The association between Barrett's esophagus and Helicobacter pylori infection: a meta-analysis

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.

Analysis of Barrett's Esophagus and Its Risk Factors: A Cross-Sectional Study of 10,122 Subjects at a Japanese Health Examination Center

INTRODUCTION

Helicobacter pylori eradication is expected to significantly change the prevalence of Barrett's esophagus (BE). However, few reports on this relationship exist. We analyzed the risk factors of BE using the current consensus on length of BE considering H. pylori infection status.

METHODS

We analyzed 10,122 individuals (5,962 men; mean age = 52.9 ± 9.9 years) who had undergone esophagogastroduodenoscopy as part of a medical checkup. Correlations among factors including H. pylori infectious status, endoscopic findings, and BE ≥1 cm were analyzed.

RESULTS

Prevalence of BE, long-segment BE, and esophageal adenocarcinoma was 22.5%, 0.014%, and 0%, respectively. Logistic regression analysis showed that the risk factors for BE were hiatal hernia (odds ratio [OR]: 2.89 [2.59-3.24]), female sex (OR: 0.52 [0.46-0.59]), social drinking (OR:0.77 [0.68-0.87]), H. pylori eradication therapy (OR: 1.34 [1.19-1.51]), proton pump inhibitor (PPI) use (OR: 1.52 [1.18-1.96]), bile reflux (OR: 1.18 [1.04-1.33]), age ≥50 years (OR: 1.13 [1.02-1.26]), and nonsteroidal anti-inflammatory drug (NSAID) use (OR: 1.29 [1.02-1.62]). Although reflux esophagitis (RE) was more common in H. pylori-negative patients (17.2%) than in those after H. pylori eradication therapy (11.8%, p < 0.00001), the latter was correlated with BE, disputing RE as a strong risk factor for BE. Therefore, we conducted a subgroup analysis; most of the risk factors except for PPI use (p = 0.75), H2-receptor antagonist use (p = 0.078), and atrophic gastritis absence (p = 0.72) were positively correlated with BE after H. pylori eradication therapy compared with H. pylori-negative status.

CONCLUSIONS

H. pylori eradication, bile reflux, PPI use, and NSAID use were risk factors for BE along with hiatal hernia, male sex, and older age.

Association of Barrett's esophagus with Helicobacter pylori infection: a meta-analysis

Background and Aims:

Barrett’s esophagus (BE) is the only recognized precursor for esophageal adenocarcinoma. Helicobacter pylori (H. pylori) infection is a major contributing factor towards upper gastrointestinal diseases, but its relationship with BE remains controversial. Some previous studies suggested that H. pylori infection negatively correlated with BE, while others did not. This may be attributed to the difference in the selection of control groups among studies. The present meta-analysis aims to clarify their association by combining all available data from well-designed studies.

Methods:

The PubMed, EMBASE, and Cochrane Library databases were searched. Odds ratios (ORs) with 95% confidence intervals (CIs) were pooled by a random-effects model. Heterogeneity was evaluated using the Cochran’s Q test and I² statistics. Meta-regression, subgroup, and leave-one-out sensitivity analyses were employed to explore the sources of heterogeneity.

Results:

Twenty-four studies with 1,354,369 participants were included. Meta-analysis found that patients with BE had a significantly lower prevalence of H. pylori infection than those without (OR = 0.53, 95% CI = 0.45–0.64; p < 0.001). The heterogeneity was statistically significant (I² = 79%; p < 0.001). Meta-regression, subgroup, and leave-one-out sensitivity analyses did not find any source of heterogeneity. Meta-analysis of 7 studies demonstrated that CagA-positive H. pylori infection inversely correlated with BE (OR = 0.25, 95% CI = 0.15–0.44; p = 0.000), but not CagA-negative H. pylori infection (OR = 1.22, 95% CI = 0.90–1.67; p = 0.206). Meta-analysis of 4 studies also demonstrated that H. pylori infection inversely correlated with LSBE (OR = 0.39, 95% CI = 0.18–0.86; p = 0.019), but not SSBE (OR = 0.73, 95% CI = 0.30–1.77; p = 0.484).

Conclusion:

H. pylori infection negatively correlates with BE. More experimental studies should be necessary to elucidate the potential mechanisms in future.

Gastroesophageal reflux disease and paraneoplastic neurological syndrome associated with long-term survival in limited stage small-cell lung cancer

Introduction

Patients with small‐cell lung cancer (SCLC) have a very poor prognosis. However, a subset of SCLC achieves long‐term survival. The objective of this study was to investigate factors and pattern of long‐term survival in patients with limited‐stage small cell lung cancer (LS‐SCLC) who achieved a complete response (CR) after chemoradiotherapy.

Patient and Methods

This was a single‐center retrospective study. The analysis of hazard ratio (HR) and 95% confidence interval (CI) was performed using Cox proportional hazards model. For pattern analysis, the date of recurrence was used as the endpoint. The nominal categorical variables were analyzed by the χ² test. Survival was estimated using the Kaplan–Meier model, and the results were reported as the median and interquartile range.

Results

We identified 162 patients, median age was 64.7 (56.2–70.2) years, and 94 (58%) were females. Eighty‐one patients (50%) had recurrence during follow‐up. Gastroesophageal reflux disease (GERD) (HR, 0.65; 95% CI, 0.45–0.93; p = 0.016) and neurological paraneoplastic syndrome (PNS) (HR, 0.46; 95% CI, 0.29–0.72; p < 0.001) were independent factors associated with improved overall survival (OS). Patients with GERD had prolonged recurrence free survival (RFS) compared to patients without GERD (median, 29.1 months vs. 13.9 months, p < 0.001), whereas patients with neurological PNS had a reduced recurrence rate compared to those patients without neurological PNS (No. [%], 8 [20.5] vs. 73 [59.3], p < 0.001).

Conclusions

Patients with LS‐SCLC achieving a CR after chemoradiotherapy, GERD, and neurological PNS were associated with improved OS. GERD and neurological PNS were associated with longer RFS and lower recurrence rate, respectively.

Predicting Hospital Readmission for Campylobacteriosis from Electronic Health Records: A Machine Learning and Text Mining Perspective

(1) Background: This study investigates influential risk factors for predicting 30-day readmission to hospital for Campylobacter infections (CI). (2) Methods: We linked general practitioner and hospital admission records of 13,006 patients with CI in Wales (1990–2015). An approach called TF-zR (term frequency-zRelevance) technique was presented to evaluates how relevant a clinical term is to a patient in a cohort characterized by coded health records. The zR is a supervised term-weighting metric to assign weight to a term based on relative frequencies of the term across different classes. Cost-sensitive classifier with swarm optimization and weighted subset learning was integrated to identify influential clinical signals as predictors and optimal model for readmission prediction. (3) Results: From a pool of up to 17,506 variables, 33 most predictive factors were identified, including age, gender, Townsend deprivation quintiles, comorbidities, medications, and procedures. The predictive model predicted readmission with 73% sensitivity and 54% specificity. Variables associated with readmission included male gender, recurrent tonsillitis, non-healing open wounds, operation for in-gown toenails. Cystitis, paracetamol/codeine use, age (21–25), and heliclear triple pack use, were associated with a lower risk of readmission. (4) Conclusions: This study gives a profile of clustered variables that are predictive of readmission associated with campylobacteriosis.

Helicobacter pylori infection is associated with reduced risk of Barrett's esophagus: a meta-analysis and systematic review

BACKGROUND

Helicobacter pylori (Hp) is a class I carcinogen in gastric carcinogenesis, but its role in Barrett's esophagus (BE) is unknown. Therefore, we aimed to explore the possible relationship.

METHODS

We reviewed observational studies published in English until October 2019. Summary odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for included studies.

RESULTS

46 studies from 1505 potential citations were eligible for inclusion. A significant inverse relationship with considerable heterogeneity was found between Hp (OR = 0.70; 95% CI, 0.51-0.96; P = 0.03) and BE, especially the CagA-positive Hp strain (OR = 0.28; 95% CI, 0.15-0.54; P = 0.0002). However, Hp infection prevalence was not significantly different between patients with BE and the gastroesophageal reflux disease (GERD) control (OR = 0.99; 95% CI, 0.82-1.19; P = 0.92). Hp was negatively correlated with long-segment BE (OR = 0.47; 95% CI, 0.25-0.90; P = 0.02) and associated with a reduced risk of dysplasia. However, Hp had no correlated with short-segment BE (OR = 1.11; 95% CI, 0.78-1.56; P = 0.57). In the present infected subgroup, Hp infection prevalence in BE was significantly lower than that in controls (OR = 0.69; 95% CI, 0.54-0.89; P = 0.005); however, this disappeared in the infection history subgroup (OR = 0.88; 95% CI, 0.43-1.78; P = 0.73).

CONCLUSIONS

Hp, especially the CagA-positive Hp strain, and BE are inversely related with considerable heterogeneity, which is likely mediated by a decrease in GERD prevalence, although this is not observed in the absence of current Hp infection.

Systematic review with meta-analysis: association of Helicobacter pylori infection with gastro-oesophageal reflux and its complications

BACKGROUND

Conflicting results exist on the association between Helicobacter pylori infection and gastro-oesophageal reflux (GOR), and its complications, such as erosive oesophagitis (EO) and Barrett's oesophagus (BO).

AIMS

To explore the association of H. pylori infection with GOR symptoms and their complications METHODS: We searched Embase, PubMed, Web of Science and Scopus databases through December 2020 for relevant articles. Regarding the association between H. pylori and GOR symptoms (heartburn, regurgitation or reflux), we included observational studies comparing the prevalence of GOR symptoms between H. pylori-positive and -negative individuals. Concerning the association between H. pylori and complications of GOR, we included studies comparing the prevalence of EO or BO between H. pylori-positive and -negative individuals.

RESULTS

In total, 36 papers were eligible. Based on seven cross-sectional surveys, H. pylori infection was associated with a lower odds of GOR symptoms (odds ratio [OR] 0.74, 95% confidence interval [CI] 0.61-0.90). However, in four case-control studies, H. pylori infection was not associated with odds of GOR symptoms (OR 1.10, 95% CI 0.85-0.1.43). In 26 cross-sectional studies in patients with GOR symptoms, the OR for EO was 0.70 (95% CI 0.58-0.84) in H. pylori-positive vs -negative cases. Based on nine cross-sectional studies in subjects with GOR complications, no significant association was found between H. pylori infection and either endoscopically-diagnosed (OR 1.84, 95% CI 0.67-5.02) or histologically confirmed (OR 0.85, 95% CI 0.60-1.20) BO.

CONCLUSIONS

Helicobacter pylori infection appears to be associated with a decreased odds of GOR symptoms and EO. In contrast, H. pylori infection did not seem to affect the odds of BO in patients with GER complications.

Gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease (GERD) is a common disorder in adults and children. The global prevalence of GERD is high and increasing. Non-erosive reflux disease is the most common phenotype of GERD. Heartburn and regurgitation are considered classic symptoms but GERD may present with various atypical and extra-oesophageal manifestations. The pathophysiology of GERD is multifactorial and different mechanisms may result in GERD symptoms, including gastric composition and motility, anti-reflux barrier, refluxate characteristics, clearance mechanisms, mucosal integrity and symptom perception. In clinical practice, the diagnosis of GERD is commonly established on the basis of response to anti-reflux treatment; however, a more accurate diagnosis requires testing that includes upper gastrointestinal tract endoscopy and reflux monitoring. New techniques and new reflux testing parameters help to better phenotype the condition. In children, the diagnosis of GERD is primarily based on history and physical examination and treatment vary with age. Treatment in adults includes a combination of lifestyle modifications with pharmacological, endoscopic or surgical intervention. In refractory GERD, optimization of proton-pump inhibitor treatment should be attempted before a series of diagnostic tests to assess the patient's phenotype.

Extra-Gastric Manifestations of Helicobacter pylori Infection

Helicobacter Pylori (H. pylori) is a Gram-negative flagellated microorganism that has been extensively studied since its first isolation due to its widespread diffusion and association with numerous diseases. While the bacterium is proved to be a causative factor for a number of gastric diseases such as gastritis, gastric adenocarcinoma, and MALT-lymphoma, its role at other gastrointestinal levels and in other systems is being thoroughly studied. In this article, we reviewed the latest published clinical and laboratory studies that investigated associations of H. pylori with hematologic diseases such as Vitamin B12- and iron-deficiency anemia, primary immune thrombocytopenia, and with a number of dermatologic and ophthalmic diseases. In addition, the putative role of the bacterium in inflammatory bowel diseases, esophageal disorders, metabolic, diseases, neurologic diseases and allergy were outlined.

Gastroesophageal reflux disease: key messages for clinicians

Gastroesophageal reflux disease (GERD) is a chronic common disorder for which patients often refer to specialists. In the last decades, numerous studies helped to clarify the pathophysiology and the natural history of this disease. Currently, in the clinical setting, GERD is defined by the presence of symptoms that, when endoscopic investigation is required, permit to distinguish between cases with or without associated esophageal mucosal injuries. These conditions are called erosive reflux disease and non-erosive reflux disease (NERD), respectively. The latter is the most common manifestation of GERD. Symptoms are defined typical, as heartburn and regurgitation, and atypical (also called extra-esophageal), as coughing and/or wheezing, hoarseness, sore throat, otitis media, and dental manifestations. In this context, it is crucial for clinicians to investigate the presence of features of suspected malignancy, as unexplained weight loss, anemia, dysphagia, persistent vomiting, familiar history of cancer, long history of GERD, and beginning of GERD symptoms after the age of 50 years. The presence of these risk factors should induce to perform an endoscopic examination. Particular attention should be given to functional conditions that can mimic GERD, such as functional heartburn and hypersensitive esophagus as well as, more rarely, eosinophilic esophagitis. The former ones have different pathophysiology and this explains the frequent non-response to proton pump inhibitor drugs. This narrative review provides to clinicians a useful and practical overview of the state-of-the-art on advancements in the knowledge of GERD.

Rethinking gastroesophageal reflux disorder

Gastroesophageal reflux disease (GERD) is a common clinical condition for which our understanding has evolved over the past decades. It is now considered a cluster of phenotypes with numerous anatomical and physiological abnormalities contributing to its pathophysiology. As such, it is important to first understand the underlying mechanism of the disease process for each patient before embarking on therapeutic interventions. The aim of our paper is to highlight the mechanisms contributing to GERD and review investigations and interpretation of these results. Finally, the paper reviews the available treatment modalities for this condition, ranging from medical intervention, endoscopic options through to surgery and its various techniques.

Interaction Between Ethnicity and Helicobacter pylori Infection in the Occurrence of Reflux Disease

BACKGROUND AND AIMS

Few reports are available to reliably assess the ethnic distribution of Barrett metaplasia and reflux esophagitis. The present study served to analyze the joint influence of Helicobacter pylori infection and patient demographics on the diagnoses of Barrett metaplasia and reflux esophagitis.

METHODS

The Inform Diagnostics database is a national electronic repository of histopathologic records of patients distributed throughout the United States. In a case-control study of 52,096 cases with Barrett metaplasia, 189,235 cases with reflux esophagitis, and 152,322 controls without any signs or symptoms suggestive of gastroesophageal reflux disease, we assessed the influence of age, gender, ethnicity, and H. pylori status on occurrence of Barrett metaplasia or reflux esophagitis.

RESULTS

Barrett metaplasia was less common among East Asians (with odds ratio, 0.48; 95% confidence interval, 0.44-0.53) and Hispanics (0.60, 0.57-0.63) than other ethnic groups living in the United States. Reflux esophagitis was also less common among East Asians (0.86, 0.82-0.90), but more common among Hispanics (1.18, 1.14-1.21). Both types of esophageal disease were associated with a lower prevalence rates of gastric H. pylori infection than controls, with 0.48, 0.44-0.53 for Barrett metaplasia and 0.60, 0.57-0.63 for reflux esophagitis. The prevalence rates of gastric H. pylori and both esophageal diseases were greater in older than younger and male than female patients in all ethnic groups alike.

CONCLUSIONS

Gastric H. pylori infection, ethnicity, gender, and age all influence the occurrence of Barrett metaplasia, and reflux esophagitis.

Association Between Helicobacter pylori Infection and Short-segment/Long-segment Barrett's Esophagus in a Japanese Population: A Large Cross-Sectional Study

GOAL

The goal of this study was to investigate the relationship between Helicobacter pylori (H. pylori) infection and short-segment and long-segment Barrett's esophagus (SSBE and LSBE).

BACKGROUND

H. pylori infection is reported to be inversely associated with Barrett's esophagus (BE) in western countries. However, the impact of BE segment length on the association between BE and H. pylori infection has scarcely been investigated.

MATERIALS AND METHODS

The study subjects were 41,065 asymptomatic Japanese individuals who took medical surveys between October 2010 and September 2017. Using this large database of healthy Japanese subjects, we investigated the association between H. pylori infection and SSBE/LSBE. We used multivariable logistic regression analysis to estimate odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Among the study subjects, 36,615 were eligible for the analysis. H. pylori seropositivity was significantly associated with a lower rate of LSBE (OR: 0.42; 95% CI: 0.16-0.91) and a higher rate of SSBE (OR: 1.66; 95% CI: 1.56-1.78) after multivariate adjustment. In the subgroup analysis, H. pylori seropositivity was significantly associated with a high rate of SSBE in subjects without reflux esophagitis (RE) (OR: 1.73; 95% CI: 1.61-1.85). However, H. pylori seropositivity was not associated with SSBE in subjects with RE (OR: 1.07; 95% CI: 0.84-1.37).

CONCLUSION

In a Japanese population, H. pylori infection was inversely associated with LSBE but significantly associated with SSBE only in subjects without RE. H. pylori may be a risk factor for SSBE, especially in individuals without RE.

Epidemiologie bösartiger Tumoren der Speiseröhre in Deutschland unter Berücksichtigung der histologischen Typen

Im vorliegenden Beitrag werden erstmals für Deutschland Inzidenz- und Überlebensraten für die beiden wesentlichen Formen des Speiseröhrenkarzinoms präsentiert, basierend auf den Daten der bevölkerungsbezogenen Krebsregister. Für beide Geschlechter ist seit 1999 ein Anstieg der altersstandardisierten Inzidenzraten der Adenokarzinome zu erkennen, während die Raten für Plattenepithelkarzinome (SCC) bei Frauen stagnieren und bei Männern zuletzt rückläufig sind. Zuletzt (2016) überwogen in Deutschland die Adenokarzinome mit 3340 Fällen gegenüber 3030 Plattenepithelkarzinomen. Knapp jede fünfte (Adeno-Ca.) bzw. jede dritte Neuerkrankung (SCC) trat bei Frauen auf. Die Verteilung der Tumorstadien war für beide Formen bei Frauen etwas günstiger als bei Männern, für das Plattenepithelkarzinom lagen auch die relativen Überlebensraten für Frauen höher. Auch unabhängig vom Tumorstadium wiesen Adenokarzinome eine etwas günstigere Prognose auf, dies galt vor allem im frühen Stadium (UICC I). Über 10 Jahre haben sich die relativen 5‑Jahres-Überlebensraten um 4,1 (Adeno-Ca.) bzw. 2,0 Prozentpunkte (SCC) verbessert.

IS THERE A RELATION BETWEEN HELYBACTER PYLORI AND INTESTINAL METAPLASIA IN SHORT COLUMN EPITELIZATION UP TO 10 MM IN THE DISTAL ESOPHAGUS?

Background:

The presence of intestinal metaplasia in the distal esophagus (Barrett’s esophagus) is an important precursor of adenocarcinoma. Knowledge of the risk factors and the process by which the Barrett develops is very important and Helicobacter pylori (HP) can contribute to this development.

Aim:

To analyze the impact of HP in the gastric mucosa with intestinal metaplasia in the distal esophagus in areas of columnar epithelialization smaller than 10 mm in length and epidemiological data on prevalence

Method:

A retrospective study in which were included 373 consecutive patients diagnosed with columnar epithelium in the distal esophagus was done. In all, HP was investigated by urease and histology, exclusion and inclusion factors were applied and patients were divided into two groups: the first grouping the ones without histological diagnosis of Barrett’s esophagus (235-63%) and the second with it (138-37%).

Results:

There was no significant difference between HP and non-HP patients in relation to the probability of having intestinal metaplasia (p=0.587). When related to the general group, there was an inverse association between the bacterium and the columnar epithelia in the distal esophagus. Age (p=0.031), gender (p=0.013) and HP (p=0.613) when related together to intestinal metaplasia showed no significant relation. In isolation, when related to age and gender, regardless of HP, results confirmed that patients in more advanced age and women present a higher incidence of intestinal metaplasia.

Conclusion:

There is an inverse relation between HP and the areas of columnar epithelization in the distal esophagus, regardless of the presence or absence of intestinal metaplasia. Age and gender, regardless of HP, showed higher prevalence in women and in older the number of cases with intestinal metaplasia in the distal esophagus.

Gastric Peptides-Gastrin and Somatostatin

Gastric acid secretion (i) facilitates digestion of protein as well as absorption of micronutrients and certain medications, (ii) kills ingested microorganisms, including Helicobacter pylori, and (iii) prevents bacterial overgrowth and enteric infection. The principal regulators of acid secretion are the gastric peptides gastrin and somatostatin. Gastrin, the major hormonal stimulant for acid secretion, is synthesized in pyloric mucosal G cells as a 101-amino acid precursor (preprogastrin) that is processed to yield biologically active amidated gastrin-17 and gastrin-34. The C-terminal active site of gastrin (Trp-Met-Asp-Phe-NH₂ ) binds to gastrin/CCK₂ receptors on parietal and, more importantly, histamine-containing enterochromaffin-like (ECL) cells, located in oxyntic mucosa, to induce acid secretion. Histamine diffuses to the neighboring parietal cells where it binds to histamine H₂ -receptors coupled to hydrochloric acid secretion. Gastrin is also a trophic hormone that maintains the integrity of gastric mucosa, induces proliferation of parietal and ECL cells, and is thought to play a role in carcinogenesis. Somatostatin, present in D cells of the gastric pyloric and oxyntic mucosa, is the main inhibitor of acid secretion, particularly during the interdigestive period. Somatostatin exerts a tonic paracrine restraint on gastrin secretion from G cells, histamine secretion from ECL cells, and acid secretion from parietal cells. Removal of this restraint, for example by activation of cholinergic neurons during ingestion of food, initiates and maximizes acid secretion. Knowledge regarding the structure and function of gastrin, somatostatin, and their respective receptors is providing novel avenues to better diagnose and manage acid-peptic disorders and certain cancers. Published 2020. Compr Physiol 10:197-228, 2020.

Inflammation, Immunity, and Vaccine Development for the Gastric Pathogen Helicobacter pylori

It has been over 30 years since a link was established between H. pylori infection of the gastric mucosa and the development of chronic gastric diseases. Research in rodent models supported by data from human tissue demonstrated that the host immune response to H. pylori is limited by host regulatory T cells. Immunization has been shown to induce a potent Th1- and Th17-mediated immune response capable of eradicating or at least significantly reducing the bacterial load of H. pylori in the stomach in small animal models. These results have not translated well to humans. Clinical trials employing many of the strategies used in rodents for oral immunization including the use of a mucosal adjuvant such as Escherichia coli LT or delivery by attenuated enteric bacteria have failed to limit H. pylori infection and have highlighted the potential toxicity of exotoxin-based mucosal adjuvants. A recent study, however, utilizing a recombinant fusion protein of H. pylori urease and the subunit B of E. coli LT, was performed on over 4000 children. Efficacy of over 70% was demonstrated against naturally acquired infection compared to control volunteers one year post-immunization. Efficacy was reduced, but still above 50% at three years. This study provided new insight into the strategies for developing an improved vaccine for widespread use in countries with high infection rates and where gastric cancer (GC) remains one of the most common causes of death due to cancer.

Racial Disparity in the Sex Distribution, the Prevalence, and the Incidence of Dysplasia in Barrett's Esophagus

GOALS

Our aim was to study the prevalence of dysplasia and progression to high-grade dysplasia (HGD) and esophageal adenocarcinoma (EAC) in African Americans (AA) with Barrett's esophagus (BE) and compare it with that of non-Hispanic white (NHW) controls.

BACKGROUND

BE, a precursor of EAC, is a disease of predominantly white men and is uncommon in AA. The prevalence of dysplasia and progression to HGD and EAC in AA patients with BE is not clearly known.

STUDY

All AA or NHW patients with confirmed BE, that is specialized intestinal metaplasia, seen between 2002 and 2013 at our institution were included. Variables such as age, gender, medication use, the body mass index, the date of endoscopy, the hiatal hernia size, the BE length, and histologic findings were noted. Progression to HGD/EAC was evaluated.

RESULTS

Fifty-two AA and 2394 NHW patients with BE were identified. There was a higher percentage of women in the AA cohort (46.2%) than in the NHW cohort (24.9%, P<0.001). Nondysplastic BE was more prevalent in AA than in NHW (80.8% vs. 68.4%, P=0.058). In the surveillance cohort of 20 AA and 991 NHW, no racial differences in progression to HGD/EAC were observed during a median follow-up of 43 months.

CONCLUSIONS

This study includes the largest number of AA with histologically confirmed BE reported so far. About 46.2% of the AA cohort with BE in our study consisted of women. There was a trend toward a higher prevalence of nondysplastic BE in AA compared with NHW.

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.

Protective Propensity of Race or Environmental Features in the Development of Barrett's Esophagus in African Americans - A Single Center Pilot Study

BACKGROUND AND STUDY AIMS

Barrett's Esophagus (BE) is a well-recognized pre-malignant condition. Previous data indicate histologically confirmed BE frequency varies by ethnicity in the United States. However, clinical factor assessment to explain this has only occurred in a veteran population to date. The study aim was to determine which clinical factors may be associated with the ethnic variation seen in histologically confirmed BE among a general population.

PATIENTS AND METHODS

The University of Florida-Jacksonville endoscopy database was searched for all cases of endoscopic BE from September 2002 to October 2012. Histologic BE was diagnosed only if salmon colored, columnar-appearing esophageal mucosa was seen at endoscopy and biopsy revealed intestinal metaplasia with Alcian blue-stained goblet cells. Data collected included: age/BMI at diagnosis, ethnicity, sex, GERD history, atypical manifestations, endoscopic BE length, presence of esophageal stricture/ulcer/hiatal hernia, presence/absence of dysplasia and medication use (aspirin/NSAIDs/statin/PPI).

RESULTS

Salmon colored esophageal mucosa was observed in 1105 of 15,564 patients (7.1%) with BE histologically confirmed in 249 of 1105 patients (23%). Ethnic distribution of histologic BE patients: 83% non-Hispanic white (nHw), 13% African American (AA) and 4% other. No difference was seen between groups with regard to BMI, GERD symptom/complications, BE length, and cigarette, alcohol or medication use.

CONCLUSION

BE occurs primarily in nHw in north Florida. This occurs despite similarities in GERD history, cigarette/alcohol use, medications prescribed and BMI. Molecular level investigation is necessary to explain this observed disparity between nHw and AA.

Helicobacter pylori Infection Is Associated With Reduced Risk of Barrett's Esophagus: An Analysis of the Barrett's and Esophageal Adenocarcinoma Consortium

OBJECTIVES

Epidemiological studies of Helicobacter pylori infection and risk of Barrett's esophagus (BE) have reported conflicting results. We examined the association between H. pylori infection and BE and sought to determine whether the association is mediated by gastroesophageal reflux disease (GERD) and to identify potential effect modifiers.

METHODS

We used individual level data from 1308 patients with BE (cases), 1388 population-based controls, and 1775 GERD controls in the Barrett's and Esophageal Adenocarcinoma Consortium (BEACON). We estimated study-specific odds ratios (ORs) and 95% CIs using multivariable logistic regression models and obtained summary risk estimates using a random-effects meta-analytic approach. We examined potential effect modification by waist-to-hip ratio (WHR), body mass index (BMI), and smoking status by conducting stratified analyses.

RESULTS

For comparisons with population-based controls, H. pylori infection was inversely associated with the risk of BE (adjusted OR = 0.44, 95% CI = 0.36-0.55), with no evidence of between-study heterogeneity (I² = 0%). A stronger inverse association between H. pylori and BE was observed among individuals with the CagA-positive strain (P for interaction = 0.017). We found no evidence of interaction between WHR, BMI, smoking status, and H. pylori infection on the risk of BE. There was no association between H. pylori infection and BE for comparisons with GERD controls (OR = 0.96, 95% CI = 0.67-1.37; I² = 48%).

CONCLUSIONS

This study provides the strongest evidence yet that H. pylori infection is strongly inversely associated with BE. This effect is probably mediated by a decrease in GERD in infected patients, since the protective effect disappears in patients with GERD symptoms.

Helicobacter pylori infection reduces the risk of Barrett's esophagus: A meta-analysis and systematic review

INTRODUCTION

The prevalence of Helicobacter pylori infection (HPI) has been decreasing in developed countries, with an increasing prevalence of Barrett's esophagus (BE) and esophageal adenocarcinoma (EAC) at the same time. The aim of our meta-analysis was to quantify the risk of BE in the context of HPI.

METHODS

A systematic search was conducted in 3 databases for studies on BE with data on prevalence of HPI from inception until December 2016. Odds ratios for BE in HPI were calculated by the random effects model with subgroup analyses for geographical location, presence of dysplasia in BE, and length of the BE segment.

RESULTS

Seventy-two studies were included in the meta-analysis, including 84 717 BE cases and 390 749 controls. The overall analysis showed that HPI reduces the risk of BE; OR = 0.68 (95% CI: 0.58-0.79, P < .001). Subgroup analyses revealed risk reduction in Asia OR = 0.53 (95% CI: 0.33-0.84, P = .007), Australia OR = 0.56 (95% CI: 0.39-0.80, P = .002), Europe OR = 0.77 (95% CI: 0.60-0.98, P = .035), and North-America OR = 0.59 (95% CI: 0.47-0.74, P < .001). The risk was significantly reduced for dysplastic BE, OR = 0.37 (95% CI: 0.26-0.51, P < .001) for non-dysplastic BE, OR = 0.51 (95% CI: 0.35-0.75, P = .001), and for long segment BE, OR = 0.25 (95% CI: 0.11-0.59, P = .001) in case of HPI.

CONCLUSIONS

This extensive meta-analysis provides additional evidence that HPI is associated with reduced risk of BE. Subgroup analyses confirmed that this risk reduction is independent of geographical location. HPI is associated with significantly lower risk of dysplastic, non-dysplastic, and long segment BE.

Barrett's Esophagus and Esophageal Adenocarcinoma: How Common Are They Really?

Since the early 1970s, the incidence of esophageal adenocarcinoma (EA) has increased dramatically in most Western populations while the incidence of esophageal squamous cell carcinoma has decreased. As a result, EA has become the predominant subtype of esophageal cancer in North America and Europe and is an important contributor to overall cancer mortality. Barrett's esophagus (BE), a metaplastic columnar epithelium of the distal esophagus, is the known precursor lesion for EA. EA and BE occur more frequently in white men over 50 years old, as well as in people with frequent symptoms of gastroesophageal reflux, in smokers, and in people who are obese. Conversely, EA and BE are less common in persons using nonsteroidal anti-inflammatory drugs and in person with Helicobacter pylori infection. The 5-year survival rate for patients with EA, although generally poor, has improved during the past decade, and long-term survival is increasingly possible for patients with early or locally advanced disease. This review combines a synthesis of published studies with an analysis of data from the United States National Cancer Institute's Surveillance, Epidemiology, and End Results program to discuss the change in incidence of EA and summarize current knowledge of risk factors.

IVTH BRAZILIAN CONSENSUS CONFERENCE ON HELICOBACTER PYLORI INFECTION

ABSTRACT Significant progress has been obtained since the III Brazilian Consensus Conference on H. pylori infection held in 2012, in Bento Gonçalves, Brazil, and justify a fourth meeting to establish updated guidelines on the current management of H. pylori infection. Therefore, the Núcleo Brasileiro para Estudo do Helicobacter pylori e Microbiota (NBEHPM), association linked to Brazilian Federation of Gastroenterology (FBG) held its fourth meeting again in Bento Gonçalves, RS, Brazil, on August 25-27, 2017. Twenty-six delegates, including gastroenterologists, endoscopists, and pathologists from the five regions of Brazil as well as one international guest from the United States, participated in the meeting. The participants were invited based on their knowledge and contribution to the study of H. pylori infection. The meeting sought to review different aspects of treatment for infection; establish a correlation between infection, dyspepsia, intestinal microbiota changes, and other disorders with a special emphasis on gastric cancer; and reassess the epidemiological and diagnostic aspects of H. pylori infection. Participants were allocated into four groups as follows: 1) Epidemiology and Diagnosis, 2) Dyspepsia, intestinal microbiota and other afections, 3) Gastric Cancer, and, 4) Treatment. Before the consensus meeting, participants received a topic to be discussed and prepared a document containing a recent literature review and statements that should be discussed and eventually modified during the face-to-face meeting. All statements were evaluated in two rounds of voting. Initially, each participant discussed the document and statements with his group for possible modifications and voting. Subsequently, during a second voting in a plenary session in the presence of all participants, the statements were voted upon and eventually modified. The participants could vote using five alternatives: 1) strongly agree; 2) partially agree; 3) undecided; 4) disagree; and 5) strongly disagree. The adopted consensus index was that 80% of the participants responded that they strongly or partially agreed with each statement. The recommendations reported are intended to provide the most current and relevant evidences to management of H. pylori infection in adult population in Brazil.

Helicobacter pylori induces caudal-type homeobox protein 2 and cyclooxygenase 2 expression by modulating microRNAs in esophageal epithelial cells

Dysregulation of microRNAs (miRNAs) has been linked to virulence factors of Helicobacter pylori. The role of H. pylori in esophageal disease has not been clearly defined. We previously reported that H. pylori esophageal colonization promotes the incidence of Barrett's esophagus and esophageal adenocarcinoma in vivo. Here, we studied the direct effects of H. pylori on the transformation of esophageal epithelial cells, with particular focus on whether H. pylori exerts its effects by modulating miRNAs and their downstream target genes. The normal human esophageal cell line HET‐1A was chronically exposed to H. pylori extract and/or acidified deoxycholic acid for up to 36 weeks. The miRNA profiles of the esophageal epithelial cells associated with H. pylori infection were determined by microarray analysis. We found that chronic H. pylori exposure promoted acidified deoxycholic acid‐induced morphological changes in HET‐1A cells, along with aberrant overexpression of intestinal metaplasia markers and tumorigenic factors, including caudal‐type homeobox protein 2 (CDX2), mucin 2, and cyclooxygenase 2 (COX2). Helicobacter pylori modified the miRNA profiles of esophageal epithelial cells, particularly aberrant silencing of miR‐212‐3p and miR‐361‐3p. Moreover, in biopsies from Barrett's esophagus patients, esophageal H. pylori colonization was associated with a significant decrease in miR‐212‐3p and miR‐361‐3p expression. Furthermore, we identified COX2 as a target of miR‐212‐3p, and CDX2 as a target of miR‐361‐3p. Helicobacter pylori infection of esophageal epithelial cells was associated with miRNA‐mediated upregulation of oncoprotein CDX2 and COX2. Our observations provide new evidence about the molecular mechanisms underlying the association between H. pylori infection and esophageal carcinogenesis.

Prevalence of Dyspepsia in Individuals With Gastroesophageal Reflux-Type Symptoms in the Community: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

Dyspepsia and gastroesophageal reflux are highly prevalent in the general population, but they are believed to be separate entities. We conducted a systematic review and meta-analysis to estimate the prevalence of dyspepsia in individuals with gastroesophageal reflux symptoms (GERS), and to quantify overlap between the disorders.

METHODS

We searched MEDLINE, EMBASE, and EMBASE Classic databases to identify population-based studies reporting the prevalence of dyspepsia and GERS in adults, defined using specific symptom-based criteria or based on answers to questionnaires. We calculated pooled prevalence values, according to study location and criteria used to define weekly GERS or dyspepsia, as well as odds ratios (ORs) with 95% CIs. The degree of overlap between dyspepsia and GERS was examined.

RESULTS

Of 14,132 papers evaluated, 79 reported prevalence of weekly GERS. Nineteen of these study populations, comprising 111,459 participants, also reported the proportion of individuals with dyspepsia. The prevalence of dyspepsia in individuals with weekly GERS was 43.9% (95% CI, 35.1%-52.9%). The pooled OR for dyspepsia in individuals with weekly GERS, compared with those without, was 6.94 (95% CI, 4.33%-11.1%). The OR for dyspepsia in individuals with weekly GERS was significantly higher in all geographical regions studied and for all diagnostic criteria. The pooled degree of overlap between dyspepsia and GERS was 25.9% (95% CI, 19.9%-32.4%).

CONCLUSIONS

The odds of dyspepsia in individuals with weekly GERS is almost 7-fold that of individuals without GERS; dyspepsia and GERS overlap in more than 25% of individuals. Reasons for this remain speculative, but might include shared pathophysiological mechanisms or residual confounding factors. However, patients with GERS should be questioned about coexistent dyspepsia, to optimize treatment approaches.

Presentation and Epidemiology of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is the most prevalent gastrointestinal disorder in the United States, and leads to substantial morbidity, though associated mortality is rare. The prevalence of GERD symptoms appeared to increase until 1999. Risk factors for complications of GERD include advanced age, male sex, white race, abdominal obesity, and tobacco use. Most patients with GERD present with heartburn and effortless regurgitation. Coexistent dysphagia is considered an alarm symptom, prompting evaluation. There is substantial overlap between symptoms of GERD and those of eosinophilic esophagitis, functional dyspepsia, and gastroparesis, posing a challenge for patient management.

The Troublesome Epidemiology of Barrett's Esophagus and Esophageal Adenocarcinoma

Barrett's esophagus and esophageal adenocarcinoma diagnoses have increased markedly in recent decades. Recent research with patients diagnosed with Barrett's esophagus (the only known precursor for esophageal adenocarcinoma) and esophageal adenocarcinoma has identified several modifiable and nonmodifiable potential risk factors. Consistent risk factors for both disorders include increasing age, male sex, white non-Hispanic race/ethnicity, gastroesophageal reflux disease, lack of infection with Helicobacter pylori, smoking, abdominal obesity, and a Western diet. The authors present detailed discussions of these risk factors along with possible explanations for some apparent discrepancies and ideas for future study.

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.

Risk of histologic Barrett's esophagus between African Americans and non-Hispanic whites: A meta-analysis

Background

Barrett's esophagus (BE) is rare in African Americans (AA). However, the risk difference magnitude in histologic BE prevalence between AA and non-Hispanic whites (nHw) has not been quantified to date.

Objective

The objective of this article is to determine the degree of histologic BE risk difference between AA and nHw.

Methods

PubMed, Web of Science and EMBASE were searched for studies reporting histologic BE in AA/nHw for inclusion. Pooled odds ratios (ORs) with risk estimates of histologic BE occurrence between AA/nHw were calculated along with 95% confidence intervals (CIs). Forest plots were used to quantify heterogeneity. Funnel plots and the Cochrane Collaboration Risk of Bias tool were used to assess bias risk.

Results

Eight studies reported BE histologic confirmation in AA/nHw. Analysis demonstrated a nearly 400% increased histologic BE risk in nHw patients compared to AA (OR 3.949, 95% CI 3.069-5.082). In the model without the case-control study, histologic BE risk remained elevated at approximately 360% in nHw compared to AA (OR 3.618, 95% CI 2.769-4.726). Heterogeneity was not present in either model. Risk of bias was significant.

Conclusions

Histologic BE risk is elevated in nHw by 3.6-4 times compared to AA. Investigation into understanding any clinical, molecular or genetic mechanisms underlying this risk disparity is warranted.

The frequency of histologically confirmed Barrett's esophagus varies by the combination of ethnicity and gender

BACKGROUND

Barrett's esophagus (BE) is the primary risk factor for esophageal adenocarcinoma (EAC). Limited data exists regarding the frequency of histologically confirmed BE by both gender and ethnicity in the United States. The study aim was to determine whether the frequency of histologically confirmed BE varies by ethnicity and gender.

METHODS

The University of Florida-Jacksonville endoscopy database was reviewed for all cases of salmon colored esophageal mucosa from September 2002 to August 2007. Histologic BE was diagnosed only if salmon colored esophageal mucosa was seen endoscopically and biopsy confirmed intestinal metaplasia with goblet cells. Data collected included: age at diagnosis, self-reported ethnicity [non-Hispanic white (nHw) or African American (AA)], gender, procedure indication, gastroesophageal reflux disease (GERD) history, atypical manifestations, cigarette smoking, alcohol use, proton pump inhibitor (PPI) use, BE endoscopic length, absence/presence of hiatal hernia, stricture or ulcer, and absence/presence/grade of dysplasia.

RESULTS

Salmon colored esophageal mucosa was identified in 391/7,308 patients, distributed ethnically as 306 nHw and 85 AA. Histologic BE was confirmed in 111/391 patients with ethnic distribution of: 95 nHw and 16 AA. Histologically confirmed BE frequency varied both by gender and ethnicity with nHw males having the highest (42.3%) and AA females the lowest (12.3%). Histologically confirmed BE frequency differed significantly between nHw males and nHw/AA females only (P<0.005).

CONCLUSIONS

Histologically confirmed BE frequency varies by ethnicity and gender with nHw males having the highest frequency/risk and AA females the lowest. Investigation to improve understanding of the impact of race and gender in BE formation should be performed.

Insights into the genetics of gastroesophageal reflux disease (GERD) and GERD-related disorders

Gastroesophageal reflux disease (GERD) is associated with obesity and hiatal hernia, and often precedes the development of Barrett's esophagus (BE) and esophageal adenocarcinoma (EA). Epidemiological studies show that the global prevalence of GERD is increasing. GERD is a multifactorial disease with a complex genetic architecture. Genome-wide association studies (GWAS) have provided initial insights into the genetic background of GERD. The present review summarizes current knowledge of the genetics of GERD and a possible genetic overlap between GERD and BE and EA. The review discusses genes and cellular pathways that have been implicated through GWAS, and provides an outlook on how future molecular research will enhance understanding of GERD pathophysiology.

Identification of Helicobacter pylori and the evolution of an efficacious childhood vaccine to protect against gastritis and peptic ulcer disease

Establishment of Helicobacter pylori infection as an etiologic agent of peptic ulcer disease and other gastric pathologies marked a revolution in gastroenterology which spurred an enormous interest in gastric physiology and immunology research. The association was soon also demonstrated in children as well. Application of antimicrobial therapies have proven remarkably efficacious in eradicating H. pylori and curing pediatric patients of duodenal ulcers as well as gastritis, negating a lifetime of ineffective therapy and life-threatening disease. Countries with high H. pylori prevalence and where H. pylori associated gastric cancer remains a primary cause of death due to cancer however would benefit from childhood vaccination. Studies in rodents and humans utilizing oral vaccination with bacterial exotoxin adjuvants demonstrated potential for limiting H. pylori colonization in the stomach. Almost 25 y of vaccine research recently culminated in a phase III clinical trial of over 4,000 children aged 6-15 y old to test an oral vaccine consisting of the H. pylori urease B subunit genetically fused to the E. coli heat labile toxin. Vaccination was demonstrated to have an efficacy of over 70%. Vaccination may now serve as an effective strategy to significantly reduce H. pylori associated disease in children throughout the world.

Prevalence of upper gastrointestinal endoscopic findings in the community: A systematic review of studies in unselected samples of subjects

BACKGROUND AND AIM

Upper gastrointestinal endoscopic findings, such as esophagitis, Barrett's esophagus, peptic ulcer, and malignancy, represent a public health problem. This systematic review aimed to evaluate the prevalence of upper gastrointestinal endoscopic findings in the community.

METHODS

A systematic search was conducted in PUBMED and EMBASE to May 2015. Studies were eligible if they reported the prevalence of upper gastrointestinal endoscopic findings in unselected samples of the community.

RESULTS

Twelve articles were eligible, nine reported data from three endoscopic surveys (n = 3063 subjects), and three from national screening programs (n = 84 153). The overall prevalence of upper gastrointestinal endoscopic findings in the community was 30% in the Kalixanda study (Sweden), 24.9% in the Loiano-Monghidoro study (Italy), and 68.9% in the Systematic Investigation of Gastrointestinal Diseases study (China). The pooled prevalence of esophagitis, endoscopically suspected esophageal metaplasia (ESEM), peptic ulcer, and gastric cancer in all studies was 11.2, 5.1, 6.8, and 0.33%, respectively. The most frequent finding was esophagitis in Europe, with a prevalence of 15.5% in Sweden and 11.8% in Italy, and peptic ulcer in China (17.1%), both in asymptomatic and symptomatic individuals. The prevalence of Helicobacter pylori was positively associated with the prevalence of peptic ulcer (r = 0.91) but negatively associated with the prevalence of both esophagitis (r = -0.99) and ESEM (r = -0.95).

CONCLUSIONS

Upper gastrointestinal endoscopic findings are present in at least a quarter of subjects in the community with different patterns in Western and Eastern countries, both in asymptomatic and symptomatic subjects. H. pylori prevalence negatively impacts on the prevalence of reflux-related esophageal findings.

Helicobacter pylori and non-malignant upper gastrointestinal diseases

Peptic ulcer disease (PUD) has been further decreased over the last decades along with decreasing prevalence of Helicobacter pylori-associated PUD. A delayed H. pylori eradication has been associated with an increased risk of rehospitalization for complicated recurrent peptic ulcer and reemphasized the importance of eradication especially in patients with peptic ulcer bleeding (PUB). PUB associated with NSAID/aspirin intake and H. pylori revealed an additive interaction in gastric pathophysiology which favors the "test-and-treat" strategy for H. pylori in patients with specific risk factors. The H. pylori-negative and NSAID-negative "idiopathic PUD" have been increasingly observed and associated with slower healing tendency, higher risk of recurrence, and greater mortality. Helicobacter pylori-associated dyspepsia has been further investigated and finally defined by the Kyoto consensus. Helicobacter pylori eradication therapy is advised as first option in this group of patients. Only in the case of symptom persistence or recurrence after eradication therapy, dyspeptic patients should be classified as functional dyspepsia (FD). There were few new data in 2015 on the role of H. pylori infection in gastroesophageal reflux disease (GERD), and in particular Barrett's esophagus. A lower prevalence of gastric atrophy with less acid output in patients with erosive esophagitis confirmed previous findings. In patients with erosive esophagitis, no difference was observed in healing rates neither between H. pylori-positive and H. pylori-negative patients nor between patients that underwent eradication therapy compared to patients without eradication. These findings are in line with the current consensus guidelines concluding that H. pylori eradication has no effects on symptoms and does not aggravate preexisting GERD.

Guidelines for the management of Helicobacter pylori infection in Italy: The III Working Group Consensus Report 2015

Knowledge on the role of Helicobacter pylori (HP) infection is continually evolving, and treatment is becoming more challenging due to increasing bacterial resistance. Since the management of HP infection is changing, an update of the national Italian guidelines delivered in 2007 was needed. In the III Working Group Consensus Report 2015, a panel of 17 experts from several Italian regions reviewed current evidence on different topics relating to HP infection. Four working groups examined the following topics: (1) "open questions" on HP diagnosis and treatment (focusing on dyspepsia, gastro-oesophageal reflux disease, non-steroidal anti-inflammatory drugs or aspirin use and extra-gastric diseases); (2) non-invasive and invasive diagnostic tests; (3) treatment of HP infection; (4) role of HP in the prevention of gastric cancer. Statements and recommendations were discussed and a consensus reached in a final plenary session held in February 2015 in Bologna. Recommendations are based on the best current evidence to help physicians manage HP infection in Italy. The guidelines have been endorsed by the Italian Society of Gastroenterology and the Italian Society of Digestive Endoscopy.

Prevalence of Barrett's Esophagus in Asian Countries: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

The prevalence and risk factors of Barrett's esophagus (BE) in Asian countries are unclear. Studies report a wide range of BE prevalence in Asian countries. We conducted a systematic review and meta-analysis to examine the prevalence of BE and its temporal changes and risk factors in Asian countries.

METHODS

Two investigators performed independent literature searches by using PubMed and EMBASE databases, and subsequent data abstraction for studies had to meet several set inclusion and exclusion criteria. Pooled BE prevalence was calculated by using a random-effect model. Estimates of relative risk for possible risk or protective factors were also calculated.

RESULTS

A total of 51 studies (N = 453,147), mainly from Eastern Asia, were included. The pooled prevalence of endoscopic BE was 7.8% (95% confidence interval, 5.0-12.1; 23 studies) and of histologically confirmed BE was 1.3% (95% confidence interval, 0.7-2.2; 28 studies). Most of histologic BE (82.1%) was short-segment BE (<3 cm). There was a trend toward an increase in prevalence of BE over time from 1991 to 2014, especially in Eastern Asian countries. Within BE cohorts, pooled prevalence of low-grade dysplasia, high-grade dysplasia, and esophageal adenocarcinoma was 6.9%, 3.0%, and 2.0%, respectively. Reflux symptoms, male sex, hiatus hernia, and smoking were associated with a significantly increased risk of histologic BE in patients with BE compared with patients without BE. However, half of the patients with histologic BE did not have reflux symptoms.

CONCLUSIONS

BE is not uncommon in Asian countries and seems to share similar risk factors and potential for neoplastic progression to those seen in Western countries.

Microbiome and potential targets for chemoprevention of esophageal adenocarcinoma

Esophageal cancer is one of the deadliest cancers, with a dismal prognosis. It is increasingly recognized that esophageal cancer is a heterogeneous disease. It can be subdivided into two distinct groups: squamous cell carcinoma and adenocarcinoma, based on histological appearance. In the Western world, the incidence of squamous cell carcinoma was considerably higher than esophageal adenocarcinoma (EA) until the 1990s when, due to a dramatic increase, the incidence of EA surpassed that of squamous cell carcinoma. EA typically follows a well-established stepwise evolution from chronic inflammation due to reflux esophagitis (RE) that progresses to metaplasia (Barrett's esophagus [BE]) to dysplasia, which often culminates in EA. The pathophysiology of EA is complex and involves diverse factors, including gastroesophageal reflux, gastric acid secretion, dysfunction of the antireflux barrier, gastric emptying disturbances, and abnormalities in esophageal defense mechanisms. The current understanding of the etiology of EA is mainly derived from epidemiological studies of risk factors such as cigarette smoking, obesity, gastroesophageal reflux disorders (GERD), and low fruit and vegetable consumption. Numerous studies have been done, but the factors that drive the dynamic increase in the incidence of EA remain elusive. The advent of widespread antibiotic use occurred in the 1950s, preceding the surge of EA. Based on this temporal sequence, it has been hypothesized that antibiotics alter the microbiome to which the esophagus is exposed in patients who have GERD and that chronic exposure to this abnormal microbiome (ie, changes in species diversity or abundance) accounts for the increase in EA. If changes in the proposed factors alter the stepwise progression (RE-BE-dysplasia-EA), they may represent potential targets for chemoprevention. New discoveries will help improve our understanding of the biology and pathogenesis of these cancers, and aid in finding novel therapeutic targets.

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.

Recent developments in pathogenesis, diagnosis and therapy of Barrett's esophagus

The burden of illness from esophageal adenocarcinoma continues to rise in the Western world, and overall prognosis is poor. Given that Barrett’s esophagus (BE), a metaplastic change in the esophageal lining is a known cancer precursor, an opportunity to decrease disease development by screening and surveillance might exist. This review examines recent updates in the pathogenesis of BE and comprehensively discusses known risk factors. Diagnostic definitions and challenges are outlined, coupled with an in-depth review of management. Current challenges and potential solutions related to screening and surveillance are discussed. The effectiveness of currently available endoscopic treatment techniques, particularly with regards to recurrence following successful endotherapy and potential chemopreventative agents are also highlighted. The field of BE is rapidly evolving and improved understanding of pathophysiology, combined with emerging methods for screening and surveillance offer hope for future disease burden reduction.

Republished: symptomatic reflux disease: the present, the past and the future

The worldwide incidence of GORD and its complications is increasing along with the exponentially increasing problem of obesity. Of particular concern is the relationship between central adiposity and GORD complications, including oesophageal adenocarcinoma. Driven by progressive insight into the epidemiology and pathophysiology of GORD, the earlier belief that increased gastroesophageal reflux mainly results from one dominant mechanism has been replaced by acceptance that GORD is multifactorial. Instigating factors, such as obesity, age, genetics, pregnancy and trauma may all contribute to mechanical impairment of the oesophagogastric junction resulting in pathological reflux and accompanying syndromes. Progression of the disease by exacerbating and perpetuating factors such as obesity, neuromuscular dysfunction and oesophageal fibrosis ultimately lead to development of an overt hiatal hernia. The latter is now accepted as a central player, impacting on most mechanisms underlying gastroesophageal reflux (low sphincter pressure, transient lower oesophageal sphincter relaxation, oesophageal clearance and acid pocket position), explaining its association with more severe disease and mucosal damage. Since the introduction of proton pump inhibitors (PPI), clinical management of GORD has markedly changed, shifting the therapeutic challenge from mucosal healing to reduction of PPI-resistant symptoms. In parallel, it became clear that reflux symptoms may result from weakly acidic or non-acid reflux, insight that has triggered the search for new compounds or minimally invasive procedures to reduce all types of reflux. In summary, our view on GORD has evolved enormously compared to that of the past, and without doubt will impact on how to deal with GORD in the future.

Risk factors affecting the Barrett's metaplasia-dysplasia-neoplasia sequence

Esophageal adenocarcinoma has the fastest growing incidence rate of any cancer in the United States, and currently carries a very poor prognosis with 5 years relative survival rates of less than 15%. Current curative treatment options are limited to esophagectomy, a procedure that suffers from high complication rates and high mortality rates. Metaplasia of the esophageal epithelium, a condition known as Barrett’s esophagus (BE), is widely accepted as the precursor lesion for adenocarcinoma of the esophagus. Recently, radio-frequency ablation has been shown to be an effective method to treat BE, although there is disagreement as to whether radio-frequency ablation should be used to treat all patients with BE or whether treatment should be reserved for those at high risk for progressing to esophageal adenocarcinoma while continuing to endoscopically survey those with low risk. Recent research has been targeted towards identifying those at greater risk for progression to esophageal adenocarcinoma so that radio-frequency ablation therapy can be used in a more targeted manner, decreasing the total health care cost as well as improving patient outcomes. This review discusses the current state of the literature regarding risk factors for progression from BE through dysplasia to esophageal adenocarcinoma, as well as the current need for an integrated scoring tool or risk stratification system capable of differentiating those patients at highest risk of progression in order to target these endoluminal therapies.

A review of the epidemiology of Barrett's oesophagus and oesophageal adenocarcinoma

While the incidence rates of many cancers have decreased in past decades, the incidence of oesophageal adenocarcinoma continues to increase. The only known precursor for oesophageal adenocarcinoma is Barrett's oesophagus. Studies conducted have identified white race, male sex, GORD, cigarette smoking, obesity, and the absence of Helicobacter pylori status as risk factors for oesophageal adenocarcinoma. Other potential associations include dietary factors and the absence of non-steroidal anti-inflammatory drug use. Many individual studies have been limited by sample size and several meta-analyses have pooled data from studies to address this limitation. In this review we present a synthesis of these studies and summarize current knowledge of risk factors for both oesophageal adenocarcinoma and Barrett's oesophagus.

Risk factors for Barrett's esophagus compared between African Americans and non-Hispanic Whites

OBJECTIVES

Esophageal adenocarcinoma is more common among non-Hispanic Whites (NHWs) than African Americans (AAs). It is unclear whether its precursor, Barrett's esophagus (BE), is also less common among AAs, and whether differences in risk factor profiles explain the racial disparity.

METHODS

Data were from a case-control study among eligible Veterans Affairs patients scheduled for an upper endoscopy, and a sample identified from primary care clinics. Participants completed a questionnaire on sociodemographic and clinical factors and underwent a study esophagogastroduodenoscopy. We calculated race-specific BE prevalence rates and used logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (95% CIs) for BE.

RESULTS

There were 301 BE cases and 1,651 controls. BE prevalence was significantly higher among NHWs than AAs (21.3 vs. 5.0%; P<0.001). NHWs were more likely than AAs to be male, have a high waist-to-hip ratio (WHR), hiatal hernia, and use proton-pump inhibitors (PPIs), but less likely to have Helicobacter pylori (P<0.001). Among cases, NHWs were more likely to have long-segment BE and dysplasia than AAs. Independent BE risk factors for AAs included a hiatus hernia ≥3 cm (OR 4.12; 95% CI, 1.57-10.81) and a history of gastroesophageal reflux disease or PPI use (OR, 3.70; 95% CI, 1.40-9.78), whereas high WHR (OR, 2.82; 95% CI, 1.41-5.63), hiatus hernia ≥3 cm (OR, 4.95; 95% CI, 3.05-8.03), PPI use (OR, 1.88; 95% CI, 1.33-2.66), and H. pylori (OR, 0.64; 95% CI, 0.41-0.99) were statistically significantly associated with BE risk for NHWs. Among all cases and controls, race was a risk factor for BE, independent of other BE risk factors (OR for AAs, 0.26; 95% CI, 0.17-0.38).

CONCLUSIONS

Among veterans, the prevalence of BE was lower in AAs compared with NHWs. This disparity was not accounted for by differences in risk estimates or prevalence of risk factors between NHWs and AAs.

Helicobacter pylori: the balance between a role as colonizer and pathogen

The isolation of Helicobacter pylori from the human stomach produced significant changes in how gastroenterologists, immunologists, epidemiologists, pathologists and microbiologists have approached gastro-duodenal diseases in the last half of the XX century. However, research of this organism has progressed greatly in the first decade of this century, evidence suggest that H. pylori is associated with disease only in humans older than 40 years, while, the lack of H. pylori colonization is associated with the emergence of new diseases, particularly in younger individuals. These differing effects of H. pylori colonization have created two contrasting concepts: the 'bad' and the 'good' Helicobacter. Following from renewed interest in the normal human microbiome, we need to reconsider our definitions and perhaps recognize that H. pylori might be a normal member of the human gastric microbiome in ancient humans that gradually, as results of the improvement in our environment, is disappearing.

Barrett’s oesophagus: Evidence from the current meta-analyses

Guidelines have been published regarding the management of Barrett’s oesophagus (columnar-lined oesophagus). These have examined the role of surveillance in an effort to detect dysplasia and early cancer. The guidelines have provided criteria for enrolment into surveillance and some risk stratification with regard to surveillance interval. The research basis for the decisions reached with regard to cancer risk is weak and this manuscript has examined the available data published from meta-analyses up to 25^th April 2013 (much of which has been published since the guidelines and their most recent updates have been written). There were 9 meta-analyses comparing patients with Barrett’s oesophagus to control populations. These have demonstrated that Barrett’s oesophagus is more common in males than females, in subjects who have ever smoked, in subjects with obesity, in subjects with prolonged symptoms of gastro-oesophageal reflux disease, in subjects who do not have infection with Helicobacter pylori and in subjects with hiatus hernia. These findings should inform public health measures in reducing the risk of Barrett’s oesophagus and subsequent surveillance burden and cancer risk. There were 8 meta-analyses comparing different groups of patients with Barrett’s oesophagus with regard to cancer risk. These have demonstrated that there was no statistically significant benefit of antireflux surgery over medical therapy, that endoscopic ablative therapy was effective in reducing cancer risk that there was similar cancer risk in patients with Barrett’s oesophagus independent of geographic origin, that the adenocarcinoma incidence in males is twice the rate in females, that the cancer risk in long segment disease showed a trend to be higher than in short segment disease, that there was a trend for higher cancer risk in low-grade dysplasia over non-dysplastic Barrett’s oesophagus, that there is a lower risk in patients with Helicobacter pylori infection and that there is a significant protective effect of aspirin and statins. There were no meta-analyses examining the role of intestinal metaplasia. These results demonstrate that guidance regarding surveillance based on the presence of intestinal metaplasia, segment length and the presence of low-grade dysplasia has a weak basis, and further consideration should be given to gender and helicobacter status, ablation of the metaplastic segment as well as the chemoprotective role of aspirin and statins.

Helicobacter pylori and gastroesophageal reflux disease

PURPOSE OF REVIEW

The purpose of the review is to discuss key studies conducted on the intriguing relationship between Helicobacter pylori and gastroesophageal reflux disease.

RECENT FINDINGS

Epidemiological studies have repeatedly described a negative association between H. pylori infection and erosive esophagitis, Barrett's esophagus, and esophageal adenocarcinoma, but not between H. pylori and gastroesophageal reflux disease symptoms. Especially, infection with CagA-positive strains appears to protect the distal esophagus by causing fundic gland atrophy and impaired gastric acid secretion. Although earlier reports suggested the development of erosive esophagitis after H. pylori eradication, more recent studies discuss that H. pylori eradication usually does not have an important clinical impact on gastroesophageal reflux disease.

SUMMARY

Gastric atrophy is the most widely accepted mechanism by which the distal esophagus is protected from abnormal acid exposure in patients with H. pylori infection. The clinical impact of H. pylori infection on the prevalence of erosive esophagitis and Barrett's esophagus remains a matter of debate. In areas with a high prevalence of H. pylori-induced atrophic gastritis, the protection that this infection may afford against gastroesophageal reflux disease is not comparable to the risk that H. pylori poses for the development of gastric cancer.