Treating GERD in the Patient With H pylori and Gastritis

Kenneth R. DeVault, MD, FACG

Disclosures

March 13, 2003

Question

What is your approach to treatment of GERD in patients with Helicobacter pylori and gastritis?

Hasan Abello, MD

Response from Kenneth R. DeVault, MD, FACG

This is not an unusual problem because both gastroesophageal reflux disease (GERD) and H pylori infection are extremely common. In addition, there is often considerable overlap between symptoms attributable to GERD and to H pylori (such as dyspepsia). In this patient, I will assume that there are symptoms (heartburn and regurgitation) and perhaps tests (an endoscopy with esophagitis or a positive 24-hour pH test) that are consistent with GERD. H pylori infection itself does not seem to be a significant risk factor for GERD, and the infection may be protective or at least make GERD easier to treat.[1] The patient's GERD symptoms and gastritis should respond to GERD therapy, irrespective of the infection.

Another question to ask, however, is, Should the H pylori be eradicated? This decision needs to be made on a case-by-case basis. In 1996, it was suggested that the combination of an active H pylori infection and chronic therapy with a proton-pump inhibitor (PPI) put patients at an increased risk for atrophic gastritis and perhaps gastric cancer.[2] More recent studies, with better design and controls, have shown that the latter is most likely not the case.[3] Other studies suggested that eradicating H pylori may actually make the reflux more difficult to control, but this has not been confirmed in adequately designed trials.

My approach to this patient would be to treat the GERD symptoms independently of the H pylori infection, most likely with a PPI. I would certainly eradicate the H pylori if the patient has a personal history of peptic ulcer disease or if there is a family history of gastric cancer. In all other patients, I would discuss the risks and benefits (both probably fairly low) and the cost (fairly high) of therapy. In my experience, most patients will want to have the infection eradicated and will respond well to eradication regimens that include a PPI, clarithromycin, and either amoxicillin or metronidazole. If the patient truly has GERD, he or she will probably need long-term acid suppression whether or not one chooses to eradicate the H pylori.

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