Helicobacter pylori and nonmalignant diseases

Gastric juice analysis in clinical practice: why, how, and when. The experience with EndoFaster

Gastric juice analysis may be useful for clinical purposes, including the detection of H. pylori infection and diffuse atrophic gastritis on gastric mucosa. EndoFaster is a novel device which performs real-time analysis of gastric juice revealing the infection and hypochlorhydria by measuring ammonium concentrations and pH levels. This review aimed to evaluate the clinical applications of such a tool. By considering data from overall 11 studies, the values of sensitivity, specificity, positive predictive value, negative predictive value, accuracy, positive likelihood ratio, and negative likelihood ratio were 90%, 86%, 67%, 96%, 87%, 8.5, and 0.13, respectively, for H. pylori diagnosis, and 83%, 92%, 58%, 97%, 91%, 9.9 and 0.2, respectively, for suspecting diffuse atrophic gastritis. The very high value of negative predictive values for both H. pylori and mucosal atrophy would allow avoiding to perform useless negative gastric biopsies when the results of the test are negative. Some promising data suggest that gastric juice analysis may be useful also to diagnose H. pylori infection in patients with chronic active gastritis without evidence of bacteria at histology, as well as in predicting persistent acid reflux in patients on proton pump inhibitor therapy for reflux disease.

Optimized sequential therapy vs 10- and 14-d concomitant therapy for eradicating Helicobacter pylori: A randomized clinical trial

BACKGROUND

A cure for Helicobacter pylori (H. pylori) remains a problem of global concern. The prevalence of antimicrobial resistance is widely rising and becoming a challenging issue worldwide. Optimizing sequential therapy seems to be one of the most attractive strategies in terms of efficacy, tolerability and cost. The most common sequential therapy consists of a dual therapy [proton-pump inhibitors (PPIs) and amoxicillin] for the first period (5 to 7 d), followed by a triple therapy for the second period (PPI, clarithromycin and metronidazole). PPIs play a key role in maintaining a gastric pH at a level that allows an optimal efficacy of antibiotics, hence the idea of using new generation molecules.

AIM

To compare an optimized sequential therapy with the standard non-bismuth quadruple therapies of 10 and 14 d, in terms of efficacy, incidence of adverse effects (AEs) and cost.

METHODS

This open-label prospective study randomized 328 patients with confirmed H. pylori infection into three groups (1:1:1): The first group received quadruple therapy consisting of twice-daily (bid) omeprazole 20 mg, amoxicillin 1 g, clarithromycin 500 mg and metronidazole 500 mg for 10 d (QT-10), the second group received a 14 d quadruple therapy following the same regimen (QT-14), and the third group received an optimized sequential therapy consisting of bid rabeprazole 20 mg plus amoxicillin 1 g for 7 d, followed by bid rabeprazole 20 mg, clarithromycin 500 mg and metronidazole 500 mg for the next 7 d (OST-14). AEs were recorded throughout the study, and the H. pylori eradication rate was determined 4 to 6 wk after the end of treatment, using the 13C urea breath test.

RESULTS

In the intention-to-treat and per-protocol analysis, the eradication rate was higher in the OST-14 group compared to the QT-10 group: (93.5%, 85.5% P = 0.04) and (96.2%, 89.5% P = 0.03) respectively. However, there was no statistically significant difference in eradication rates between the OST-14 and QT-14 groups: (93.5%, 91.8% P = 0.34) and (96.2%, 94.4% P = 0.35), respectively. The overall incidence of AEs was significantly lower in the OST-14 group (P = 0.01). Furthermore, OST-14 was the most cost-effective among the three groups.

CONCLUSION

The optimized 14-d sequential therapy is a safe and effective alternative. Its eradication rate is comparable to that of the 14-d concomitant therapy while causing fewer AEs and allowing a gain in terms of cost.

Helicobacter pylori infection in migraine headache: a true association or an innocent bystander?

Much concern was directed towards the relationship between migraine and Helicobacter pylori (H. pylori) infection. Some researchers reported a strong association. Meanwhile, others have indicated totally negative results. The aim of this work was to clarify the association between migraine headaches and both H. pylori infection and Gastrointestinal (GIT) symptoms and to study their impact on the frequency and severity of migraine headache attacks.

This is a case control study conducted on 77 migraine patients and 77 healthy controls. History was taken from the included patients regarding the frequency of migraine headache attacks/month and GIT symptoms including dyspepsia, flatulence, weight loss, and epigastric pain. Migraine Disability Assessment Test (MIDAS) and Visual Analogue Scale (VAS) were used for assessment of migraine severity. Helicobacter pylori was detected in the stool of the included patients and controls.

There was a significantly higher prevalence of infection with H. pylori in migraine patients [77.9% (n = 60)] than control group [50.6% (n = 39)] (P-value˂ 0.001, Odds ratio= 3.439, 95% CI =1.708 - 6.923). The prevalence of dyspepsia, flatulence, and epigastric pain. was significantly higher in migraine patients in comparison to control group (P-value= 0.003, 0.017, 0.006 respectively). There was no effect of infection with H. pylori or presence of GIT symptoms on frequency of migraine attacks, MIDAS or VAS scores.

GIT symptoms and H. pylori infection are more prevalent in patients with migraine compared to controls, however, they might not have an impact on the frequency or severity of migraine headache attacks.

Third-line and rescue therapy for refractory Helicobacter pylori infection: A systematic review

BACKGROUND

Due to increasing resistance rates of Helicobacter pylori (H. pylori) to different antibiotics, failures in eradication therapies are becoming more frequent. Even though eradication criteria and treatment algorithms for first-line and second-line therapy against H. pylori infection are well-established, there is no clear recommendation for third-line and rescue therapy in refractory H. pylori infection.

AIM

To perform a systematic review evaluating the efficacy and safety of rescue therapies against refractory H. pylori infection.

METHODS

A systematic search of available rescue treatments for refractory H. pylori infection was conducted on the National Library of Medicine’s PubMed search platform based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomized or non-randomized clinical trials and observational studies evaluating the effectiveness of H. pylori infection rescue therapies were included.

RESULTS

Twenty-eight studies were included in the analysis of mean eradication rates as rescue therapy, and 21 of these were selected for analysis of mean eradication rate as third-line treatment. For rifabutin-, sitafloxacin-, levofloxacin-, or metronidazole-based triple-therapy as third-line treatment, mean eradication rates of 81.6% and 84.4%, 79.4% and 81.5%, 55.7% and 60.6%, and 62.0% and 63.0% were found in intention-to-treat (ITT) and per-protocol (PP) analysis, respectively. For third-line quadruple therapy, mean eradication rates of 69.2% and 72.1% were found for bismuth quadruple therapy (BQT), 88.9% and 90.9% for bismuth quadruple therapy, three-in-one, Pylera^® (BQT-Pylera), and 61.3% and 64.2% for non-BQT) in ITT and PP analysis, respectively. For rifabutin-, sitafloxacin-, levofloxacin-, or metronidazole-based triple therapy as rescue therapy, mean eradication rates of 75.4% and 78.8%, 79.4 and 81.5%, 55.7% and 60.6%, and 62.0% and 63.0% were found in ITT and PP analysis, respectively. For quadruple therapy as rescue treatment, mean eradication rates of 76.7% and 79.2% for BQT, 84.9% and 87.8% for BQT-Pylera, and 61.3% and 64.2% for non-BQT were found in ITT and PP analysis, respectively. For susceptibility-guided therapy, mean eradication rates as third-line and rescue treatment were 75.0% in ITT and 79.2% in PP analysis.

CONCLUSION

We recommend sitafloxacin-based triple therapy containing vonoprazan in regions with low macrolide resistance profile. In regions with known resistance to macrolides or unavailability of bismuth, rifabutin-based triple therapy is recommended.

Quality performance measures in upper gastrointestinal endoscopy for lesion detection: Italian AIGO-SIED-SIGE joint position statement

Esophagogastroduodenoscopy (EGD) plays a crucial role in the management of gastroduodenal diseases by allowing a direct and accurate evaluation of the mucosa and the execution of several operative maneuvers. Despite a constant development of new imaging tools and operative devices, the widespread use of EGD has not resulted in a significant reduction of mortality for patients affected by esophageal/gastric cancer during the last three decades in Western countries. Evidence indicates that this disheartening scenario derives from a high variability of execution of EGD which determines its quality and diagnostic yield, delaying the diagnosis of neoplastic diseases. Based on this evidence, in recent years many scientific societies have produced different position papers aimed at defining quality performance measures in EGD. Thus, the Italian Association of Gastroenterologists and Endoscopists, the Italian Society of Digestive Endoscopy and the Italian Society of Gastroenterology have produced this joint document based on the review of ASGE, ACG, BSG, ESGE and Asian Consensus EGD position papers with the aim of indicating the quality standards of EGD (pre-, intra- and post-procedure) focused on lesion detection to be adopted in the Italian context.

Real-time gastric juice analysis with EndoFaster for H. pylori diagnosis: a large, multicentre study

BACKGROUND

Helicobacter pylori infection is the main cause of the most frequent gastroduodenal diseases. Because its prevalence is decreasing in developed countries, gastric biopsies are negative in several patients. By measuring ammonium in the gastric juice, EndoFaster allows to exclude H. pylori infection during endoscopy. This study aimed to assess the accuracy of device versions working with either 6 ml or 3 ml of gastric juice.

STUDY DESIGN

This prospective study involved 12 endoscopic units. During endoscopy, EndoFaster testing was performed and standard five gastric biopsies were taken. The accuracy was calculated by considering histological assessment as the gold standard for H. pylori diagnosis.

RESULTS

Gastric juice analysis was attempted in 1279 patients, but it failed in 131 (15.5%) and in 10 (2.3%), with the 6 ml and the 3 ml device, respectively (P < 0.001). Overall, EndoFaster detected H. pylori infection with an 86.3% sensitivity, 83.3% specificity, 52.7% positive predictive value, 96.6% negative predictive value and 83.8% accuracy. The performance was not affected either by ongoing proton pump inhibitor therapy or a previous H. pylori eradication. No significant difference in accuracy emerged between the two versions of the device.

CONCLUSION

The novel version of the EndoFaster device operating with 3 ml gastric juice may be performed in virtually all patients, and it allows excluding H. pylori infection with a very high accuracy. Gastric biopsies can be avoided in a definite portion of cases without endoscopic lesions or other clinical indications.

First-line therapies for H. pylori infection in Italy: a pooled-data analysis

Background: Curing H. pylori infection remains challenging, and the use of most effective first-line therapy represents a therapeutic cornerstone. To monitor the efficacy of first-line therapies in Italy, we designed a systematic review with pooled- data analysis of data published in the last 15 years. Methods: The search was focused on standard regimens and adult patients. Studies that included modified therapy regimens, pediatric patients, case series with less than 5 patients, and those in language other than English were excluded. Results: A total of 40 studies, with 74 therapeutic arms and 13,539 patients were evaluated. Among the 14-day triple therapies, the combination with proton pump inhibitor (PPI), clarithromycin and amoxicillin achieved the highest (77.9%) success rate, whilst the lowest success rate (62.7%) was observed following the 14-day PPI, clarithromycin and tinidazole regimen. The overall efficacy of triple therapies significantly decreased from 75.7% to 72.1% in the last decade. Sequential (88.3% on 3431 patients), concomitant (88.8% on 376 patients), and the bismuth-based quadruple therapy with three-in-one capsule, containing bismuth subcitrate potassium (140 mg), metronidazole (125 mg), tetracycline (125 mg) (90.4% on 999 patients) achieved similarly high eradication rates, but data on concomitant are still limited. The bismuth-based was associated with the higher (38.7%) incidence of side-effects. Conclusions: Data found that all triple therapies, irrespective of drug combination and therapy duration, should be abandoned in Italy due to their unacceptable low success rates. Monitoring the efficacy of standard first-line therapies in other countries could be clinically useful for both patients and clinicians.

Comparison of 10 and 14 days of triple therapy versus 10 days of sequential therapy for Helicobacter pylori eradication: A prospective randomized study

BACKGROUND/AIMS

The aim of the present study was to compare between the efficacy and tolerability of a sequential therapy (ST) as the first-line treatment for adults with Helicobacter pylori infection and that of standard triple therapy (TT).

MATERIALS AND METHODS

This was a prospective, randomized open-label, single-center study. We enrolled 206 patients who were divided into the following three treatment groups: Group A (pantoprazole 40 mg bid (twice daily), amoxicillin 1 g bid, and clarithromycin 500 mg bid for 10 d), Group B (the same TT as Group A for 14 d), and Group C (pantoprazole 40 mg bid and amoxicillin 1 g bid for 5 d, followed by pantoprazole 40 mg bid, clarithromycin 500 mg bid, and metronidazole 500 mg bid for additional 5 d).

RESULTS

Intention-to-treat (ITT) analysis revealed that 14 d of TT achieved a higher eradication rate than 10 d of ST (54.8% vs. 50.7%), but the difference was not statistically significant (p=0.623); further, 10 d of TT achieved 45% eradication rate. Per-protocol (PP) analysis revealed that the success rate for 10 d of ST was more than that for 10 d of TT (70.6% vs. 65%; p=0.571); however, the success rate for 10 d of TT was not statistically different from that for 14 d of TT. The eradication rates achieved in the ITT analysis were lower than those achieved in the PP analysis for 10 (45% vs. 65%) or 14 (54.7% vs. 69%) d of TT or for 10 d of ST (50.7% vs. 70.6%). No statistically significant difference was observed. Adverse effects and compliance were not significantly different among the three groups.

CONCLUSION

Neither 10 d of ST nor 14 d of TT achieved the optimum H. pylori eradication rate.

CYP2C19 polymorphism has no influence on rabeprazole-based hybrid therapy for Helicobacter pylori eradication

AIM

To evaluate the impact of cytochrome P450 2C19 (CYP2C19) and interleukin-1β (IL-1β) polymorphisms on the efficacy of Helicobacter pylori (H. pylori) eradication by using rabeprazole-based hybrid therapy.

METHODS

A total of 88 H. pylori-infected patients were recruited to receive 14-d of hybrid therapy from March 2013 to May 2014. Three patients were excluded from analysis because of incomplete compliance. Either a follow-up endoscopy or ¹³C-urea test was performed to determine the results of H. pylori eradication therapy. The genotypes of CYP2C19 and IL-1β were analyzed to investigate the impact on treatment effect.

RESULTS

The total eradication rate of H. pylori was 92.94% (79/85). According to the CYP2C19 genotypes, the rates of H. pylori eradication were 89.19% in extensive metabolizers (EM) and 95.83% in non-EM. The H. pylori eradication rates regarding the IL-1β genotypes were 92.59% in the normal acid secretion group and 93.10% in the low acid secretion group. After multivariable logistic regression analysis, both the genotypes of CYP2C19 and IL-1β had no significant influences on the eradication rates of H. pylori.

CONCLUSION

The CYP2C19 and IL-1β polymorphisms are not significantly independent factors of H. pylori eradication using rabeprazole-based hybrid therapy.

A Comparison of Five Different Treatment Regimens as the First-Line Treatment of Helicobacter pylori in Turkey

BACKGROUND

The H. pylori eradication success is low in countries with high antibiotic resistance to H. pylori.

OBJECTIVE

We retrospectively assessed the eradication rates achieved by five different regimens and aimed to compare the efficiency of bismuth enhanced sequential therapy and other treatments in a gastroenterology outpatient clinic a university-affiliated hospital.

DESIGN

Our study was carried out with a retrospective cohort design.

SETTING

This study assessed the gastroscopy examinations of patients.

PATIENTS

A total of 621 patients were included in the study. There were 122 patients in the quadruple treatment group, 168 patients in the classical sequential treatment group, 130 patients in the bismuth enhanced sequential therapy, 113 patients in the sequential treatment with levofloxacin, and 88 patients in the hybrid treatment.

MEASUREMENTS

Eradication rates of different regimens was analyzed by performing Chi-square and Tukey's honest significant difference test.

RESULTS

Eradication rates by ITT and PP analysis achieved by treatment groups were 74.6 and 75.6% in the quadruple treatment; 70.2 and 70.4% in the sequential treatment with clarithromycin, 88.5 and 90.3% in the bismuth enhanced sequential therapy, 77.9 and 78.5% in the sequential treatment with levofloxacin, and 76.1 and 76.2% in the hybrid treatment.

LIMITATIONS

The main limitation of our study was its retrospective nature. Different proton pump inhibitors were used in the treatment arms.

CONCLUSIONS

Bismuth-enhanced sequential therapy can be recommended to overcome resistance.

Novel anti-Helicobacter pylori therapies

Helicobacter pylori is a ubiquitous gastropathogen infecting more than half of the world population. It is associated with dyspepsia, gastritis, gastroduodenal ulcers, mucus-associated lymphoid tissue lymphoma and gastric carcinoma. Current recommended therapy does not eradicate infection in all treated cases and at least 20% post-treatment patients continue to suffer. Salvage therapy helps some of these nonresponders, but resistance to available antibiotics is mounting. Hence, its treatment still remains a daunting task for the practicing physician. Novel medications with improved efficacy and tolerability and with less chances of resistance are required. The present review attempts to discuss the newer patents in this field, which demonstrate a promising future role in the management of H. pylori infection and its consequent problems.

Proton Pump Inhibitors and the Prescribing Cascade

ACTIVITY OBJECTIVES: 1. Describe the prescribing cascade of proton pump inhibitors (PPI) in nursing home residents. 2. Identify the statistically significant factors related to the use of PPI and H2 receptor blockers. DISCLOSURE STATEMENT Neither the planners nor the authors have any conflicts of interest to disclose. The current study examined the use of proton pump inhibitor (PPI) drugs in 248 nursing home residents and factors associated with being prescribed a PPI. Ninety-three percent of residents taking a PPI had done so for longer than recommended durations. As anticholinergic burden, vitamin/supplement use, and number of oral products taken daily increased, residents were more likely to be taking a PPI. Higher anticholinergic burden (p = 0.031) and number of oral products taken daily (p = 0.04) were two statistically significant predictors in the final logistic regression model. Significant predictors of PPI use in the current study may be explained by the association between polypharmacy and dyspepsia and the lowering of esophageal sphincter pressure by anticholinergic drugs. High use of PPIs in nursing home residents may represent a prescribing cascade.

Effect of Helicobacter pylori infection on mental status

AIM: To investigate the effect of Helicobacter pylori (H. pylori) infection on mental status of patients.

METHODS: Eighty-four patients diagnosed with H. pylori infection by ¹³C-Urea breath test (¹³C-UBT) at Tongling Municipal Hospital were included in an experimental group, and 84 healthy controls were used as a control group. The differences between the two groups were compared using the Symptom Checklist 90 (SCL-90) rating scale. Patients with H. pylori infection received H. pylori eradication, and then underwent ¹³C-UBT again. Patients who had successful H. pylori eradication were scored with the SCL-90 rating scale again, and the scores were compared between before and after treatment.

RESULTS: Somzatization, compulsion symptom, interpersonal relations, depression, anxiety, and terror scores differed significantly between patients with H. pylori infection and those without H. pylori infection, as well as between before and after successful eradication therapy (P < 0.05).

CONCLUSION: H. pylori infection can result in negative psychological status, and successful H. pylori eradication significantly improves such negative mental status.

Real-time diagnosis of H. pylori infection during endoscopy: Accuracy of an innovative tool (EndoFaster)

BACKGROUND

EndoFaster is novel device able to perform real-time ammonium measurement in gastric juice allowing H. pylori diagnosis during endoscopy. This large study aimed to validate the accuracy of EndoFaster for real-time H. pylori detection.

METHODS

Consecutive patients who underwent upper endoscopy in two centres were prospectively enrolled. During endoscopy, 4 ml of gastric juice were aspirated to perform automatic analysis by EndoFaster within 90 seconds, and H. pylori was considered present (>62 ppm/ml) or absent (≤62 ppm/ml). Accuracy was measured by using histology as gold standard, and (13)C-urea breath test (UBT) in discordant cases. Accuracy, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) were calculated.

RESULTS

Overall, 189 patients were enrolled, but in seven (3.4%) the aspirated gastric juice amount was insufficient to perform the test. The accuracy, sensitivity, specificity, PPV, and NPV were 87.4%, 90.3%, 85.5%, 80.2%, 93.1%, respectively, and 92.6%, 97.1%, 89.7%, 85.9%, 98.0%, respectively, when H. pylori status was reclassified according to the UBT result in discordant cases.

CONCLUSIONS

This study found a high accuracy/feasibility of EndoFaster for real-time H. pylori diagnosis. Use of EndoFaster may allow selecting those patients in whom routine gastric biopsies could be avoided.

Structural and biochemical characterization of GTP cyclohydrolase II from Helicobacter pylori reveals its redox dependent catalytic activity

GTP cyclohydrolase II (GCHII), catalyzes the conversion of GTP to 2,5-diamino-6-β-ribosyl-4(3H)-pyrimidinone-5'-phosphate and has been shown to be essential for pathogens. Here we describe the biochemical, kinetic and structural characterization of GCHII from Helicobacter pylori (hGCHII). The crystal structure of hGCHII, unlike other GCHII structures, revealed that cysteines at the active site existed in oxidized state forming two disulfide bonds and lacked Zn(2+) that was shown to be indispensable for catalytic activity in other species. However, incubation of hGCHII with hydrogen peroxide, an oxidizing agent, followed by PAR-assay showed that Zn(2+) was intrinsically present, indicating that all cysteines at the catalytic site remained in reduced state. Moreover, site directed mutagenesis of catalytic site cysteines revealed that only three, out of four cysteines were essential for hGCHII activity. These results, though, indicated that hGCHII crystallized in oxidized form, the expulsion of Zn(2+) upon oxidation of catalytic cysteines revealed its ability to act in response to the redox environment. Exploring further, incubation of hGCHII with reversible thiol modifying agent S-methyl-methane-thiosulfonate resulted in loss of GCHII activity due to oxidation of its cysteine residues as revealed by mass spectrometry studies. However, addition of reducing agent DTT partially restored the hGCHII catalytic activity. Taken together, these results demonstrate that hGCHII can regulate its catalytic activity depending on the redox environment, a function hitherto unknown for GCHII.

Effect of Helicobacter pylori infection on gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a common chronic disease of the digestive system. In recent years, due to the better understanding of Helicobacter pylori (H. pylori) and the wide clinical application of proton pump inhibitors, the rate of H. pylori infection is declining, while the incidence of GERD is increasing. This phenomenon suggests a possible relationship between H. pylori infection and the incidence of GERD. The pathogenesis of GERD is related to the dysfunction of the protective esophageal barrier, esophageal motility, gastric acidity and gastric emptying, and H. pylori infection may affect these factors to exert an impact on the incidence of GERD.

N-acetyl cysteine as an adjunct to standard anti-Helicobacter pylori eradication regimen in patients with dyspepsia: A prospective randomized, open-label trial

Background:

Increasing antibiotic resistance of Helicobacter pylori (H. pylori) which is associated with diseases of the upper gastrointestinal tract, has made alternative treatments necessary. This study compares the efficacy of adding N-acetyl cysteine (NAC) to standard regimen for H. pylori eradication.

Materials and Methods:

We conducted a randomized, open-label trial, comparing the efficacy of 14 days of quadruple therapy with Amoxicillin, Bismuth citrate, Omeprazole, Clarithromycin (group A) versus 14 days of above regimen plus NAC (group B) in adult patients with dyspepsia. Primary objective was H. pylori eradication. Compliance and side effects were determined by questionnaires. Our analysis was by intention-to-treat (ITT) and per-protocol. This study is registered with www.IRCT.ir, number: IRCT201201078634N1.

Result:

A total of 121 participants aged 21-76 years with a mean age of 44.5 ± 14.1, and 52.9% female, were randomly allocated a treatment: 60 with 14-day standard therapy and 61 with 14-day standard therapy with NAC. The eradication rate in groups A and B with ITT analyses was 49/60 (81.7%; 95% [confidence intervals] CI = 71.6-91.8%) and 50/61 (82%; 95% CI = 72-91.9%), respectively (P = 0.96). In per-protocol analysis, the rate of H. pylori eradication in groups A and B was 45/54 (83.3%; 95% CI = 73.1-93.6%) and 45/53 (84.9%; 95% CI = 74.9-94.9%), respectively (P = 0.82). Minor well tolerated side effects were reported in 15 (34.9%) and 21 (35.6%) patients of groups A and B, respectively, and only one therapy cessation in group A was created.

Conclusion:

Standard 14-day triple-drug therapy with NAC is not preferable to standard drug regimens for H. pylori infection.

Comparison of Helicobacter pylori eradication rates of standard 14-day quadruple treatment and novel modified 10-day, 12-day and 14-day sequential treatments

BACKGROUND & AIM

This study aimed to compare the efficacy and safety of bismuth-included standard regimen and modified sequential treatments in Turkey, where the success rate of standard triple therapy is very low.

METHODS

One-hundred and sixty patients with dyspeptic complaints and naïve Helicobacter pylori infection were randomized into four groups: 41 patients received standard 14-day quadruple treatment (STD) (Rabeprazole 20mg-bid, bismuth subcitrate (120 mg-qid), Tetracycline 500 mg-qid, Metronidazole 500 mg-tid) for 2 weeks. The modified sequential therapy groups received 20 mg rabeprazole and 1g amoxicillin, twice daily for the first 5 days, followed by Rabeprazole 20mg-bid, bismuth subcitrate (120 mg-qid), Tetracycline 500 mg-qid, Metronidazole 500 mg-tid for the remaining 5 (10 day sequential therapy group-10S) (42 patients), 7 (12 day sequential therapy group-12S) (42 patients) and 9 (14 day sequential therapy group-14S) (41 patients) days.

RESULTS

The overall compliance and H. pylori eradication rate among the 160 patients who completed the H. pylori eradication regimens were 86.9% (139/160) and 78.1% (125/160), respectively. The results were not statistically different between groups in the eradication rates. Per-protocol eradication rates were 76.5% in STD, 71.4% in 10S, 82.4% in 12S and 83.3% in 14S groups (p=0.7). Intention-to-treatment rates were 77.5% in STD, 72.5% in 10S, 82.5% in 12S and 80.0% in 14S groups (p=0.5).

CONCLUSION

The eradication rates of standard 14-day and different sequential quadruple treatment regimens are comparable and much more higher than with standard 14-day triple H. pylori eradication treatment that has been reported previously in Turkey.

Sequential, concomitant and hybrid first-line therapies for Helicobacter pylori eradication: a prospective randomized study

Helicobacter pylori eradication remains a challenge for physicians. Sequential, concomitant and the hybrid regimens have been proposed as novel, more effective therapies. We compare the efficacy of these therapies. Dyspeptic patients referred for upper endoscopy with H. pylori infection were enrolled. Patients were randomized to receive: (a) sequential therapy - 20 mg omeprazole and 1 g amoxicillin for 5 days, followed by 20 mg omeprazole, 500 mg clarithromycin and 500 mg tinidazole for the successive 5 days; (b) concomitant therapy - 20 mg omeprazole, 1 g amoxicillin, 500 mg clarithromycin and 500 mg tinidazole for either 5 days (5 day concomitant) or 14 days (14 day concomitant); or (c) hybrid therapy - 20 mg omeprazole and 1 g amoxicillin for 7 days, followed by 20 mg omeprazole, 1 g amoxicillin, 500 mg clarithromycin and 500 mg tinidazole for the successive 7 days. All drugs were given twice daily. Bacterial eradication was checked by using a [(13)C]urea breath test. In 'intention-to-treat' analysis, sequential therapy achieved the highest eradication rate, which was higher than that of 5 day concomitant therapy (90  vs 78.1 %; P = 0.02). The success rate did not statistically differ among the sequential and either 14 day concomitant (90  vs 86.3 %; P = not significant) or hybrid therapies (90  vs 82.7 %; P = not significant). The 10 day sequential, 14 day concomitant and 14 day hybrid therapies, but not the 5 day concomitant regimen, achieved similarly high eradication rates. The lower therapeutic cost coupled with the lower number of tablets needed would favour the sequential therapy as the first-line H. pylori treatment in clinical practice.

Symptomatic mesenteric atherosclerotic disease-lessons learned from the diagnostic workup

OBJECTIVE

This study aims to analyze the diagnostic workup in patients referred for endovascular mesenteric revascularization for symptomatic mesenteric atherosclerotic disease.

MATERIAL AND METHODS

Fifty-five patients were identified between 2006 and 2011. Median follow-up time was 24 months.

RESULTS

Median age was 71 years, 67 % were women. Forty patients had acute on chronic mesenteric ischemia, eight had acute mesenteric ischemia, and seven had chronic mesenteric ischemia. Other manifestations of atherosclerotic disease were present in 71 %. Body mass index (BMI) <20 kg/m(2) was found in 37 %. Endoscopy diagnosed duodenitis (38 %; 13/34) and colitis in the right colon (57 %;12/21). All ulcers tested for Helicobacter pylori were negative (n = 17). Patients received proton pump inhibitor, antibiotic, and cortisone therapy during diagnostic workup in 73, 42, and 29 % of the cases, respectively. Previous hospitalization for the same complaints had occurred in 78 %. CT angiography showed occlusion (n = 30) and high-grade stenosis (n = 25) of the superior mesenteric artery (SMA). Forty-eight patients were treated with stenting of the SMA. The BMI increased in both women (p = 0.001) and men (p = 0.03) after endovascular therapy. The in-hospital mortality rate was 18 %.

CONCLUSION

Patients with abdominal pain, known atherosclerotic disease, right-sided colitis or H. pylori-negative duodenitis should undergo CT angiography immediately to be able to identify symptomatic mesenteric atherosclerotic disease.

Sleep apnea and risk of peptic ulcer bleeding: a nationwide population-based study

OBJECTIVE

Patients with sleep apnea sustain cessation of breath during sleep, leading to intermittent hypoxia, systemic inflammation, and sympathetic activation. These insults may contribute to initiation or progression of peptic ulcers. This retrospective matched-control cohort study explored the relationship of sleep apnea and subsequent development of peptic ulcer bleeding.

METHODS

From 2000 to 2009, patients with newly diagnosed sleep apnea were identified from the Taiwan National Health Insurance Research Database. A control group without sleep apnea, matched for age, gender, comorbidities, and medications, was selected for comparison. In both groups, subjects with history of peptic ulcer bleeding, nonspecific gastrointestinal bleeding, or malignancy were excluded. The 2 cohorts were followed up and observed for occurrence of peptic ulcer bleeding.

RESULTS

Of the 35,480 sampled patients (7096 patients with sleep apnea vs 28,384 controls), 84 (0.24%) experienced peptic ulcer bleeding during a follow-up period of 3.57±2.61 years, including 32 (0.45% of patients with sleep apnea) from the sleep apnea cohort and 52 (0.18% of control) from the control group (log-rank test, P<.0001). In comparison with subjects without development of peptic ulcer bleeding, those with peptic ulcer bleeding were older and had a higher percentage of sleep apnea, coronary artery disease, peptic ulcer, ischemic stroke, and medication for nonsteroidal anti-inflammatory drugs. By Cox regression analysis, sleep apnea, older age, and peptic ulcer history were independent predictors of peptic ulcer bleeding. Patients with sleep apnea experienced a 2.400-fold (95% confidence interval, 1.544-3.731; P<.001) higher risk for incident peptic ulcer bleeding after adjusting for other variables.

CONCLUSIONS

Sleep apnea may be an independent risk factor for peptic ulcer bleeding.

Helicobacter pylori eradication and reflux disease onset: Did gastric acid get "crazy"?

Gastroesophageal reflux disease (GORD) is highly prevalent in the general population. In the last decade, a potential relationship between Helicobacter pylori (H. pylori) eradication and GORD onset has been claimed. The main putative mechanism is the gastric acid hypersecretion that develops after bacterial cure in those patients with corpus-predominant gastritis. We performed a critical reappraisal of the intricate pathogenesis and clinical data available in this field. Oesophagitis onset after H. pylori eradication in duodenal ulcer patients has been ascribed to a gastric acid hypersecretion, which could develop following body gastritis healing. However, the absence of an acid hypersecretive status in these patients is documented by both pathophysiology and clinical studies. Indeed, duodenal ulcer recurrence is virtually abolished following H. pylori eradication. In addition, intra-oesophageal pH recording studies failed to demonstrated increased acid reflux following bacterial eradication. Moreover, oesophageal manometric studies suggest that H. pylori eradication would reduce - rather than favor - acid reflux into the oesophagus. Finally, data of clinical studies would suggest that H. pylori eradication is not significantly associated with either reflux symptoms or erosive oesophagitis onset, some data suggesting also an advantage in curing the infection when oesophagitis is already present. Therefore, the legend of “crazy acid” remains - as all the others - a fascinating, but imaginary tale.

Standard triple and sequential therapies for Helicobacter pylori eradication: an update

H. pylori infection remains a worldwide spread disease with a definite morbidity and mortality. Unfortunately, no current therapy regimen is able to cure the infection in all treated patients. The efficacy of the widely recommended triple therapies is decreasing, and a novel 10-day sequential therapy has been proposed. Data of 3 previous meta-analyses showed a significantly higher eradication rate following the sequential as compared to the 7-10 days triple therapies. The sequential therapy achieved significantly better results than triple therapies in children, elderly patients, non-ulcer dyspepsia patients, and in those infected with resistant strains towards either clarithromycin or metronidazole. We identified further 10 randomized trials. By pooling data, H. pylori infection was cured in 2,454 (86%; 95% CI: 84.7-87.3) out of 2,853 patients with the sequential therapy and in 2,320 (75.3%; 95% CI: 73.8-76.9) out of 3,079 patients treated with standard triple therapies (p<0.001), corresponding to a number to treat (NNT) of 9. The comparison between the 10-day sequential regimen and 14-day triple therapies deserves further investigations.

Modified sequential therapy regimens for Helicobacter pylori eradication: a systematic review

BACKGROUND

Different modified sequential therapies have been proposed for Helicobacter pylori eradication. However, the efficacy of these regimens is controversial.

METHODS

We performed a systematic review of the literature and pooled-data analysis to assess: (a) the efficacy of different modified sequential therapies for H. pylori eradication, (b) the eradication rates achieved by these regimens as compared to either standard triple therapies or standard sequential regimen when available.

RESULTS

Overall 21 trials met inclusion criteria. The most used modified sequential therapy was the seven plus seven tetracycline-based regimen which achieved an overall 73.3% eradication rate (6 trials). Such therapy was more effective than the 14-day triple therapy (77.2% vs. 63.6%; 3 trials). The most used five plus five levofloxacin-based sequential therapy achieved a 95.8% and 90% cure rates when 250 mg and 500 mg levofloxacin twice daily were used, respectively. These success rates were higher as compared to that of either standard sequential or triple therapies. Other modified sequential therapies did not achieved acceptably high cure rates. Contradictory results emerged from 2 studies assessing the efficacy of a levofloxacin-based sequential regimen as a second-line therapy.

CONCLUSIONS

Both levofloxacin- and tetracycline-based sequential therapies have been proved to be more effective than standard triple therapies, confirming that the 'sequential' administration of drugs is a successful therapeutic procedure for H. pylori infection.

Levofloxacin/amoxicillin-based schemes vs quadruple therapy for Helicobacter pylori eradication in second-line

Worldwide prevalence of Helicobacter pylori (H. pylori) infection is approximately 50%, with the highest being in developing countries. We compared cure rates and tolerability (SE) of second-line anti-H. pylori levofloxacin/amoxicillin (LA)-based triple regimens vs standard quadruple therapy (QT). An English language literature search was performed up to October 2010. A meta-analysis was performed including randomized clinical trials comparing 7- or 10-d LA with 7-d QT. In total, 10 articles and four abstracts were identified. Overall eradication rate in LA was 76.5% (95% CI: 64.4%-97.6%). When only 7-d regimens were included, cure rate was 70.6% (95% CI: 40.2%-99.1%), whereas for 10-d combinations, cure rate was significantly higher (88.7%; 95% CI: 56.1%-109.9%; P < 0.05). Main eradication rate for QT was 67.4% (95% CI: 49.7%-67.9%). The 7-d LA and QT showed comparable efficacy [odds ratio (OR): 1.09; 95% CI: 0.63-1.87], whereas the 10-d LA regimen was significantly more effective than QT (OR: 5.05; 95% CI: 2.74-9.31; P < 0.001; I² = 75%). No differences were reported in QT eradication rates among Asian and European studies, whereas LA regimens were more effective in European populations (78.3% vs 67.7%; P = 0.05). Incidence of SE was lower in LA therapy than QT (OR: 0.39; 95% CI: 0.18-0.85; P = 0.02). A higher rate of side effects was reported in Asian patients who received QT. Our findings support the use of 10-d LA as a simple second-line treatment for H. pylori eradication with an excellent eradication rate and tolerability. The optimal second-line alternative scheme might differ among countries depending on quinolone resistance.

Helicobacter pylori therapy: Present and future

Helicobacter pylori (H. pylori) plays a crucial role in the pathogenesis of chronic active gastritis, peptic ulcer and gastric mucosa-associated lymphoid tissue-lymphoma, and is also involved in carcinogenesis of the stomach. H. pylori treatment still remains a challenge for physicians, since no current first-line therapy is able to cure the infection in all treated patients. Several factors may help in the eradication of therapy failure. We reviewed both bacterial and host factors involved in therapeutic management of the H. pylori infection. In addition, we evaluated data on the most successful therapy regimens - sequential and concomitant therapies - currently available for H. pylori eradication.

Helicobacter pylori Eradication Therapy: Current Availabilities

Background. Though Helicobacter pylori (HP) infections have progressively declined throughout most of the industrialized countries, a gradual increase in failure of HP eradication treatments is observed. Aim. To critically review evidence on the efficacy of the therapeutic availabilities for HP eradication, as yet. Methods. A selection of Clinical Trials, Systematic Reviews and Meta-analyses within the time period 2010–2012, was performed through a Medline search. Previous references were included when basically supporting the first selection. Results. An increasing rise in HP resistance rates for antimicrobial agents is currently observed. Further causes of HP treatment failure include polymorphisms of the CYP 2C19, an increased body mass index (BMI), smoking, poor compliance and re-infections. Alternative recent approaches to standard triple therapy have been attempted to increase the eradication rate, including bismuth-containing quadruple therapy, non-bismuth containing quadruple therapy, sequential therapy and levofloxacin-containing regimens. Conclusions. The main current aims should be the maintenance of a high eradication rate (>85%) of HP and the prevention of any increase in antimicrobial resistance. In the next future, the perspective of a tailored therapy could optimize eradication regimens within the different countries.

Newer agents for Helicobacter pylori eradication

Helicobacter pylori infection remains widespread internationally, with a definite morbidity and mortality. The efficacy of standard 7–14 day triple therapies is decreasing, mainly due to increasing primary bacterial resistance to antibiotics. Currently, the most effective treatments are either the sequential regimen or the concomitant therapy. Different patents have been registered showing high bactericidal effects in vitro, some of which are active against clarithromycin- and metronidazole-resistant strains, even at low pH values. Among these novel molecules, benzimidazole-derivatives, polycyclic compounds, pyloricidin, and arylthiazole analogues seem to be the more promising. The identification of essential genes for either bacterial colonization or growth represents a route for potential target therapies in the near future.