Reflux esophagitis after eradication of Helicobacter pylori is associated with the degree of hiatal hernia

Association Between Gastroesophageal Flap Valve and Endoscopically Diagnosed Gastroesophageal Reflux Disease According to Lyon Consensus: A Meta-analysis of Asian Studies

BACKGROUND

Lyon Consensus altered the previous understanding of endoscopic gastroesophageal reflux disease (GERD) and pointed out that only high-grade reflux esophagitis (RE) [Los Angeles (LA) grades C or D], Barrett's esophagus or peptic stricturing were considered confirmatory evidence for GERD but low-grade RE (LA grades A or B) was regarded as suspected GERD. We aimed to summarize the possible relationship between gastroesophageal flap valve (GEFV) and endoscopic GERD according to Lyon Consensus using meta-analysis of studies done in Asia.

MATERIALS AND METHODS

Comprehensive searches of PubMed, WOS, Embase, SinoMed, and CNKI databases were completed to identify eligible studies published before September 22, 2019. A total of 237 articles have been reviewed and 2 reviewers independently evaluated the eligibility for inclusion, extracted, and analyzed the statistical data. The pooled risk ratios (RRs) with 95% confidence intervals (CI) were measured for the association. Random-effects models were used when observing significant heterogeneity.

RESULTS

A total of 15 studies were included and we found that abnormal GEFV (III and IV) could be associated with RE and the correlation become stronger as the grade increases (RE-A vs. controls-RR: 2.186, 95% CI: 1.560-3.064, P<0.001; RE-B vs. RE-A-RR: 1.268, 95% CI: 1.128-1.425, P<0.001; RE-C vs. RE-B-RR: 1.181, 95% CI: 1.000-1.395, P=0.049; RE-D vs. RE-C-RR: 1.471, 95% CI: 1.151-1.879, P=0.002). Both suspected GERD (RR: 2.400, 95% CI: 1.761-3.271, P<0.001) and endoscopic GERD (RR: 1.388, 95% CI: 1.127-1.711, P=0.002) were related to abnormal GEFV.

CONCLUSION

Abnormal GEFV could provide useful information for reflux conditions, but it could not distinguish confirmatory GERD from low-grade RE under the upper endoscopy.

Increased Reflux Esophagitis after Helicobacter pylori Eradication Therapy in Cases Undergoing Endoscopic Submucosal Dissection for Early Gastric Cancer

BACKGROUND

The role of Helicobacter pylori in the pathogenesis of reflux esophagitis is controversial. This study investigated the frequency of reflux esophagitis before and after H. pylori eradication in patients having endoscopic submucosal dissection for early gastric cancer.

METHODS

This study included 160 patients that fulfilled the study's criteria. Endoscopy was performed before and after H. pylori eradication, and reflux esophagitis was evaluated during the follow-up period.

RESULTS

Seropositivity for H. pylori in patients with early gastric cancer was 68.8%, 101 of them received eradication therapy. During the follow-up period, the incidence of reflux esophagitis increased from 3.1% to 18.8% in the successful eradication group but no case of reflux esophagitis was observed in the failed eradication group. The univariate and multivariate analyses showed a significant correlation between successful H. pylori eradication rate and the development of reflux esophagitis.

CONCLUSIONS

This study demonstrated that a successful H. pylori eradication therapy is a risk factor for newly developed reflux esophagitis in patients with endoscopic submucosal dissection for early gastric cancer.

Esophagogastric Junction Morphology on Hill's Classification Predicts Gastroesophageal Reflux with Good Accuracy and Consistency

INTRODUCTION

Hill's classification provides a reproducible endoscopic grading system for esophagogastric junction morphology and competence, specifically whether the gastroesophageal flap valve (GEFV) is normal (grade I/II) or abnormal (grades III/IV). However, it is not routinely used in clinical practice. We report a systematic review and meta-analysis to determine association between abnormal GEFV and gastroesophageal reflux disorder (GERD).

METHODS

A comprehensive literature search of MEDLINE and Scopus databases was conducted to identify studies that reported the association between abnormal GEFV and GERD. The search and quality assessment were performed independently by two authors. Fixed- and random-effects meta-analyses were conducted using symptomatic GERD and erosive esophagitis as outcomes.

RESULTS

A total of 11 studies met inclusion criteria that included a total of 5054 patients. In the general population, patients with abnormal GEFV had greater risk of symptomatic GERD compared to patients with a normal GEFV (risk ratio [RR] 1.88, 95% CI 1.57-2.24). Further, in patients with symptomatic GERD, patients with abnormal GEFV had greater risk of erosive esophagitis compared to patients with normal GEFV (RR 2.17, 95% CI 1.40-3.36). Finally, the specificity of abnormal GEFV for symptomatic GERD was 73.3% (95% CI 69.3-77.0%) and 75.7% (95% CI 65.9-83.4%) for erosive esophagitis in symptomatic GERD.

CONCLUSION

Our systematic review and meta-analysis showed consistent association between abnormal GEFV indicated by Hill's classification III/IV and symptomatic GERD and erosive esophagitis. Our recommendation is to include Hill's classification in routine endoscopy reports and workup for GERD.

Interactions between Helicobacter pylori and gastroesophageal reflux disease

Interactions between Helicobacter Pylori (HP) and gastroesophageal reflux disease (GERD) are a complex issue. Several pathophysiological factors influence the development and the course of GERD, HP infection might be only one of these. Many studies emphasize the co-existence of these diseases. HP infection could contribute to GERD through both a protective and an aggressive role. Gastric acid secretion is a key factor in the pathophysiology of reflux esophagitis. Depending on the type of gastritis related to HP, acid secretion may either increase or decrease. Gastritis in corpus leads to hypoacidity, while antrum gastritis leads to hyperacidity. In cases of antral gastritis and duodenal ulcers which have hyperacidity, the expectation is an improvement in pre-existing reflux esophagitis after eradication of HP. In adults, HP infection is often associated with atrophic gastritis in the corpus. Atrophic gastritis may protect against GERD. Pangastritis which leads to gastric atrophy is commonly associated with CagA strains of HP and it causes more severe gastric inflammation. In case of HP-positive corpus gastritis in the stomach, pangastritis, and atrophic gastritis, reflux esophagitis occurs frequently after eradication of HP. Nonetheless, as a predisposing disease of gastric cancer, HP should be treated. In conclusion, as the determinative factors affecting GERD involving in HP, detailed data on the location of gastric inflammation and CagA positivity should be obtained by the studies at future.

Abnormal Gastroesophageal Flap Valve Is Associated With High Gastresophageal Reflux Disease Questionnaire Score and the Severity of Gastroesophageal Reflux Disease in Vietnamese Patients With Upper Gastrointestinal Symptoms

Background/Aims

There have been no studies investigating the distribution of abnormal gastroesophageal flap valve (GEFV) among patients with dyspepsia, non-erosive reflux disease (NERD), and reflux esophagitis (RE) in the same set of patients. The aims of this study are to investigate (1) the association between GEFV and gastroesophageal reflux disease questionnaire (GERDQ) score, and (2) the distribution of abnormal GEFV in Vietnamese patients presenting with upper gastrointestinal symptoms.

Methods

Three hundred and thirty-one patients recruited in this prospective cross-sectional study were classified into 3 groups: reflux esophagitis (RE), non-erosive reflux disease (NERD) (GERDQ score ≥ 8, no endoscopic mucosal injury), and dyspepsia (GERDQ score < 8, no endoscopic mucosal injury). The GEFV was graded endoscopically according to the Hill classification. GEFV grades I and II were regarded as normal, while grades III and IV were regarded as abnormal GEFV.

Results

There were 215 (65.0%) patients with dyspepsia, 55 (16.6%) patients with NERD, and 61 (18.4%) patients with RE. Abnormal GEFV was an independent risk factor for GERD (OR, 2.93; CI 95%, 1.76–4.88) and RE (OR, 3.41; CI 95%, 1.78–6.53). The mean GERDQ score of patients with abnormal GEFV was significantly higher than that of patients with normal GEFV (5.7 ± 2.4 vs 4.9 ± 2.7, P = 0.011). The prevalence of abnormal GEFV gradually increased in patients with dyspepsia (27.4%), NERD (43.6%), grade A RE (56.8%), and grades B/C RE (80.0%) (P < 0.001).

Conclusions

Abnormal GEFV was significantly associated with high GERDQ score. Its prevalence gradually increased in patients with dyspepsia, NERD, and RE, respectively.

The Effect of Ineffective Esophageal Motility on Gastroesophageal Reflux Disease

BACKGROUND/AIMS

Ineffective esophageal motility (IEM) is the most common gastrointestinal motility disorder. Studies have reported that IEM is related to gastroesophageal reflux disease (GERD). However, the relationship between IEM and GERD remains uncertain. This study aims to clarify this relationship retrospectively.

METHODS

We analyzed 195 subjects who underwent high-resolution manometry between January 2011 and September 2016. Of these subjects, 72 had normal esophageal motility (NEM) and 26 had IEM. We investigated differences in the clinical characteristics, severity and duration of GERD symptoms, and comorbid extra-esophageal symptoms of the subjects. Comorbid extra-esophageal symptoms were assessed with the Gastrointestinal Symptom Rating Scale questionnaire. Investigation-defined GERD was diagnosed when erosive esophagitis or abnormal multichannel intraluminal impedance was present.

RESULTS

We found no significant difference in the prevalence of IEM between patients with and without GERD (37.5 and 21.1%, respectively; p = 0.174). There were no differences in age, gender, body mass index, presence of hiatal hernia, or duration of GERD between the groups. Compared to patients with NEM, those with IEM were significantly less likely to have comorbid extra-esophageal symptoms (p < 0.05).

CONCLUSION

There is no association between IEM and GERD.

Helicobacter pylori-Induced Changes in Gastric Acid Secretion and Upper Gastrointestinal Disease

Appropriate management of Helicobacter pylori infection of the human stomach is evolving and remains a significant clinical challenge. Acute infection results in hypochlorhydria, whereas chronic infection results in either hypo- or hyperchlorhydria, depending upon the anatomic site of infection. Acute hypochlorhydria facilitates survival of the bacterium and its infection of the stomach. Interestingly, most patients chronically infected with H. pylori manifest a pangastritis with reduced acid secretion due to bacterial virulence factors, inflammatory cytokines, and various degrees of gastric atrophy. While these patients are predisposed to develop gastric adenocarcinoma (~1%), there is increasing evidence from population studies that they are also protected from gastroesophageal reflux disease (GERD), Barrett's esophagus (BE), and esophageal adenocarcinoma (EAC). Eradication of H. pylori, in these patients, may provoke GERD in predisposed individuals and may be a contributory factor for the rising incidence of refractory GERD, BE, and EAC observed in Westernized societies. Only ~10% of chronically infected patients, mainly the young, manifest an antral predominant gastritis with increased acid secretion due to a decrease in somatostatin and increase in gastrin secretion; these patients are predisposed to develop peptic ulcer disease. H. pylori-induced changes in acid secretion, in particular hypochlorhydria, may allow ingested microorganisms to survive transit through the stomach and colonize the distal intestine and colon. Such perturbation of gut microbiota, i.e. dysbiosis, may influence human health and disease.

Management of Helicobacter pylori infection-the Maastricht V/Florence Consensus Report

Important progress has been made in the management of Helicobacter pylori infection and in this fifth edition of the Maastricht Consensus Report, key aspects related to the clinical role of H. pylori were re-evaluated in 2015. In the Maastricht V/Florence Consensus Conference, 43 experts from 24 countries examined new data related to H. pylori in five subdivided workshops: (1) Indications/Associations, (2) Diagnosis, (3) Treatment, (4) Prevention/Public Health, (5) H. pylori and the Gastric Microbiota. The results of the individual workshops were presented to 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 the various clinical scenarios.

Reflux esophagitis triggered after Helicobacter pylori eradication: a noteworthy demerit of eradication therapy among the Japanese?

In the February 2013 Revision of Insured Medical Treatment, bacterial eradication for all Helicobacter pylori-positive individuals in Japan was covered under the insurance scheme. However, reflux esophagitis is believed to occur in approximately 10% of Japanese patients who undergo eradication therapy. Hence, the risk of reflux esophagitis among such cases should be carefully considered, particularly in the treatment for H. pylori-positive patients who are otherwise healthy. The eradication of H. pylori in cases of H. pylori-positive gastritis markedly suppresses gastric inflammation, and inhibits gastric mucosal atrophy and its progression to intestinal metaplasia. In a long-term follow-up study (10–20 years), eradication treatment was found to reduce the risk of subsequent gastric cancer. However, the fact that eradication-induced reflux esophagitis could increase the long-term risk of Barrett's esophagus and esophageal adenocarcinoma should also be considered in the Japanese population. Appropriate treatment with proton pump inhibitors should be taken into consideration for patients undergoing eradication therapy in clinical practice.

Lower esophageal microbiota species are affected by the eradication of Helicobacter pylori infection using antibiotics

The aim of this study was to investigate the effect of Helicobacter pylori (H. pylori) infection on the lower esophageal microbiota and the eradication of H. pylori through the use of antibiotics. Forty-five BALB/C mice were randomly divided into negative control, infection and treatment groups. The mice were sacrificed and DNA was extracted from the lower esophageal microbiota. Polymerase chain reaction-denaturing gradient gel electrophoresis (PCR-DGGE) was performed to determine the composition of the microbiota. Quantity One^® 1-D Analysis Software was used for the analysis of the DGGE profiles. The different bands from the groups were amplified with 16S rDNA V6 region primers. DNA sequencing and Basic Local Alignment Search Tool analysis were performed for the identification of the bands. H. pylori colonization led to severe ulcers in the stomachs of the mice, and these ulcers were alleviated by antibiotic treatment. The infection group had an increased number of bacterial species in the stomach compared with the control and treatment groups. DGGE fingerprinting of the lower esophagus showed that there were significant differences in the number of bands (P<0.05), diversity index and abundance among the groups (P<0.05); however, no significant differences in homogeneity were observed (P>0.05). Although the composition of flora species in the lower espohagus varied, the dominant species, and their relative contents, were similar in the control, infection and treatment groups. The present study provided a microecological basis for the understanding of the pathogenesis of lower esophageal diseases, following the eradication of H. pylori infection with antibiotics.

Esophageal Adenocarcinoma Developing after Eradication of Helicobacter pylori

A 75-year-old man underwent endoscopic hemostatic therapy for hemorrhagic gastric ulcer in September 2002. After healing of the gastric ulcer, he underwent Helicobacter pylori eradication therapy in February 2003. In August 2007, an irregular tumor was detected in the lower esophagus at annual checkup for gastric cancer screening using X-ray. Endoscopic examination showed that the lower margin of the tumor almost coincided with the esophagogastric junction and that a short segment of Barrett's epithelium existed near the tumor. Biopsies of the tumor showed moderately to poorly differentiated adenocarcinoma. Mild reflux esophagitis and minor hiatal hernia was also observed, and the previously treated gastric ulcer was not recurrent. Absence of H. pylori was confirmed by serum antibody and urea breath test. Surgical resection of the lower esophagus and proximal stomach was performed. The tumor invaded into the muscularis propria of the esophageal wall but had no evidence of lymph node metastasis. Based on macroscopic and pathological findings, the tumor was recognized as esophageal adenocarcinoma. Previous endoscopic examination did not detect any apparent signs of tumor in the esophagogastric junction. As far as we know, this is the first report documenting a newly developed esophageal adenocarcinoma after the successful eradication of H. pylori.

Gastroesophageal reflux disease in Asia: A historical perspective and present challenges

Gastroesophageal reflux disease (GERD), previously uncommon in Asia, has now become an important disease in the region. Although much variability exists between studies, most endoscopy-based studies show a prevalence of erosive esophagitis of more than 10%. Symptom-based studies also show a prevalence of 6-10%. Two longitudinal follow-up studies on GERD symptoms have shown an increase with time, and several endoscopy-based time trend studies have also shown a significant increase in erosive reflux esophagitis. Studies on Barrett's esophagus have been confounded by the description of short (SSBE) and long segment (LSBE) Barrett's esophagus. Great variation in prevalence rates has been reported. SSBE vary from 0.1% to more than 20% while LSBE vary from 1-2%. Of the putative causative factors, obesity has been the most important. Many studies have linked GERD-esophagitis as well as occurrence of reflux symptoms with an increase in body mass index (BMI), obesity, especially visceral or central obesity, and metabolic syndrome. A decline in Helicobacter pylori infection with growing affluence in Asia has been broadly thought to result in healthier stomachs and a higher gastric acid output resulting in reflux disease. However, variable results have been obtained from association and H. pylori eradication studies.

Is there an increased risk of GERD after Helicobacter pylori eradication?: a meta-analysis

OBJECTIVES

Some studies suggest that eradication of Helicobacter pylori (Hp) might increase the risk of gastroesophageal reflux disease (GERD) in a portion of patients. We aimed to conduct a meta-analysis to investigate this.

METHODS

A comprehensive, English, multiple-source literature search was performed from 1983 to February 2007. Only randomized controlled trial (RCT) and cohort studies comparing the prevalence of GERD in patients free from GERD at baseline with Hp eradication vs. those with persistent Hp were included. Quality of RCTs and cohorts was assessed by Jadad and New Castle-Ottawa scores, respectively. Meta-analysis of pooled odds ratios (ORs) was performed using Review Manager 4.2.10.

RESULTS

Twelve (7 RCTs and 5 cohorts) of 271 articles were included. In six RCTs using erosive GERD as outcome, the OR for the frequency of GERD in Hp eradicated group vs. persistent Hp group was 1.11 (0.81-1.53, P=0.52). In five RCTs using symptomatic outcome, the OR for the frequency of GERD in Hp eradicated group vs. persistent Hp was 1.22 (0.89-1.69, P=0.22). In cohort studies, the OR for the frequency of GERD in Hp eradicated group vs. persistent Hp was 1.37 (0.89-2.12; P=0.15). Test of heterogeneity was not significant for any analyses. The results were consistent in subgroup and sensitivity analyses, including cohort studies vs. RCTs, high-quality studies vs. low-quality studies, and use of endoscopic vs. symptomatic outcomes except for the subgroup of patients with peptic ulcer disease (PUD) in cohort studies (OR: 2.04 (1.08-3.85); P=0.03).

CONCLUSIONS

There is no association between Hp eradication and development of new cases of GERD in the population of dyspeptic patients. However, in cohort studies, there seems to be a twofold higher risk of development of erosive GERD in patients with PUD. The effect in RCTs of patients with PUD did not show a significant difference.

Epidemiology and clinical characteristics of GERD in the Japanese population

We reviewed articles on the epidemiology and clinical characteristics of gastroesophageal reflux disease (GERD) in Japan to clarify these features of GERD in this country. Although the definition of GERD depends on the individual study, the prevalence of GERD has been increasing since the end of the 1990s. The reasons for the increase in the prevalence of GERD may be due to increases in gastric acid secretion, a decrease in the Helicobacter pylori infection rate, more attention being paid to GERD, and advances in the concept of GERD. More than half of GERD patients had non-erosive reflux disease, and the majority (87%) of erosive esophagitis was mild type, such as Los Angeles classification grade A and grade B. There were several identified risk factors, such as older age, obesity, and hiatal hernia. In particular, mild gastric atrophy and absence of H. pylori infection influence the characteristics of GERD in the Japanese population. We also discuss GERD in the elderly; asymptomatic GERD; the natural history of GERD; and associations between GERD and peptic ulcer disease and H. pylori eradication. We examined the prevalence of GERD in patients with specific diseases, and found a higher prevalence of GERD, compared with that in the general population, in patients with diabetes mellitus, those with obstructive sleep apnea syndrome, and those with bronchial asthma. We provide a comprehensive review of GERD in the Japanese population and raise several clinical issues.

Barrett's esophagus and endoscopically assessed esophagogastric junction integrity in 1000 consecutive Turkish patients undergoing endoscopy: a prospective study

Barrett's esophagus (BE) appears to be more common in Western than in Asian countries. BE is a complication of gastroesophageal reflux disease (GERD). Anatomical abnormalities of the esophagogastric junction (EGJ) are an important factor in the pathogenesis of GERD. We aimed to determine the prevalence of BE in Turkey, which is geographically located between Europe and Asia, and to investigate the frequency of BE according to the degree of anatomical disruption in the EGJ. This prospective study was performed on 1000 consecutive patients referred for endoscopy for any clinical indication. All patients underwent a structured interview that assessed major symptoms of GERD (regurgitation and heartburn). BE was diagnosed when specialized intestinal metaplasia was detected histologically in the esophageal biopsy specimens. Endoscopically assessed integrity of the EGJ was classified as one of three types, as follows: 1 Normal EGJ. The endoscope shaft was gripped tightly by the cardia in retroflexed endoscopy, or it was gripped less tightly but the cardia was seen to open and close with respiration. 2 Widened EGJ. The cardia was open during all phases of respiration in retroflexed endoscopy, but there was no endoscopic evidence of hiatal hernia (HH) on the antegrade view. 3 HH. The axial length from the EGJ to the diaphragmatic hiatus was at least 2 cm. BE was found in 12 patients (1.2%). Normal EGJ was seen in 90.7% of patients, widened EGJ in 4.3%, and HH in 5%. Patients with widened EGJ had a significantly higher incidence of major reflux symptoms and erosive esophagitis compared with those with normal EGJ (P= 0.001). BE was found in 14% of patients with HH and in 0.5% of patients with a normal EGJ (P= 0.001). None of the patients with widened EGJ had BE. In terms of BE frequency, these patients did not differ significantly from those with normal EGJ (P= 0.793) but did differ significantly from those with HH (P= 0.014). The prevalence of BE was 1.2% in a Turkish population undergoing endoscopy for any reason. In terms of EGJ integrity, comparison of the groups showed that even in the absence of HH, patients with widening of the EGJ had an increased prevalence of major reflux symptoms and erosive esophagitis. However, histologically confirmed BE was not seen among patients with widened EGJ.

Influence of Helicobacter pylori eradication on reflux esophagitis in Japanese patients

The relationship between Helicobacter pylori eradication and reflux esophagitis is controversial. We analyzed the development of reflux esophagitis and the change in the grade of pre-existing reflux esophagitis after eradication. Enrolled were 559 Japanese patients who received eradication therapy for H. pylori. The grade of reflux esophagitis by endoscopy before and after therapy was evaluated retrospectively. No esophagitis was present before eradication in 526 patients. H. pylori was and was not eradicated in 429 and 97, respectively. Reflux esophagitis developed in 40 of the eradication group and in three of the treatment failure group, with prevalence higher with successful eradication (P = 0.04). Successful eradication and hiatus hernia were significant risk factors for reflux esophagitis development. Twenty-seven of 33 patients with pre-existing reflux esophagitis had successful eradication and six treatment failure. The reflux esophagitis grade worsened in two (Los Angeles classification from A to B) and improved in 14 patients after eradication. With treatment failure, reflux esophagitis worsened in none and improved in three patients. There showed no significant change in the grade of pre-existing reflux esophagitis after H. pylori eradication but the sample size was too small to evaluate the difference. In conclusion, the eradication of H. pylori increases the prevalence of reflux esophagitis, and hiatus hernia was a significant risk factor for the development of reflux esophagitis.

Control of gastric acid secretion in health and disease

Recent milestones in the understanding of gastric acid secretion and treatment of acid-peptic disorders include the (1) discovery of histamine H(2)-receptors and development of histamine H(2)-receptor antagonists, (2) identification of H(+)K(+)-ATPase as the parietal cell proton pump and development of proton pump inhibitors, and (3) identification of Helicobacter pylori as the major cause of duodenal ulcer and development of effective eradication regimens. This review emphasizes the importance and relevance of gastric acid secretion and its regulation in health and disease. We review the physiology and pathophysiology of acid secretion as well as evidence regarding its inhibition in the management of acid-related clinical conditions.

Helicobacter pylori infection and related gastrointestinal diseases

Helicobacter pylori has been implicated in the pathogenesis of a number of digestive tract disorders, such as chronic active gastritis, peptic ulceration, gastric cancer, and mucosa-associated lymphoid tissue lymphoma. Disease outcome is dependent on many factors, including bacterial genotype, host physiology and genetics, and environmental factors such as diet. Researchers continue to explore the complexities of H. pylori infection, seeking to explain why some individuals have asymptomatic infection, whereas others experience clinical disease. The importance of treating H. pylori infection in patients with gastrointestinal problems has been confirmed in recent years, with clinical trials showing that cure of infection can prevent duodenal ulcer and, to a lesser extent, gastric ulcer recurrence; cure early stage mucosa-associated lymphoid tissue lymphoma; and reduce the chances of developing gastric cancer in high-risk individuals.

Helicobacter pylori eradication therapy on histologic change in the distal esophagus

BACKGROUND

Although cases of reflux esophagitis (RE) developing after treatment to eradicate Helicobacter pylori have been discussed in some detail, no reports are available concerning the histologic examination of RE both before and after eradication therapy.

MATERIALS AND METHODS

Sixty-one patients and 111 specimens were investigated using endoscopic and histologic techniques. The histologic findings including basal zone height, papillar height, Ki-67 labeling index, and COX-2 expression before and after treatment for H. pylori infection were compared with those in normal controls and patients with endoscopic RE.

RESULTS

Twelve months after eradication therapy, the incidence of newly developed endoscopic RE was 20% (5/25). Basal zone height and papillar height had increased at 1 month, but had returned to pretreatment levels after 12 months of eradication therapy. The Ki-67 labeling index was significantly increased 1 and 12 months after eradication therapy compared to values before treatment. COX-2 expression gradually increased after the treatment. The phenomena linked to esophagitis appeared after eradication therapy. However, the severity and extent of these signs were not so high after the treatment of H. pylori than those in patients with overt reflux esophagitis. Focusing on the patients with hiatal hernia, papillar height and Ki-67 labeling index increased significantly after eradication therapy, values being almost the same as those in the patients with endoscopic RE.

CONCLUSIONS

Hiatal hernia plays an important role in the possible occurrence of hidden RE after treatment for a H. pylori infection.

Gastric secretion

PURPOSE OF REVIEW

The purpose of this review is to summarize the pertinent literature published in the past year regarding the regulation of gastric exocrine and endocrine secretion.

RECENT FINDINGS

Gastric acid aids protein digestion; facilitates the absorption of iron, calcium, and vitamin B12; thwarts enteric infection; and prevents bacterial overgrowth. When levels of acid and proteolytic enzymes overwhelm the mucosal defense mechanisms, ulcers occur. To avoid damage under these harsh conditions, gastric acid must be finely regulated by overlapping neural (e.g. orexin, pituitary adenylate cyclase-activating polypeptide, nitric oxide, and galanin), hormonal (e.g. gastrin, cholecystokinin, and ghrelin), paracrine (e.g. histamine and somatostatin), and autocrine (e.g. transforming growth factor-alpha) pathways. The precise mechanisms whereby Helicobacter pylori induces perturbations in acid secretion are not known, but they seem to involve changes in somatostatin and perhaps ghrelin secretion. Acid secretion by parietal cells involves intracellular elevation of calcium and/or cyclic AMP, followed by a cascade that triggers translocation of the proton pump, HK-adenosine triphosphatase, from cytoplasmic tubulovesicles to the secretory canaliculi.

SUMMARY

An improved understanding of the pathways and mechanisms regulating gastric acid secretion may lead to the development of new strategies to prevent and treat acid peptic disorders as well as circumvent the adverse effects of currently prescribed antisecretory medications.

Helicobacter pylori and non-malignant diseases

This paper reviews new literature data from March 2004 to April 2005 about the association between Helicobacter pylori and non-malignant disease of the upper gastrointestinal tract. Eradication of H. pylori is indicated for all patients with non-malignant diseases associated with this pathogen. However, its effect is variable, ranging from the highest benefit in the cure of peptic ulcer disease to a small benefit in patients with non-ulcer dyspepsia. Test and treat strategy is still cost-effective for management of patients with uninvestigated dyspepsia. The only limitations of the strategy are the patient's age and the cost benefit ratio in case of low prevalence of the infection. H. pylori eradication is of value in chronic NSAID users, but is insufficient to prevent NSAID-related ulcer disease. In developed countries H. pylori eradication does not cause gastro-esophageal reflux disease (GORD), however, a negative association between H. pylori and GORD does exist, especially in Asia, but the nature of this relationship should be further clarified.