Clinical Update on Inflammatory Disorders of the Gastrointestinal Tract

J. Mayerle, H. Tilg, G. Rogler

• Publisher: S. Karger
• Year: 2009
• Print ISBN: 9783805592949
• eBook ISBN: 9783805592956
• Topic: Medicine
• Subtopic: Gastroenterology & Hepatology

Digestive-disease-associated mortality accounts for a major part of all deaths in Western societies and inflammatory diseases such as GI infections, viral hepatitis, GERD or cancers due to chronic inflammation have a tangible economic and social impact. What further aggravates the situation is the fact that complex immunological disorders have surfaced where anti-infective treatments are not effective. Fortunately, due to breakthroughs in basic research that are being successfully translated into clinical practice, new treatment strategies are constantly evolving. In addition to the development of new therapeutic measures, however, it is also mandatory to review and periodically refine established treatment regimens to reflect current knowledge and ensure up-to-date medical care.

Gastric Disorders

Mayerle J, Tilg H (eds): Clinical Update on Inflammatory Disorders of the Gastrointestinal Tract.
Front Gastrointest Res. Basel, Karger, 2010, vol 26, pp 186–198

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Helicobacter pylori Infection: To Eradicate or Not to Eradicate

Kerstin Schütte · Arne Kandulski · Michael Selgrad · Peter Malfertheiner

Department of Gastroenterology, Hepatology and Infectious Diseases, Otto von Guericke University Magdeburg, Magdeburg, Germany

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Abstract

The discovery of Helicobacter pylori signalled a turning point in our understanding of gastroduodenal pathology. While the infection with H. pylori leads to chronic gastritis in all affected individuals, the disease does not progress to any complication in 80% of patients. However, in a subset of patients H. pylori causes peptic ulcer disease, mucosa-associated lymphoid tissue lymphoma and gastric adenocarcinoma. While there is a clear indication to eradicate the infection with H. pylori in every patient with an associated complication, the question of eradication therapy for preventive purposes is debated. Nevertheless, H. pylori eradication before the development of gastric atrophy or intestinal metaplasia has the best potential to prevent gastric cancer. The challenge for the future will not only be to cure peptic ulcer disease and to prevent gastric cancer by eradication of H. pylori but to prevent even the infection itself.

Copyright © 2010 S. Karger AG, Basel

The discovery of Helicobacter pylori over 25 years ago [1] signalled a turning point in our understanding of gastroduodenal pathology. Chronic active gastritis is initiated in all subjects infected with H. pylori and, in its various phenotypic expressions, it is the basis for the development of several diverse complications. Still, it needs to be mentioned that around 80% of all infected patients will not progress to any complication. This review gives an overview on the role of H. pylori in gastrointestinal diseases, including peptic ulcer disease and ulcers associated with non-steroidal anti-inflammatory drugs, gastro-oesophageal reflux disease (GERD), functional dyspepsia, mucosa-associated lymphoid tissue (MALT) lymphoma and gastric adenocarcinoma as well as in some extragastrointestinal diseases such as iron deficiency anaemia and idiopathic thrombocytopenic purpura. While H. pylori must be eradicated in patients with related complications (table 1), the question whether to eradicate for the purpose of prevention is still a matter of debate.

Table 1. Indications for H. pylori eradication according to the Maastricht III Consensus Report [4]

Recommendation	Level of evidence	Grade of recommendation
Eradication is an appropriate option for patients infected with H. pylori and investigated non-ulcer dyspepsia	1a	A
Test and treat is an appropriate option for patients with uninvestigated dyspepsia	1a	A
Test and treat or empirical acid suppression are appropriate options in populations with a low H. pylori prevalence	2a	B
H. pylori does not cause GERD	1b	A
Eradication does not affect the outcome of PPI treatment in patients with GERD in Western populations	1b	A
Routine H. pylori testing is not recommended in GERD	1b	A
Testing should be considered for patients receiving long-term maintenance treatment with PPIs	2b	B
H. pylori eradication is inferior to PPI maintenance therapy in patients receiving long-term NSAIDs and who have peptic ulcer and/or ulcer bleeding in preventing ulcer recurrence and/or bleeding	1b	A
Eradication is of value in chronic NSAID users but is insufficient to prevent NSAID-related ulcer disease completely	1b	A
Eradication may prevent peptic ulcer and/or bleeding in naive users of NSAIDs	1b	A

Peptic Ulcer Disease

The lifetime risk for developing peptic ulcer disease in H. pylori infected patients is approximately 15% [2]. However, the clinical outcome of H. pylori infection varies depending on host, environmental and bacterial virulence factors. While antralpredominant gastritis shows a strong correlation to the development of duodenal ulcers the risk for developing gastric ulcers, gastric atrophy, intestinal metaplasia and finally adenocarcinoma is higher in patients with corpus-predominant gastritis [3]. Eradication therapy is imperative in H. pylori infected patients who have a current or past medical history of peptic ulcer disease [4].

Furthermore, the annual relapse rate for gastric or duodenal ulcer can dramatically be reduced from more than 50% to 0-10% by eradication of H. pylori [5].

Besides H. pylori infection, NSAIDs significantly and independently increase the risk of peptic ulcer bleeding. Ninety percent of ulcers can be attributed to one or both of these factors [6]. Although the interaction of H. pylori and NSAIDs concerning gastrointestinal epithelial damage and the pathogenesis of ulceration is complex and not currently understood in detail, a significantly increased risk of peptic ulcer bleeding in H. pylori infected patients compared to H. pylori negative subjects on NSAID treatment has been shown by a number of clinical studies. A well-performed systematic review reports an OR of 6.1 (95% CI 3.9-9.6) for NSAID-treated patients infected with the bacterium in comparison to an OR of 4.8 (95% CI 3.8-6.2) for those who are not infected [7].

However, controversy still surrounds the indication for eradication therapy in patients under long-term treatment with NSAIDs due to conflicting results from clinical trials.

Chan et al. [8] performed a prospective randomized controlled trial in 102 patients who were NSAID naïve, H. pylori positive, had a past medical history of dyspepsia or ulcer disease and required long-term NSAID treatment. Patients were either treated with omeprazol in combination with amoxicillin and clarithromycin as eradication therapy for 1 week or with omeprazol and placebo antibiotics for 1 week. The 6-month probability of ulcers was significantly lower in the eradication group [12.1% (95% CI 3.1-21.1) vs. 34.4% (95% CI 21.1-47.7), p = 0.0085] and the same held true for the risk of complicated ulcers [4.2% (95% CI 1.3-9.7) vs. 27.1% (95% CI 14.7-39.5%), p = 0.0026]. These results led to the recommendation to screen for and treat H. pylori infection in patients before starting long-term NSAID treatment [8]. On the other hand, a prospective randomized controlled trial on 347 patients already on long-term NSAID treatment and positive on H. pylori serologic testing that were either treated with H. pylori eradication or placebo failed to show a significant difference in the development of gastroduodenal erosions or dyspepsia [9]. This was in concordance with a previous randomized double-blind placebo-controlled trial in H. pylori positive patients requiring NSAID therapy without past or present peptic ulcer disease. In that study, patients were assigned to 1 of 4 arms, either receiving eradication therapy followed by placebo, eradication therapy follo...

Table of contents

• Cover Page
• Front Matter
• Non-Alcoholic Fatty Liver Disease
• Fibrosis in the GI Tract: Pathophysiology, Diagnosis and Treatment Options
• Chronic Hepatitis B: Pathophysiology, Diagnosis and Treatment Options
• Chronic Hepatitis C: Pathophysiology, Diagnosis and Treatment Options
• Clinical Update on Inflammatory Disorders of the GI Tract: Liver Transplantation
• Hepatocellular Carcinoma
• Coeliac Disease
• Anti-TNF Therapy in Inflammatory Bowel Diseases
• Role of Epithelial Cells in Inflammatory Bowel Disease
• GI Immune Response in Functional GI Disorders
• Probiotics in GI Diseases
• Microscopic Colitis
• Inflammatory Proteins as Prognostic Markers in Acute Pancreatitis
• Antibiotics, Probiotics and Enteral Nutrition: Means to Prevent Infected Necrosis in AP
• IKK/NF-κB/Rel in Acute Pancreatitis and Pancreatic Cancer: Torments of Tantalus
• Immunotherapy of Pancreatic Carcinoma: Recent Advances
• Helicobacter pylori Infection: To Eradicate or Not to Eradicate
• Carcinogenesis and Treatment of Gastric Cancer
• Author Index
• Subject Index