Eradication of Helicobacter pylori: A Clinical Update

Marco Romano, MD; Antonio Cuomo, MD

Disclosures
In This Article

Whom Should We Treat?

According to the guidelines put forth in the Maastricht 2-2000 Consensus Report,[15] eradication is strongly recommended in all patients with peptic ulcer, including those with complications; in patients with low-grade mucosa-associated lymphoid tissue (MALT) lymphoma; in individuals with atrophic gastritis; and after gastric cancer resection. Eradication of H pylori infection is also strongly recommended for patients who are first-degree relatives of individuals with gastric cancer.

Whether patients with functional dyspepsia, patients on chronic nonsteroidal anti-inflammatory drug (NSAID) therapy, or individuals with gastroesophageal reflux disease (GERD) should have their H pylori eradicated remains a matter of debate. There is no definitive evidence that eradication of H pylori infection has an impact on dyspeptic symptoms.[16,17,18] However, it is well known that H pylori-infected individuals with nonulcer dyspepsia and corpus-predominant gastritis are more susceptible to the development of gastric adenocarcinoma compared with individuals with peptic ulcer disease who have antral-predominant gastritis.[7] Therefore, eradication treatment should be advised in patients with nonulcer dyspepsia, particularly if they show a corpus-predominant gastritis at histology.

An argument against eradication of H pylori infection in patients scheduled for chronic NSAID therapy derives from the concept that the organism protects the gastric mucosa from the damaging effect of the drugs due to the increased cyclooxygenase activity and prostaglandin production.[19] However, eradication of H pylori prior to use of NSAIDs reduces the incidence of peptic ulcer.[20] Additionally, NSAID-related peptic ulcer disease can be safely and efficiently prevented by instituting PPI therapy. Therefore, H pylori eradication should be advisable in patients on chronic NSAID therapy.

It has been shown that curing H pylori infection may provoke reflux esophagitis.[21] Moreover, it has been suggested that H pylori infection may enhance the ability of PPIs to reduce intragastric acidity, and therefore, that patients with H pylori-positive esophagitis heal faster with PPIs than uninfected individuals.[21] Furthermore, rebound acid hypersecretion has been observed in H pylori-negative patients after stopping PPI therapy.[22] Therefore, there is concern that treatment of H pylori in patients with GERD may exacerbate the disease, reduce the ability of PPIs to treat symptoms effectively, and promote rebound acid hypersecretion once the drug is discontinued. However, H pylori eradication does not increase relapse rates in GERD patients, and treating H pylori infection does not dramatically impair the efficacy of PPI therapy.[23] Additionally, patients with H pylori infection are at risk of developing gastric mucosal atrophy, and a cohort study[24] suggested that long-term PPI therapy for GERD may accelerate this process.

Therefore, the decision as to whether H pylori eradication therapy should be offered to infected GERD patients rests on the individual beliefs of clinicians about the risk of developing corpus atrophy and intestinal metaplasia during prolonged acid suppression. In this author's opinion, H pylori-infected GERD patients should be advised to eradicate their H pylori infection.

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