Effect of Helicobacter pylori eradication therapy on risk of hospitalization for a major ulcer event

Delay in Retreatment of Helicobacter pylori Infection Increases Risk of Upper Gastrointestinal Bleeding

BACKGROUND & AIMS

Little is known about risk of upper gastrointestinal bleeding (UGIB) in patients failed by Helicobacter pylori eradication therapy. We investigated the effects of different time until retreatment, after failure of initial H pylori eradication therapy, on subsequent risk of UGIB.

METHODS

We performed a territory-wide retrospective cohort study of 70,518 patients with H pylori infection who had received their first course of clarithromycin-based triple therapy from January 2003 through December 2012 in Hong Kong. Patients who required retreatment after failed initial therapy (n = 8330, 11.8%) were categorized based on time between initial and final H pylori eradication (3 months or less, 3-12 months, and more than 12 months). We collected clinical data from 30 days after prescription of the last course of H pylori therapy until hospitalization for non-variceal UGIB, death, or the end of the study (30 Jun 2016; median follow-up time, 7.65 years). The primary outcome was difference in development UGIB (determined from ICD-9 codes) between patients who required retreatment and those who did not (reference group).

RESULTS

Compared with the reference group, patients who required retreatment had an overall higher risk of UGIB, even after last eradication therapy (adjusted hazard ratio (HR), 1.50, 95% CI, 1.34-1.69). There was a progressive increase in risk of UGIB with longer time from initial until final eradication therapy: hazard ratio for time less than 3 months, 1.16; 95% CI, 0.88-1.54, hazard ratio for time 3-12 months, 1.35; 95% CI, 1.07-1.69, and hazard ratio for time more than 12 months, 1.68; 95% CI, 1.46-1.94 (P for trend = .038).

CONCLUSION

In a retrospective study of patients in Hong Kong, we found that those failed by initial H pylori eradication have an increased risk of UGIB, compared to patients who responded to the initial therapy. Risk increased progressively with longer time until retreatment. Early retreatment within 3 months should be considered to minimize subsequent UGIB risk.

A Longitudinal, Population-Level, Big-Data Study of Helicobacter pylori-Related Disease across Western Australia

Helicobacter pylori, responsible for chronic ulcers and most stomach cancers, infects half of the world’s population. The Urea Breath Test (UBT) is one of the most accurate and reliable non-invasive methods for diagnosing active H. pylori infection. The objective was to use longitudinal, population-wide UBT data for Western Australia to look for H. pylori-related disease patterns. We collected 95,713 UBT results from 77,552 individuals for the years 2010–2015, likely representing all of the UBT samples analysed in Western Australia. Data collected also included sex, age and residential postcode. Other data reported here were inferred via a comparison with the 2011 Australian Census using a specially written Python program. While women appear to have more H. pylori-related disease than men, there is no difference in the disease rates once women’s higher rates of presentation for testing are taken into account. On the other hand, while the treatment strategy for H. pylori infection is generally very effective in Western Australia, failure of the first-line treatment is significantly more common in women than men. Migrants and Aboriginal Australians have elevated rates of H. pylori-related disease, while the rate for non-Aboriginal Australian-born West Australians is very low. However, no significant associations were found with other socio-economic indicators. We conclude that, for some people, H. pylori-related disease is not a solved problem.

Increased incidence of herpes zoster in adult patients with peptic ulcer disease: a population-based cohort study

BACKGROUND

Peptic ulcer disease (PUD) has been linked to immunological dysfunctions and malnutrition—both are predictors of herpes zoster(HZ). We hypothesized that PUD patients might have a greater risk for developing HZ.

METHODS

Using the longitudinal National Health Insurance Research Database, we conducted a retrospective population-based cohort study to evaluate the incidence of HZ in adult PUD patients and controls matched by age and gender. Kaplan-Meier analysis and Cox regression were conducted to compare differences in the development of HZ. The effects of comorbidities on the risk of HZ and the associations between different risk factors of PUD and HZ were assessed by subgroup analyses.

RESULTS

We identified 41 229 adults PUD patients and 41 229 controls. Over an 8-year follow-up, the cumulative incidence of HZ in PUD patients(11.76/1000 person-years) was significantly higher than controls(6.56/1000 person-years) (P<0.001, by log-rank test). After adjusting for potential confounders, PUD was an independent predictor for HZ (adjusted hazard ratio: 1.77, 95% confidence interval 1.64–1.91, P<0.001). Major risk factors of PUD were non-selective nonsteroidal anti-inflammatory drugs (nsNSAID) usage and Helicobacter pylori infection. Subgroup analyses revealed that PUDis an independent predictor of HZ after excluding the potential confounding effects of the comorbidities; PUD associated with the combination of nsNSAID usage and Helicobacter pylori infection leads to greatest risk of HZ.

CONCLUSIONS

Adults with PUD are at increased risk of HZ independently compared with the general population. Further studies are required to clarify the nature of the associations between HZ and PUD.

Consensus on control of risky nonvariceal upper gastrointestinal bleeding in Taiwan with National Health Insurance

BACKGROUND AND AIMS

To compose upper gastrointestinal bleeding (UGIB) consensus from a nationwide scale to improve the control of UGIB, especially for the high-risk comorbidity group.

METHODS

The steering committee defined the consensus scope to cover preendoscopy, endoscopy, postendoscopy, and overview from Taiwan National Health Insurance Research Database (NHIRD) assessments for UGIB. The expert group comprised thirty-two Taiwan experts of UGIB to conduct the consensus conference by a modified Delphi process through two separate iterations to modify the draft statements and to vote anonymously to reach consensus with an agreement ≥80% for each statement and to set the recommendation grade.

RESULTS

The consensus included 17 statements to highlight that patients with comorbidities, including liver cirrhosis, end-stage renal disease, probable chronic obstructive pulmonary disease, and diabetes, are at high risk of peptic ulcer bleeding and rebleeding. Special considerations are recommended for such risky patients, including raising hematocrit to 30% in uremia or acute myocardial infarction, aggressive acid secretory control in high Rockall scores, monitoring delayed rebleeding in uremia or cirrhosis, considering cycloxygenase-2 inhibitors plus PPI for pain control, and early resumption of antiplatelets plus PPI in coronary artery disease or stroke.

CONCLUSIONS

The consensus comprises recommendations to improve care of UGIB, especially for high-risk comorbidities.

Helicobacter pylori associated chronic gastritis, clinical syndromes, precancerous lesions, and pathogenesis of gastric cancer development

Helicobacter pylori (H. pylori) infection is well known to be associated with the development of precancerous lesions such as chronic atrophic gastritis (AG), or gastric intestinal metaplasia (GIM), and cancer. Various molecular alterations are identified not only in gastric cancer (GC) but also in precancerous lesions. H. pylori treatment seems to improve AG and GIM, but still remains controversial. In contrast, many studies, including meta-analysis, show that H. pylori eradication reduces GC. Molecular markers detected by genetic and epigenetic alterations related to carcinogenesis reverse following H. pylori eradication. This indicates that these changes may be an important factor in the identification of high risk patients for cancer development. Patients who underwent endoscopic treatment of GC are at high risk for development of metachronous GC. A randomized controlled trial from Japan concluded that prophylactic eradication of H. pylori after endoscopic resection should be used to prevent the development of metachronous GC, but recent retrospective studies did not show the tendency. Patients with precancerous lesions (molecular alterations) that do not reverse after H. pylori treatment, represent the "point of no return" and may be at high risk for the development of GC. Therefore, earlier H. pylori eradication should be considered for preventing GC development prior to the appearance of precancerous lesions.

Association of thiazolidinediones with gastric cancer in type 2 diabetes mellitus: a population-based case-control study

BACKGROUND

It has been shown that peroxisome proliferator-activated receptors (PPAR) have physiological and pharmacological ligands. The objective is to assess the association between thiazolidinediones (TZDs) and the occurrence of gastric cancer.

METHODS

We conducted a population-based nested case-control study. Data were retrospectively collected from the National Health Insurance Research Database (NHIRD). The cases consisted of all diabetes mellitus (DM) patients aged 30 to 99 years, and who had a first time diagnosis of gastric cancer in the study cohort. The controls were matched to cases by age, sex, and index date. The adjusted odds ratio (OR) and 95% confidence interval (CI) were estimated by using multiple logistic regression.

RESULTS

Records from 357 gastric cancer and 1,428 selected matched controls were included in the analyses of gastric cancer risk. A total of 7% or 9.5% of the cases and 10.8% or 14.8% of the controls had used any quantity of at least 2 prescriptions for pioglitazone or rosiglitazone, respectively. After adjusting for possible confounders, pioglitazone (OR = 0.93, P > 0.05) and rosiglitazone (OR = 1.21, P > 0.05), had no significant association of decreasing gastric cancer. After adjusting for possible confounders, pioglitazone (OR = 0.70, P > 0.05) or rosiglitazone (OR = 0.79, P > 0.05), had no significant trend toward decreasing gastric cancer risk with increasing cumulative doses ≥ 260 defined daily doses (DDDs), respectively. Moreover, adjusting for possible confounders pioglitazone (OR = 0.68, P > 0.05) or rosiglitazone (OR = 0.74, P > 0.05) had no significant trend toward decreasing gastric cancer risk with increasing cumulative doses ≥ 1 year, respectively.

CONCLUSIONS

Our results did not show evidence to support that TZD derivatives in DM patients reduces gastric cancer occurrence.

Helicobacter Pylori Infection in a Group of Egyptian Children With Upper Gastro-Intestinal Bleeding

Background

Upper gastrointestinal bleeding is a life threatening condition in children. Common sources of upper gastrointestinal bleeding in children include mucosal lesions and variceal hemorrhage. Helicobacter pylori (H. pylori) is a Gram negative spiral-shaped bacterium that is found in the gastric mucous layer or adherent to the epithelial lining of the stomach. It causes more than 90% of duodenal ulcers and up to 70-80% of gastric ulcers. The relationship between H. pylori infection and upper GIT bleeding in children is still un-clear. This study aimed to estimate the incidence of H. pylori infection in children presented with upper GIT bleeding and correlation between H. pylori infection and endoscopic findings of the cause of bleeding.

Methods

The study included 70 children presented with upper GIT bleeding indicated for upper gastrointestinal endoscopy admitted in pediatric department, Minia University Hospital, Egypt during the period from February 2010 to December 2012. Thirty healthy children were included as a control group with age and sex matched. After medical history taking and physical examination all children were exposed for laboratory investigations (CBC, prothrombin time and concentration, liver function tests, hepatitis viral markers, blood urea and serum creatinine and Helicobacter pylori stool antigen test). Upper endoscopy was done for patients only. Patients were classified into variceal and non variceal groups according to upper endoscopy.

Results

Helico-pylori infection was significantly higher in children with non-variceal bleeding than controls (P = 0.02) and children with variceal bleeding (P = 0.03) with no significant difference between children with variceal bleeding and controls (P = 0.9). Both weights and BMIs centile were significantly lower in variceal and non-variceal groups than controls (P = 0.01 & 0.001 and 0.01 & 0.001 respectively). AST, ALT and direct bilirubin levels were significantly higher in variceal group than controls (P = 0.001, 0.004 & 0.001 respectively). Prothrombin concentration and albumin levels were significantly lower in variceal group than controls (P = 0.001 & 0.01 respectively). Hemoglobin levels were significantly lower in variceal and non-variceal groups than controls (P = 0.01 & 0.001 respectively). No significant differences were present as regards age, sex, height or platelets count between cases (variceal and non-variceal) and controls.

Conclusions

H. pylori infection is significantly higher in children with non-variceal bleeding than controls. No significant difference between children with variceal bleeding and controls. Triad of increased ALT, decreased albumin levels and negative H. pylori infection could be a significant triad in predicting variceal bleeding as a cause of upper GIT bleeding in children.

Helicobacter pylori is not the predominant etiology for liver cirrhosis patients with peptic ulcer disease

OBJECTIVES

Patients with liver cirrhosis (LC) often develop peptic ulcers. The differentiation of Helicobacter pylori etiology in LC patients from that of peptic ulcers in non-LC patients is critical. This study aimed to determine whether H. pylori plays a central role in LC patients with peptic ulcers.

METHODS

LC was defined by International Classifications of Diseases, Revision 9, and Clinical Modification (ICD-9-CM) codes 571.2, 571.5, and 571.6. To be defined as non-LC, we did not identify patients in an inpatient setting or by one or more ambulatory care claims containing the International Classifications of Diseases, Revision 9, and Clinical Modification codes 571.2, 571.5, and 571.6. The sample included 9465 H. pylori-positive patients and 3418 H. pylori-negative patients. A logistic regression model was used to calculate the odds ratio (OR) and a 95% confidence interval was used to determine whether LC was an independent factor of lower H. pylori infection rates in peptic ulcer patients.

RESULTS

This study included 102 decompensated LC patients with peptic ulcers, 39 H. pylori-positive and 63 H. pylori-negative. There were 360 compensated LC patients with peptic ulcers, 193 H. pylori-positive and 167 H. pylori-negative. Among the non-LC patients with peptic ulcers, 9233 were H. pylori-positive and 3188 were H. pylori-negative. On the basis of logistic regression analysis, decompensated LC patients (OR=0.23, P<0.001) and compensated LC patients (OR=0.48, P<0.001) had lower H. pylori infection rates.

CONCLUSION

H. pylori is not the predominant etiology for LC, especially the decompensated type, either with peptic ulcer disease or with recurrent ulcer disease.