a heavy medical burden for healthcare systems. We constituted a guideline development committee to review the existing guidelines on the management of functional dyspepsia. This committee drafted statements and conducted a systematic review and meta-analysis of various studies, guidelines, and randomized control trials. External review was also conducted by selected experts. These clinical practice guidelines for FD were developed based on evidence recently accumulated with the revised version of FD guidelines released in 2011 by the Korean Society of Neurogastroenterology and Motility. These guidelines apply to adults with chronic symptoms of FD and include the diagnostic role of endoscopy, Helicobacter pylori screening, and systematic review and meta-analyses of the various treatment options for FD (proton pump inhibitors, H.pylori eradication, and tricyclic antidepressants), especially according to the FD subtype. The purpose of these new guidelines is to aid the understanding, diagnosis, and treatment of FD, and the targets of the guidelines are clinicians, healthcare workers at the forefront of patient care, patients, and medical students. The guidelines will continue to be revised and updated periodically.

Helicobacter pylori Eradication Therapy for Functional Dyspepsia: A Meta-Analysis by Region and H. pylori Prevalence

BACKGROUND

Previous studies on the effect of Helicobacter pylori eradication on functional dyspepsia (FD) are conflicting. We performed a comprehensive meta-analysis on this issue according to region and prevalence of H. pylori.

METHODS

Randomized controlled trials (RCTs) evaluating the effect of eradication of H. pylori on functional dyspepsia up to December 2018 were searched through PubMed, EMBASE, and the Cochrane Library. Subgroup analyses by the outcome measure, region, and prevalence of H. pylori were performed. All data were analyzed with Review Manager 5.3.

RESULTS

Eighteen RCTs were included in our meta-analysis. Overall, the H. pylori eradication group showed significant improvement of symptoms compared with the control group (risk ratio (RR) = 1.18; 95% confidence interval (CI): 1.07-1.30, p < 0.01). There was moderate heterogeneity among studies (I2 = 34%) and the number needed to treat (NNT) was 15.0. Helicobacter pylori eradication improved dyspeptic symptoms both in low (<50%) and high (≥50%) H. pylori prevalence regions (RR = 1.21 and 1.17; 95% CI: 1.02-1.44 and 1.06-1.29, I2 = 49% and 5%, respectively.) In the analysis of studies from Asia, however, the effect of eradication on improvement of dyspepsia was not significant (RR = 1.14; 95% CI: 0.99-1.33, p = 0.08, I2 = 37%).

CONCLUSION

Overall, H. pylori eradication provides significant improvement of symptoms in functional dyspepsia patients regardless of H. pylori prevalence. However, in the analysis of studies from Asia, the eradication did not significantly improve dyspeptic symptoms. In this region, eradication for dyspepsia can be individualized.

Helicobacter pylori eradication in dyspepsia: New evidence for symptomatic benefit

A causal relationship between Helicobacter pylori (H. pylori) infection and functional dyspepsia (FD) is well established in a subset of infected patients. In the Kyoto and Maastricht/Florence consensus reports H. pylori-associated dyspepsia is defined as an independent entity distinct from FD. H. pylori eradication is therefore the most cost-effective approach for infected patients with dyspeptic symptoms and superior to other medical therapies, such as Proton Pump Inhibitors. The therapeutic gain of H.pylori eradication for symptom relief compared to other therapeutic options is significant with the number needed to benefit of 12. Furthermore H.pylori cures chronic gastritis except in severe cases of atrophic gastritis and may prevent severe complications attributable to the infection. Several pathophysiological mechanisms are suggested for the generation of symptoms and are related to the distinct topographic expression and degree of gastric inflammation as well as changes of gastric acid secretion, gastrointestinal motility and visceral hypersensitivity.

Review article: treatment options for functional dyspepsia

BACKGROUND

Functional dyspepsia, consisting of epigastric pain syndrome and postprandial distress syndrome, is a prevalent functional gastrointestinal disorder. To date, only limited treatment options are available and conflicting results in terms of efficacy have been reported. Consequently, nonpharmacological treatment options are increasingly being explored for functional dyspepsia.

AIM

To provide an overview of current pharmacological and nonpharmacological treatment options for functional dyspepsia.

METHODS

A literature search was conducted on Pubmed and other sources to identify relevant studies.

RESULTS

Acid suppressive therapy reduced symptoms in 30%-70% of the patients, with higher benefit in epigastric pain syndrome and superior effectiveness for proton pump inhibitors compared to H₂ -antagonists. Prokinetic agents, primarily used to treat postprandial distress syndrome, showed variable efficiency: 59%-81% responder rate for dopamine receptor antagonists, 32%-91% for serotonin-4-receptor agonists and 31%-80% for muscarinic receptor antagonists. H Pylori eradication, recommended in infected patients, was effective in 24%-82%. Refractory symptoms are addressed with neuromodulators. However, their efficacy in functional dyspepsia remains incompletely elucidated, available data showing symptom reduction in 27%-71% of the patients. Regarding herbal agents, peppermint oil reduced symptoms in 66%-91%, rikkunshito in 29%-34% and iberogast in 20%-95%. Lastly, acupuncture, cognitive behavioural therapy and hypnotherapy may help to provide symptom control, but research on their efficacy remains sparse.

CONCLUSIONS

None of the available therapies is effective in the majority of patients without being associated with major side effects. Developing new treatment options is challenging due to the heterogeneity of functional dyspepsia, the lack of readily identified target mechanisms and the poor association between pathophysiological disturbances and symptoms.

Helicobacter Pylori Infection

BACKGROUND

Infection with Helicobacter pylori (H. pylori) is a major pathogenic factor for gastroduodenal ulcer disease and gastric carcinoma, as well as for other types of gastric and extragastric disease. As a result of changing epidemiologic conditions (e.g., immigration), changing resistance patterns with therapeutic implications, and new knowledge relating to the indications for pathogen eradication, the medical management of H. pylori is a dynamic process in need of periodic reassessment.

METHODS

This review is based on pertinent publications retrieved by a selective search in PubMed and the Cochrane Database, with particular attention to three international consensus reports and the updated German S2k guideline.

RESULTS

H. pylori is now dealt with as an infection, whether or not the infected individual has symptoms or suffers from and H.-pylori-induced illness. H.-pylori-associated dyspepsia and functional dyspepsia are distinct entities that can only be diagnosed when competing elements in the differential diagnosis have been ruled out. H. pylori can be detected with noninvasive methods (13C-urea breathing test, stool antigen detection) and with invasive methods (histology, culture, rapid urease test). An important consideration for treatment is that primary clarithromycin resistance is common in many groups of patients; in Germany, its prevalence is now 10.9%. Primary treatment can be with either standard triple therapy (clarithromycin and amoxicillin or metronidazole) or bismuth-containing quadruple therapy. Treatment for 10 to 14 days is more likely to eradicate the pathogen than treatment for 7 days. When H. pylori infection is initially diagnosed in a patient over age 50, gastritis risk stratification should be performed by means of endoscopic biopsy and histologic examination.

CONCLUSION

The new, clinically relevant developments that are presented and commented upon in this review now enable evidence-based management of H. pylori infection.

Comparison of the early effects of vonoprazan, lansoprazole and famotidine on intragastric pH: a three-way crossover study

To promote symptom relief from acid-related diseases, a medicine with a rapid-onset effect is ideal. The aim of this study was to investigate the early inhibitory effect on gastric acid secretion after a single oral administration of vonoprazan, which represents a new class of proton pump inhibitors, and to compare this effect with those of lansoprazole and famotidine. Ten Helicobacter pylori (HP)-negative male subjects participated in this randomized, three-way crossover study. A single oral administration of vonoprazan (20 mg), lansoprazole (30 mg) or famotidine (20 mg) was performed, and the intragastric pH was continuously monitored for 6 h. Each drug was administered at least seven days apart. The average intragastric pH during the 6-h period after the administration of famotidine was higher than that after the administration of lansoprazole (median: 4.45 vs 2.65; p = 0.0284). A similar result was observed for vonoprazan and lansoprazole (median: 4.30 vs 2.65; p = 0.0322). In conclusions, oral administration of vonoprazan and famotidine in HP-negative healthy male subjects caused the intragastric pH to rise more quickly than did lansoprazole. (Trial Registration: UMIN000020989)

Helicobacter pylori management in ASEAN: The Bangkok consensus report

Helicobacter pylori (H. pylori) infection remains to be the major cause of important upper gastrointestinal diseases such as chronic gastritis, peptic ulcer, gastric adenocarcinoma, and mucosa-associated lymphoid tissue lymphoma. H. pylori management in ASEAN: the Bangkok consensus report gathered key opinion leaders for the region to review and evaluate clinical aspects of H. pylori infection and to develop consensus statements, rationales, and grades of recommendation for the management of H. pylori infection in clinical practice in ASEAN countries. This ASEAN Consensus consisted of 34 international experts from 10 ASEAN countries, Japan, Taiwan, and the United States. The meeting mainly focused on four issues: (i) epidemiology and disease association; (ii) diagnostic tests; (iii) management; and (iv) follow-up after eradication. The final results of each workshop were presented for consensus voting by all participants. Statements, rationale, and recommendations were developed from the available current evidence to help clinicians in the diagnosis and treatment of H. pylori and its clinical diseases.

Prevalence of Helicobacter Pylori Infection and Stress, Anxiety or Depression in Functional Dyspepsia and Outcome after Appropriate Intervention

INTRODUCTION

The association between psychological factors and non-ulcer dyspepsia remains controversial.

AIM

To determine the prevalence of Helicobacter pylori (HP) and Stress/Anxiety/Depression (SAD) in patients with Functional Dyspepsia (FD) and assess the outcome at three months after appropriate intervention.

MATERIALS AND METHODS

This prospective non-randomized interventional study was conducted on 120 patients with FD. Initial workup included upper gastrointestinal endoscopy to confirm HP infection with either of two tests, the urease test or histopathology. Patient Health Questionnaire-9 scale (PHQ-9) was used to assess depression, General Anxiety Disorder-7 scale (GAD-7) for anxiety and Perceived Stress Scale (PSS) for stress. Patients were considered positive when they had significant scores on one or more of the questionnaires (SAD+). The subjects were then classified into four groups: Group A (positive for HP and SAD, n=35), Group B (positive for HP and negative for SAD, n=31), Group C (negative for HP and positive for SAD, n=33) and Group D (negative for HP and SAD, n=21). The groups were then treated as follows: Group A: HP eradication plus psychiatric intervention, Group B: HP eradication alone, Group C: psychiatric intervention alone and Group D: proton pump inhibitors. Modified Glasgow Dyspepsia Symptom Score (Mod. GDSS) was used to assess the severity of dyspepsia at baseline and to monitor the change in score over three months. Statistical analysis was done using the Statistical Package for the Social Sciences version 16.0. Non-parametric data like proportions of response in different groups to treatment was analysed using the Chi square test and quantitative data using ANOVA. Gender wise distribution and response to treatment was calculated using the z-test and unpaired t-test.

RESULTS

Overall 120 patients were recruited across four groups. A 55% of the subjects were positive for HP and 56.7% for SAD and 29.2% for both. In all three groups with psychiatric comorbidity, females exceeded males in a proportion of 3:1. Mod. GDSS was not significantly different at baseline between HP+ and HP- patients (p=0.1278) except when HP positivity was also associated with SAD (p<0.001), whereas SAD positivity alone significantly increased the baseline Mod. GDSS (p=0.006). Mod. GDSS declined in all four groups at three months. When a fall of four or more was considered as an indicator of significant response to intervention, it was seen that overall 74.2% responded to intervention with the best response in Group B and the poorest was in Group C.

CONCLUSION

There is a significant prevalence of HP and SAD in FD. Appropriate intervention is beneficial except in those who are HP negative and SAD positive. This latter group requires further investigation and or drug intervention for SAD.

ACG and CAG Clinical Guideline: Management of Dyspepsia

We have updated both the American College of Gastroenterology (ACG) and the Canadian Association of Gastroenterology (CAG) guidelines on dyspepsia in a joint ACG/CAG dyspepsia guideline. We suggest that patients ≥60 years of age presenting with dyspepsia are investigated with upper gastrointestinal endoscopy to exclude organic pathology. This is a conditional recommendation and patients at higher risk of malignancy (such as spending their childhood in a high risk gastric cancer country or having a positive family history) could be offered an endoscopy at a younger age. Alarm features should not automatically precipitate endoscopy in younger patients but this should be considered on a case-by-case basis. We recommend patients <60 years of age have a non-invasive test Helicobacter pylori and treatment if positive. Those that are negative or do not respond to this approach should be given a trial of proton pump inhibitor (PPI) therapy. If these are ineffective tricyclic antidepressants (TCA) or prokinetic therapies can be tried. Patients that have an endoscopy where no pathology is found are defined as having functional dyspepsia (FD). H. pylori eradication should be offered in these patients if they are infected. We recommend PPI, TCA and prokinetic therapy (in that order) in those that fail therapy or are H. pylori negative. We do not recommend routine upper gastrointestinal (GI) motility testing but it may be useful in selected patients.

Acid-inhibitory effects of vonoprazan 20 mg compared with esomeprazole 20 mg or rabeprazole 10 mg in healthy adult male subjects--a randomised open-label cross-over study

BACKGROUND

Proton pump inhibitors (PPIs) are widely used for the treatment of acid-related diseases. Vonoprazan is a member of a new class of acid suppressants; potassium-competitive acid blockers. Vonoprazan may thus be an alternative to PPIs.

AIM

To evaluate efficacy, rapidity and duration of acid-inhibitory effects of vonoprazan vs. two control PPIs, esomeprazole and rabeprazole, in 20 healthy Japanese adult male volunteers with CYP2C19 extensive metaboliser genotype.

METHODS

In this randomised, open-label, two-period cross-over study, vonoprazan 20 mg and esomeprazole 20 mg (Study V vs. E) or rabeprazole 10 mg (Study V vs. R) were orally administered daily for 7 days. Primary pharmacodynamic endpoint was gastric pH over 24 h measured as percentage of time pH ≥3, ≥4 and ≥5 (pH holding time ratios; HTRs) and mean gastric pH.

RESULTS

Acid-inhibitory effect (pH4 HTR) of vonoprazan was significantly greater than that of esomeprazole or rabeprazole on both Days 1 and 7; Day 7 difference in pH4 HTR for vonoprazan vs. esomeprazole was 24.6% [95% confidence interval (CI): 16.2-33.1] and for vonoprazan vs. rabeprazole 28.8% [95% CI: 17.2-40.4]. The Day 1 to Day 7 ratio of 24-h pH4 HTRs was >0.8 for vonoprazan, compared with 0.370 for esomeprazole and 0.393 for rabeprazole. Vonoprazan was generally well tolerated. One vonoprazan subject withdrew due to a rash which resolved after discontinuation.

CONCLUSIONS

This study demonstrated a more rapid and sustained acid-inhibitory effect of vonoprazan 20 mg vs. esomeprazole 20 mg or rabeprazole 10 mg. Therefore, vonoprazan may be a potentially new treatment for acid-related diseases.

Kyoto global consensus report on Helicobacter pylori gastritis

OBJECTIVE

To present results of the Kyoto Global Consensus Meeting, which was convened to develop global consensus on (1) classification of chronic gastritis and duodenitis, (2) clinical distinction of dyspepsia caused by Helicobacter pylori from functional dyspepsia, (3) appropriate diagnostic assessment of gastritis and (4) when, whom and how to treat H. pylori gastritis.

DESIGN

Twenty-three clinical questions addressing the above-mentioned four domains were drafted for which expert panels were asked to formulate relevant statements. A Delphi method using an anonymous electronic system was adopted to develop the consensus, the level of which was predefined as ≥80%. Final modifications of clinical questions and consensus were achieved at the face-to-face meeting in Kyoto.

RESULTS

All 24 statements for 22 clinical questions after extensive modifications and omission of one clinical question were achieved with a consensus level of >80%. To better organise classification of gastritis and duodenitis based on aetiology, a new classification of gastritis and duodenitis is recommended for the 11th international classification. A new category of H. pylori-associated dyspepsia together with a diagnostic algorithm was proposed. The adoption of grading systems for gastric cancer risk stratification, and modern image-enhancing endoscopy for the diagnosis of gastritis, were recommended. Treatment to eradicate H. pylori infection before preneoplastic changes develop, if feasible, was recommended to minimise the risk of more serious complications of the infection.

CONCLUSIONS

A global consensus for gastritis was developed for the first time, which will be the basis for an international classification system and for further research on the subject.

Systematic review with meta-analysis: post-infectious functional dyspepsia

BACKGROUND

The prevalence of functional dyspepsia (FD) following infectious gastroenteritis has not been systematically reviewed.

AIM

To conduct a systematic review and calculate the summary odds ratio (OR) for the development of FD following infectious gastroenteritis, as compared to a control population.

METHODS

Published studies in PubMed, EmBASE, and Cochrane Database and abstracts from standard sources were screened for eligible studies. Data from studies meeting inclusion criteria were pooled for meta-analysis.

RESULTS

Nineteen studies were eligible for inclusion. The mean prevalence of FD following acute gastroenteritis (AGE) was 9.55% (FD, n = 909; AGE, n = 9517) in adult populations. The summary OR for the development of post-infectious FD was 2.54 (95% CI = 1.76-3.65) at more than 6 months after AGE, as compared to the prevalence in controls within the same population. This is compared with the summary OR (3.51; 95% CI = 2.05-6.00) for the development of post-infectious irritable bowel syndrome (IBS) in the same population at more than 6 months after AGE. There was significant statistical heterogeneity with an I(2) of 72.8% for the summary OR of post-infectious FD. Several pathogens, including Salmonella spp., Escherichia coli O157, Campylobacter jejuni, Giardia lamblia and Norovirus have been shown to be associated with post-infectious FD symptoms.

CONCLUSIONS

Infectious gastroenteritis is associated with an increased risk for subsequent dyspepsia as well as for irritable bowel syndrome. Post-infectious FD and post-infectious irritable bowel syndrome may represent different aspects of the same pathophysiology. Further studies will be needed to determine this.

Effect of licorice versus bismuth on eradication of Helicobacter pylori in patients with peptic ulcer disease

Background:

Different therapeutic regimens were used for eradication of Helicobacter pylori, based on the cost, effectiveness and patient's compliance. The aim of this study was the evaluation of licorice compared with bismuth in quadruple regimen on eradication of H. pylori in patients with peptic ulcer disease (PUD).

Materials and Methods:

In a double-blind clinical trial study, 60 patients with PUD and positive rapid urease test were enrolled. The patients were randomly allocated into two equal groups. In first group, licorice, amoxicillin, metronidazole and omeprazole and in the second (control) group, bismuth subsalicylate, amoxicillin, metronidazole and omeprazole were prescribed respectively, and 4 weeks after treatment, in order to evaluate H. pylori eradication, urea breath test was done in all patients. The outcome of the study was the preference usage of licorice as an effective medication for H. pylori eradication.

Results:

Mean age of the patients in the control and case groups were 40.8 ± 15.5 and 42.2 ± 15.8 years, respectively (P = 0.726). Seventeen (56.7%) patients in control group and 16 (53.3%) in the case group were female (P = 0.795). Both groups were similar based on frequency of gastric or duodenal ulcer. Response to treatment were seen in 20 (67%) and 17 (57%) patients of case and control groups, respectively (P > 0.05).

Conclusion:

Our study showed that licorice is as effective as bismuth in H. pylori eradication; therefore, in patients whom bismuth is contraindicated, licorice can be used safely instead.

Should we still subcategorize helicobacter pylori-associated dyspepsia as functional disease?

Functional dyspepsia is a group of disorders featuring symptoms believed to be derived from the stomach and duodenum such as upper abdominal discomfort, pain, postprandial fullness and early satiety. A key diagnostic requisite is the absence of organic, metabolic, or systemic disorders to explain "dyspeptic symptoms." Therefore, when peptic ulcer diseases (including scars), erosive esophagitis and upper gastrointestinal malignancies are found at endoscopic examinations, the diagnosis of functional dyspepsia is excluded. One notable exception, however, is Helicobacter pylori infection. According to the Rome III definition, H. pylori infection is included in functional dyspepsia. This is an obvious deviation from the diagnostic principle of functional dyspepsia, since H. pylori infection is a definite cause of mucosal inflammation, which affects a number of important gastric physiologies such as acid secretion, gastric endocrine function and motility. The chronic persistent nature of infection also results in more dramatic mucosal changes such as atrophy or intestinal metaplasia, the presence of which in the esophagus (Barrett's esophagus) precludes the diagnosis of functional dyspepsia. Since careful endoscopic examination can diagnose reliably H. pylori infection not only in Japan but also in Western contries, it is now feasible and more logical to exclude patients with chronic gastritis caused by H. pylori infection as having dyspeptic symptoms. It is time to establish the Asian consensus to declare that H. pylori infection should be separated from functional dyspepsia.

Symptom-based tendencies of Helicobacter pylori eradication in patients with functional dyspepsia

AIM: To investigate whether there were symptom-based tendencies in the Helicobacter pylori (H. pylori) eradication in functional dyspepsia (FD) patients.

METHODS: A randomized, single-blind, placebo-controlled study of H. pylori eradication for FD was conducted. A total of 195 FD patients with H. pylori infection were divided into two groups: 98 patients in the treatment group were treated with rabeprazole 10 mg twice daily for 2 wk, amoxicillin 1.0 g and clarithromycin 0.5 g twice daily for 1 wk; 97 patients in the placebo group were given placebos as control. Symptoms of FD, such as postprandial fullness, early satiety, nausea, belching, epigastric pain and epigastric burning, were assessed 3 mo after H. pylori eradication.

RESULTS: By per-protocol analysis in patients with successful H. pylori eradication, higher effective rates of 77.2% and 82% were achieved in the patients with epigastric pain and epigastric burning than those in the placebo group (P < 0.05). The effective rates for postprandial fullness, early satiety, nausea and belching were 46%, 36%, 52.5% and 33.3%, respectively, and there was no significant difference from the placebo group (39.3%, 27.1%, 39.1% and 31.4%) (P > 0.05). In 84 patients who received H. pylori eradication therapy, the effective rates for epigastric pain (73.8%) and epigastric burning (80.7%) were higher than those in the placebo group (P < 0.05). The effective rates for postprandial fullness, early satiety, nausea and belching were 41.4%, 33.3%, 50% and 31.4%, respectively, and did not differ from those in the placebo group (P > 0.05). By intention-to-treat analysis, patients with epigastric pain and epigastric burning in the treatment group achieved higher effective rates of 60.8% and 65.7% than the placebo group (33.3% and 31.8%) (P < 0.05). The effective rates for postprandial fullness, early satiety, nausea and belching were 34.8%, 27.9%, 41.1% and 26.7% respectively in the treatment group, with no significant difference from those in the placebo group (34.8%, 23.9%, 35.3% and 27.1%) (P > 0.05).

CONCLUSION: The efficacy of H. pylori eradication has symptom-based tendencies in FD patients. It may be effective in the subgroup of FD patients with epigastric pain syndrome.

1-[5-(2-Fluorophenyl)-1-(pyridin-3-ylsulfonyl)-1H-pyrrol-3-yl]-N-methylmethanamine monofumarate (TAK-438), a novel and potent potassium-competitive acid blocker for the treatment of acid-related diseases

Proton pump inhibitors (PPIs) are widely used in the treatment of acid-related diseases. However, several unmet medical needs, such as suppression of night-time acid secretion and rapid symptom relief, remain. In this study, we investigated the pharmacological effects of 1-[5-(2-fluorophenyl)-1-(pyridin-3-ylsulfonyl)-1H-pyrrol-3-yl]-N-methylmethanamine monofumarate (TAK-438), a novel potassium-competitive acid blocker (P-CAB), on gastric acid secretion in comparison with lansoprazole, a typical PPI, and SCH28080 [3-(cyanomethyl)-2-methyl,8-(phenylmethoxy)imidazo(1,2-a)pyridine], a prototype of P-CAB. TAK-438, SCH28080, and lansoprazole inhibited H(+),K(+)-ATPase activity in porcine gastric microsomes with IC(50) values of 0.019, 0.14, and 7.6 μM, respectively, at pH 6.5. The inhibitory activity of TAK-438 was unaffected by ambient pH, whereas the inhibitory activities of SCH28080 and lansoprazole were weaker at pH 7.5. The inhibition by TAK-438 and SCH28080 was reversible and achieved in a K(+)-competitive manner, quite different from that by lansoprazole. TAK-438, at a dose of 4 mg/kg (as the free base) orally, completely inhibited basal and 2-deoxy-d-glucose-stimulated gastric acid secretion in rats, and its effect on both was stronger than that of lansoprazole. TAK-438 increased the pH of gastric perfusate to a higher value than did lansoprazole or SCH28080, and the effect of TAK-438 was sustained longer than that of lansoprazole or SCH28080. These results indicate that TAK-438 exerts a more potent and longer-lasting inhibitory action on gastric acid secretion than either lansoprazole or SCH28080. TAK-438 is a novel antisecretory drug that may provide a new option for the patients with acid-related disease that is refractory to, or inadequately controlled by, treatment with PPIs.

Helicobacter pylori and gastroduodenal ulcer disease

BACKGROUND

Helicobacter pylori-associated diseases and gastroduodenal ulcer disease are common conditions of major clinical and economic importance. There is thus a need for a guideline that incorporates the scientific knowledge gained in recent years and that takes specific aspects of the situation in Germany into account with regard to epidemiology, resistance status, diagnostic evaluation, and treatment.

METHODS

This level-S3 consensus guideline was developed in accordance with the recommendations of the Association of Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF). It was commissioned by the German Association for Digestive and Metabolic Diseases (Deutsche Gesellschaft für Verdauungs- und Stoffwechselkrankheiten, DGVS) and prepared in cooperation with other scientific societies. After search terms were compiled, a systematic, IT-supported literature search was performed in the PubMed and Cochrane databases. The search was restricted to articles that appeared in German or English from 2000 onward.

RESULTS

H. pylori infection can be accurately diagnosed either non-invasively (with a (13)C-urea breath test or a stool antigen test) or invasively (with a rapid urease test, by histology, or by culture). Gastric and duodenal ulcer and gastric MALT lymphoma are absolute indications for eradication therapy; relative indications include functional dyspepsia, the prevention of gastric cancer in persons at risk, the initiation of long-term treatment with non-steroidal anti-inflammatory drugs (NSAID), and the prior occurrence of gastroduodenal complications with the use of either NSAID or acetylsalicylic acid (ASA). First-line therapy consists of a proton-pump inhibitor (PPI) and clarithromycin combined with either metronidazole or amoxicillin, given for at least one week.

CONCLUSION

This guideline enables the structured, evidence-based diagnosis and treatment of H. pylori infection and associated conditions, as well as of gastroduodenal ulcer disease.

Role of Helicobacter pylori infection on neuronal expression in the stomach and spinal cord of a murine model

OBJECTIVE

To investigate the effect of Helicobacter pylori (H. pylori) infection on neuronal expressions in the stomach and spinal cord of mice so as to explain dyspepsia symptoms in H. pylori infected patients.

METHODS

C57BL/6 female mice were studied at 2 weeks (acute infection group) and 12 weeks (chronic infection group) after H. pylori inoculation. Histological analyses for gastric inflammation and bacterial colonization were assessed by HE staining and Warthin-Starry staining. Fos, vasoactive intestinal polypeptide (VIP) and calcitonin gene-related peptide expressions (CGRP) were studied by immunohistochemistry.

RESULTS

H. pylori colonization was present mainly in pyloric region, but bacterial density was similar in both infected groups. The intensity of mucosal inflammation and activity was significantly higher in two infected groups than in those in the control group. The degree of mononuclear and polymorphonuclear cell infiltration in proventricular-glandular region and gastric corpus at 12 weeks after H. pylori inoculation was higher than that at 2 weeks after inoculation. The neuronal expressions of fos, VIP, and CGRP in the stomach and spinal cord were significantly more marked in the infected groups than in the control group, but there was no significant difference between two infected groups.

CONCLUSION

H. pylori infection induced different degrees of gastric mucosal inflammation in the murine model. Both early and chronic infection groups of mice showed enhanced neuronal expressions of fos, VIP and CGRP of stomach and spinal cord and these could form a basis for appearance of functional dyspeptic symptoms in patients with H. pylori infection.

Symptoms, endoscopic findings and histology predicting symptomatic benefit of Helicobacter pylori eradication

OBJECTIVE

To analyse factors predicting changes in dyspeptic symptoms after Helicobacter pylori eradication.

MATERIAL AND METHODS

Of a total of 342 patients referred for upper gastrointestinal endoscopy at 23 centres in various parts of Finland, those tested positive for the rapid urease test were recruited in the study. Clinical and demographic data and data on dyspeptic symptoms (Gastrointestinal Symptoms Rating Scale) were collected via a structured questionnaire before and a year after the eradication therapy. Gastric biopsies were analysed according to the updated Sydney system.

RESULTS

A total of 216 H. pylori-positive patients treated successfully with eradication therapy had complete data to be analysed. After the therapy, dyspeptic symptoms decreased by 29-32%. In a univariate analysis, it was found that duodenal ulcer, female gender, gastric antral neutrophilic inflammation, smoking and age from 50 to 59 years enhanced symptom improvement whereas atrophy in the gastric body reduced it. In a multivariate analysis, duodenal ulcer (odds ratio (OR) 3.2, 95% CI 1.3-7.8) and age from 50 to 59 years (OR 2.2; 95% CI 1.2-3.9) and antral neutrophilic inflammation (OR 1.9, 95% CI 1.1-3.3) were better predictors of symptomatic response.

CONCLUSION

The symptomatic benefit from H. pylori eradication therapy was greatest among duodenal ulcer patients.

American College of Gastroenterology guideline on the management of Helicobacter pylori infection

Helicobacter pylori (H. pylori) remains a prevalent, worldwide, chronic infection. Though the prevalence of this infection appears to be decreasing in many parts of the world, H. pylori remains an important factor linked to the development of peptic ulcer disease, gastric malignanc and dyspeptic symptoms. Whether to test for H. pylori in patients with functional dyspepsia, gastroesophageal reflux disease (GERD), patients taking nonsteroidal antiinflammatory drugs, with iron deficiency anemia, or who are at greater risk of developing gastric cancer remains controversial. H. pylori can be diagnosed by endoscopic or nonendoscopic methods. A variety of factors including the need for endoscopy, pretest probability of infection, local availability, and an understanding of the performance characteristics and cost of the individual tests influences choice of evaluation in a given patient. Testing to prove eradication should be performed in patients who receive treatment of H. pylori for peptic ulcer disease, individuals with persistent dyspeptic symptoms despite the test-and-treat strategy, those with H. pylori-associated MALT lymphoma, and individuals who have undergone resection of early gastric cancer. Recent studies suggest that eradication rates achieved by first-line treatment with a proton pump inhibitor (PPI), clarithromycin, and amoxicillin have decreased to 70-85%, in part due to increasing clarithromycin resistance. Eradication rates may also be lower with 7 versus 14-day regimens. Bismuth-containing quadruple regimens for 7-14 days are another first-line treatment option. Sequential therapy for 10 days has shown promise in Europe but requires validation in North America. The most commonly used salvage regimen in patients with persistent H. pylori is bismuth quadruple therapy. Recent data suggest that a PPI, levofloxacin, and amoxicillin for 10 days is more effective and better tolerated than bismuth quadruple therapy for persistent H. pylori infection, though this needs to be validated in the United States.

STW 5, a phytopharmacon for patients with functional dyspepsia: results of a multicenter, placebo-controlled double-blind study

BACKGROUND

Functional dyspepsia (FD) constitutes a complex picture with a variety of epigastric symptoms. No standard therapy is currently available for FD.

OBJECTIVE

This multicenter, placebo-controlled, double-blind study evaluated the efficacy and tolerability of the herbal drug STW 5, mainly comprising a fresh plant extract from Iberis amara.

METHODS

Patients with FD were included. Gastrointestinal endoscopy, H. pylori-status, and a 7-day run-in phase were required. A total of 315 patients were treated with 3 x 20 drops/day of either STW 5 or placebo. Symptom assessment: day 0, 2, 4, and 8 wk of treatment. The principal outcome criterion was the change in a validated Gastrointestinal Symptom Score (GIS). Symptom severity was rated using the Likert scale.

RESULTS

A total of 315 patients remained in the safety population. Of them, 158 were treated with STW 5 and 157 with placebo. The intention-to-treat population comprised 308 patients. Dropout number was similar in both groups. GIS showed improvement during the treatment period. The STW 5 group improved 6.9+/-4.8 points up to day 56, placebo group by 5.9+/-4.3 (P<0.05). H. pylori did not influence the results. Drug tolerability and safety were similar in both groups.

CONCLUSION

This placebo-controlled study with an 8-wk treatment period documents the efficacy of STW 5 in FD.

Review article: current and emerging therapies for functional dyspepsia

Functional dyspepsia represents a heterogeneous group of gastrointestinal disorders marked by the presence of upper abdominal pain or discomfort. Although its precise definition has evolved over the last several decades, this disorder remains shrouded in controversy. The symptoms of functional dyspepsia may overlap with those of other functional bowel disorders including irritable bowel syndrome and non-erosive reflux disease. There may be coexistent psychological distress or disease complicating its presentation and response to therapy. Given the prevalence and chronicity of functional dyspepsia, it remains a great burden to society. Suspected physiological mechanisms underlying functional dyspepsia include altered motility, altered visceral sensation, inflammation, nervous system dysregulation and psychological distress. Yet the exact pathophysiological mechanisms that cause symptoms in an individual patient remain difficult to delineate. Numerous treatment modalities have been employed including dietary modifications, pharmacological agents directed at various targets within the gastrointestinal tract and central nervous system, psychological therapies and more recently, complementary and alternative treatments. Unfortunately, to date, all of these therapies have yielded only marginal results. A variety of emerging therapies are being developed for functional dyspepsia. Most of these therapies are intended to normalize pain perception and gastrointestinal motor and reflex function in this group of patients.

Helicobacter pylori eradication versus prokinetics in the treatment of functional dyspepsia: a randomized, double-blind study

BACKGROUND

This randomized, double-blind study compared the efficacy of Helicobacter pylori eradication against prokinetics in H. pylori-infected functional dyspepsia patients.

METHODS

Patients with moderately severe or severe dyspepsia fulfilling the Rome II criteria were randomized to either H. pylori eradication for 1 week and 6 weeks of placebo prokinetics or 6 weeks of prokinetics and placebo H. pylori eradication in the first week. Symptoms were assessed at baseline and at 6 and 12 months using the Glasgow Dyspepsia Severity Score (GDSS). Global response to treatment was assessed at 12 months.

RESULTS

Altogether 130 patients were enrolled (H. pylori eradication, 71; prokinetics, 59). The mean baseline GDSS was 9.3 for the H. pylori eradication group and 8.9 for the prokinetic group. At 6 months, the score was 3.6 and 4.1, respectively, and it remained at 3.5 and 3.8, respectively, at 12 months. With H. pylori eradication, 31.0% had complete symptom resolution (GDSS 0 or 1) at 12 months compared with 23.7% with prokinetics (a nonsignificant difference). At 12 months, global symptomatic improvement was seen in 62.0% of the H. pylori eradication group compared with 67.8% of the prokinetics group.

CONCLUSIONS

Both H. pylori eradication and prokinetic therapy resulted in symptom improvement in two-thirds of dyspeptic patients at 1 year. More patients tended to achieve complete symptom relief with H. pylori eradication.

Drug treatment of functional dyspepsia

Symptomatic improvement of patients with functional dyspepsia after drug therapy is often incomplete and obtained in not more than 60% of patients. This is likely because functional dyspepsia is a heterogeneous disease. Although great advance has been achieved with the consensus definitions of the Rome I and II criteria, there are still some aspects about the definition of functional dyspepsia that require clarification. The Rome criteria explicitly recognise that epigastric pain or discomfort must be the predominant complaint in patients labelled as suffering from functional dyspepsia. However, this strict definition can create problems in the daily primary care clinical practice, where the patient with functional dyspepsia presents with multiple symptoms. Before starting drug therapy it is recommended to provide the patient with an explanation of the disease process and reassurance. A thorough physical examination and judicious use of laboratory data and endoscopy are also indicated. In general, the approach to treat patients with functional dyspepsia based on their main symptom is practical and effective. Generally, patients should be treated with acid suppressive therapy using proton-pump inhibitors if the predominant symptoms are epigastric pain or gastroesophageal reflux symptoms. Although the role of Helicobacter pylori (H pylori) in functional dyspepsia continues to be a matter of debate, recent data indicate that there is modest but clear benefit of eradication of H pylori in patients with functional dyspepsia. In addition, H pylori is a gastric carcinogen and if found it should be eliminated. Although there are no specific diets for patients with FD, it may be helpful to guide the patients on healthy exercise and eating habits.

Clinical outcomes of eradication of Helicobacter pylori in nonulcer dyspepsia in a population with a high prevalence of infection: results of a 12-month randomized, double blind, placebo-controlled study

Ninety-one Helicobacter pylori-positive patients with nonulcer dyspepsia were randomized to receive either lansoprazole, amoxicillin, and clarithromycin or lansoprazole and placebo. A validated questionnaire assessed dyspeptic symptoms at baseline and at 3, 6, and 12 months. Endoscopies and biopsies were performed at baseline and at 3 and 12 months. There was an overall trend, although not statistically significant, for a benefit of H. pylori eradication. Of the patients in the antibiotics group, 16 of 46 (35%) had symptomatic improvement, versus 9 of 43 (21%) in the control group (P = 0.164). In a secondary analysis, it was found that of the patients without endoscopic gastric erosions, 15 of 34 (44%) in the antibiotics group and 5 of 33 (15%) of controls had symptomatic improvement (P = 0.015). Helicobacter pylori eradication did not prove to be clinically beneficial, although a tendency to symptomatic benefit was detected. Further studies are necessary to confirm the implications of endoscopic gastric erosions in these patients.

Nonulcer dyspepsia and Helicobacter pylori eradication in children

BACKGROUND

Controversy exists over Helicobacter pylori eradication therapy in the treatment of patients with nonulcer dyspepsia. The lack of pediatric studies has made it difficult to draw conclusions about the use of eradication in dyspeptic children. The aim of this study was to examine long-term symptom severity in pediatric patients with nonulcer dyspepsia and H pylori gastritis after H pylori eradication.

METHODS

Thirty-nine children (mean age, 9.0 years) with dyspepsia and H pylori gastritis were prospectively recruited. Severity of symptoms was graded before H pylori eradication. Each patient was followed up at 6, 12, and on average, 61.6 months after eradication, with reassessment of symptoms and H pylori status.

RESULTS

There was a significant reduction in the severity of symptoms at 6 and 12 months, and at long-term follow-up compared with the preeradication scores (all P < . 001). At long-term follow-up, reinfection with H pylori was associated with more severe symptoms than if the patients remained free of infection (P = .045).

CONCLUSIONS

This study has demonstrated a significant long-term improvement in nonulcer dyspepsia in children after eradication of H pylori. This provides further evidence for the consideration of H pylori eradication in pediatric patients presenting with nonulcer dyspepsia.

Functional dyspepsia pathogenesis and therapeutic options--implications for management

Functional dyspepsia is far more common than dyspepsia due to organic disease, both in the community and general practice. Proposed aetiopathogenic factors include gastric acid, Helicobacter pylori infection, delayed emptying, hypersensitivity or impaired accommodation of the stomach, dysfunction of the duodenum or brain-gut axis, psychosocial morbidity and post-infective mucosal damage. More effective therapy will depend on the development of drugs targeted at these putative pathophysiological mechanisms. On current evidence tricyclic antidepressants appear to be more effective than either acid suppressants or H. pylori eradication.

Review article: Helicobacter pylori and gastro-oesophageal reflux disease

Epidemiological studies demonstrate a negative association between Helicobacter pylori infection and gastro-oesophageal reflux disease and its complications. This might represent a protective effect because of the tendency for H. pylori infection to lower gastric acid secretion with advancing age. However, studies of the effect of H. pylori eradication on gastro-oesophageal reflux disease have failed to show any worsening of gastro-oesophageal reflux disease symptoms. Several interactions between H. pylori and proton-pump inhibitor therapy used to treat gastro-oesophageal reflux disease need to be considered. Helicobacter pylori infection improves the control of gastric acidity by proton-pump inhibitors and this produces a small advantage in clinical control of reflux disease. The infection prevents rebound acid hypersecretion occurring when proton-pump inhibitor therapy is discontinued. However, concerns have been expressed that the body gastritis induced by proton-pump inhibitor therapy in H. pylori-infected subjects might increase the risk of gastric cancer. At present, it is unclear whether H. pylori should be eradicated in gastro-oesophageal reflux disease patients.

[Effect of the Helicobacter pylori eradication in patients with functional dyspepsia: randomised placebo-controlled trial]

BACKGROUND AND OBJECTIVE

The Helicobacter pylori eradication in patients with functional dyspepsia has been the subject of controversy because trials come to contradictory conclusions. The objective of this trial was to evaluate the effect, compared with placebo, of the eradication treatment in patients with functional dyspepsia.

PATIENTS AND METHOD

Randomized double blind placebo controlled trial. We included 158 patients attended by family physicians (Area 10 Primary Care, Health Institute of Madrid) with functional dyspepsia and Helicobacter pylori infection detected by the ureasa test in endoscopy. An OCA (ameprazole clarithromycin and amoxicillin group (n = 79) and a placebo group (n = 79) were randomized. During 7 days, patients at the OCA group received omeprazole (20 mg bid), clarithromycin (500 mg bid) and amoxicillin (1000 mg bid) daily, and patients at the control group received the placebo agent twice daily. Dyspepsia improvement according to a Likert scale (5 steps), and eradication of H. pylori by 13C-urea breath test were evaluated during one year.

RESULTS

Both groups were homogeneous in relation to age, sex and dyspepsia degree. The average age (standard deviation) of studied patients was 41.99 (13.93) years. At one year of follow up, H. pylori was eradicated in 81.01% (64/79) of the OCA group and 5.06% (4/79) of the placebo group. The difference of dyspepsia improvement (22.78%; 95% confidence interval [CI], 7.62-37.79) between the OCA group (41.77%; 95% CI, 30.77-53.41), and the placebo group (18.99%; 95% CI 11.03-29.38) was significant (p = 0.0018).

CONCLUSION

Eradication of Helicobacter pylori in patients with functional dyspepsia is more effective improving symptoms than placebo.

Helicobacter pylori eradication does not cause reflux oesophagitis in functional dyspeptic patients: a randomized, investigator-blinded, placebo-controlled trial

BACKGROUND

The protective role of Helicobacter pylori in gastro-oesophageal reflux disease has been widely discussed.

AIM

To assess the risk of reflux oesophagitis in patients with functional dyspepsia after treatment for H. pylori infection.

METHODS

A randomized, placebo-controlled, investigator-blinded trial was carried out on 157 functional dyspeptic patients. Patients were randomized to receive lansoprazole, amoxicillin and clarithromycin (antibiotic group) or lansoprazole and identical antibiotic placebos (control group). Upper gastrointestinal endoscopy was performed at baseline, 3 and 12 months after randomization. The primary aim was to detect the presence of reflux oesophagitis. Analyses were performed on an intention-to-treat basis.

RESULTS

A total of 147 patients (94%) and 133 (85%) completed 3 months and 12 months follow-up, respectively. The eradication rate of H. pylori was 90% in the antibiotic group (74 of 82) and 1% (one of 75) in the control group. At 3 months, reflux oesophagitis was diagnosed in 3.7% (three of 82) in the antibiotic group and 4% (three of 75) in the control group (P > 0.2). At 12 months, diagnosis was established in five new cases within the first group and in four within the second (P > 0.2). No difference was found in heartburn symptoms.

CONCLUSIONS

H. pylori eradication does not cause reflux oesophagitis in this western population of functional dyspeptic patients.