Eradication of Helicobacter pylori in developing countries]

A NIH Consensus Conference recommended Helicobacter pylori eradication to all ulcer patients, based mainly on information coming from countries with a low prevalence of infection in general population. The epidemiological situation is different in developing countries, where a pandemic of H. pylori goes unchecked, and most people become infected at young age. It is possible that response to eradication therapies and reinfection rate were to be included among the differences between developed and developing countries, raising doubts about the worldwide applicability of NIH recommendations. Limited published evidence and our experience suggest that eradication therapies have a lower efficacy and reinfection rate is significantly higher in developing compared to developed countries. In spite of this, the risk of ulcer recurrence after H. pylori eradication is substantially reduced compared to antisecretory therapy. Model analysis to evaluate the cost-effectiveness of H. pylori eradication, using figures that probably include the clinical and costs situation of developing countries, suggests that also from an economic perspective H. pylori eradication should be the standard treatment for peptic ulcer disease in developing countries. Local studies must determine the best eradication therapy for a particular geographical location, and longer follow-up of eradicated patients is needed to determine the true reinfection rate.     

Characterization of the active site of a hydrogen sensor from Alcaligenes eutrophus

BACKGROUND: The Maastricht Consensus Report advises that, in Helicobacter pylori-positive patients after surgery for peptic ulcer disease, H. pylori should be eradicated. The aim of the present study was to investigate the symptomatic response of H. pylori eradication in previously vagotomized peptic ulcer patients with persistent dyspeptic complaints. METHODS: The study was performed as a randomized, double-blind, placebo-controlled study. Pretreatment diagnostic upper endoscopy was omitted. All the results were submitted to intention-to-treat and efficacy analyses. RESULTS: We could not find any differences between the two groups with regard to intensity or frequency of upper abdominal pain, nausea, heartburn, or other abdominal symptoms during the 12-month follow-up. The triple therapy eradication rate was 88% at both 3- and 12-month controls. CONCLUSION: Vagotomized peptic ulcer patients with persistent dyspeptic complaints should undergo a diagnostic upper endoscopy to detect ulcer recurrence before H. pylori eradication treatment is considered.     

High prevalence of Helicobacter pylori in liver cirrhosis: relationship with clinical and endoscopic features and the risk of peptic ulcer

In 153 consecutive patients with cirrhosis we assessed: (1) the prevalence of IgG to Helicobacter pylori and compared it with that found in 1010 blood donors resident in the same area; and (2) the relationships of IgG to Helicobacter pylori with clinical and endoscopic features and with the risk of peptic ulcer. The IgG to Helicobacter pylori prevalence of cirrhotics was significantly higher than in blood donors (76.5% vs 41.8%; P < 0.0005) and was not associated with sex, cirrhosis etiology, Child class, gammaglobulins and hypertensive gastropathy. In both groups, the prevalence of IgG to Helicobacter pylori was significantly higher in subjects over 40. Among patients with cirrhosis a significantly higher prevalence of Helicobacter pylori was found in patients with previous hospital admission (P = 0.02) and/or upper gastrointestinal endoscopy (P = 0.01) and patients with peptic ulcer (P = 0.0004). Multivariate analysis identified increasing age and male sex as risk factors for a positive Helicobacter pylori serology and no independent risk factors for peptic ulcer. The high prevalence of Helicobacter pylori-positive serology found in the present series is related to age and sex and might also be explained by previous hospital admissions and/or upper gastrointestinal endoscopy. Our results do not confirm the role of Helicobacter pylori as risk factor for peptic ulcer in patients with liver cirrhosis.     

Epidemiology of peptic ulcer disease in cirrhotic patients: role of Helicobacter pylori infection

OBJECTIVE: The aim of this study was to investigate the clinical and epidemiological factors associated with the appearance of peptic ulcer in patients with cirrhosis and, in particular, the role of Helicobacter pylori infection. METHODS: A total of 201 of 220 consecutive patients included in a prospective study that aimed to evaluate the effect of dietary intervention on cirrhotic complications and survival underwent upper gastrointestinal endoscopy. At entry, an epidemiological and clinical questionnaire was completed and the presence of peptic ulcer disease or esophageal varices at endoscopy was prospectively collected. Sera were obtained and stored at -70 degrees C until analyzed, being tested afterward for Helicobacter pylori antibodies using a commercial ELISA kit. RESULTS: Eleven of 201 patients had borderline anti-Helicobacter pylori IgG titers and were excluded from further analysis. In the remaining 190 patients, point prevalence of peptic ulcer was 10.5% and lifetime prevalence 24.7%. Multivariate analysis selected male sex (OR 2.3; 95%CI 1.09-4.89) and Helicobacter pylori seropositivity (OR: 1.7, 95%CI 1.02-2.81) as the variables independently related to peptic ulcer disease. CONCLUSIONS: Male sex and seropositivity for Helicobacter pylori are the major risk factors for peptic ulcer in cirrhosis.     

Ether extract of fetal calf serum protects cultured rat cortical neurons against glutamate cytotoxicity

OBJECTIVE: To elucidate the role of Helicobacter pylori in relapsing disease after partial gastrectomy for peptic ulcer. DESIGN: Retrospective study of gastroscopies between January 1985 and February 1988. SETTING: Department of Surgery, Helsinki University Central Hospital, Finland. PARTICIPANTS: One hundred and fifty-five patients, who had undergone partial gastrectomy for peptic ulcer disease. MAIN OUTCOME MEASURES: Correlation between clinical and laboratory data, macroscopic findings at gastroscopy and histopathology. RESULTS: At gastroscopy 41 patients showed an ulcer at the site of anastomosis or in the gastric stump and two patients had a history of a previous ulcer recurrence. The median time interval between operation and relapse was 4 years. There was no correlation between ulcer recurrence, sex, age, ABO blood group or other diseases. Smokers and patients using non-steroidal anti-inflammatory drugs (NSAIDs) or alcohol had more relapses, but the difference was not significant. The recurrence rate was higher after Billroth II (BII; 34%) than after Roux-en-Y (14%; P = 0.03) or Billroth I (BI) reconstruction (24%). Giemsa staining demonstrated H. pylori in the gastric stump of 37% of the patients. H. pylori expression was related to age but unrelated to sex, ABO blood group, NSAID use, smoking or alcohol consumption. H. pylori positivity was more common (52%) after BI than after BII (28%; P = 0.04) or Roux-en-Y resection (40%). Recurrent ulcer was more often found in gastric remnants with normal mucosa (36%) than in those with H. pylori-positive gastritis (18%; P = 0.03) or H. pylori-negative gastritis (26%). CONCLUSION: It seems that H. pylori infection plays a minor role in the pathogenesis of ulcer recurrence after partial gastrectomy for peptic ulcer disease. Eradication of H. pylori of the remnant stomach is therefore presumably not effective in preventing ulcer recurrence.     

Prospects for the development of a vaccine against Helicobacter pylori

Over 50% of the world population is chronically infected by the gastric pathogen, Helicobacter pylori, which is responsible for most peptic ulcer disease and is closely associated with adenocarcinoma of the stomach. Current therapies for peptic ulcer disease include antibiotic eradication of H. pylori infection. While effective, the high cost, difficulty of patient compliance with the treatment regimens, and risks of selection for resistant strains make these therapies impractical on a large scale. Studies of the pathogenesis of H. pylori have led to the identification of bacterial antigens as candidates for inclusion in novel vaccines against this disease. Both prophylactic and therapeutic vaccination have been demonstrated in animal models of Helicobacter infection. Preclinical evaluations of several antigens are at present under way and trials of vaccination in humans are planned.     

Racial differences in Helicobacter pylori seroprevalence in Singapore: correlation with differences in peptic ulcer frequency

The aim of this study was to determine, first, whether racial differences exist in the seroprevalence of Helicobacter pylori infection in Singapore, and second, whether these differences correlate with racial differences in peptic ulcer frequency. A commercial serological test for immunoglobulin (Ig)G antibody to H. pylori which was 90% sensitive and 83% specific in our population was used to screen 403 adult blood donors of Chinese, Malay and Indian origin, aged between 15-60 years. Serum specimens from 84 paediatric patients admitted to the Paediatrics Department, National University of Singapore, with non-gastroenterological illnesses were also tested. In all three races, seroprevalence of H. pylori increased with age. Indians have the highest prevalence of infection followed by Chinese and Malays. Peptic ulcer prevalences are known to be highest in Chinese, followed by Indians and Malays. The Malays have the lowest prevalence of H. pylori and peptic ulcer among the three races in Singapore. Indians have a higher prevalence of H. pylori antibodies but a lower frequency of peptic ulcer than the Chinese. Racial differences in peptic ulcer frequency between Chinese and Indians are not explained by the prevalence of H. pylori infection; other environmental or genetic factors may be involved.     

Isolation and characterization of Helicobacter pylori strains from peptic ulcer patients in Dhaka, Bangladesh

To study the association of Helicobacter pylori with peptic ulcer and the associated histopathological changes, to characterize the isolated strains in terms of their protein profile, 83 peptic ulcer cases were studied. A high association of H pylori with peptic ulcer (duodenal ulcer 77%, gastric ulcer 75%) and gastritis (74%) was observed. Age and smoking did not have any relationship with H pylori infection. The infection was predominantly associated with the 'quiescent' form of chronic gastritis. Comparative sodium dodecyl sulfate polyacrylamide gel electrophoresis of whole cell extracts of the local isolates and a reference strain from Australia showed a general homogeneity between the strains with obvious interstrain differences. However, the difference between the local isolates and the reference strain was more marked. Significant association of H. pylori with peptic ulcer along with strain variations were observed.     

Helicobacter pylori CagA antigen antibodies

BACKGROUND: CagA antigen of Helicobacter pylori is highly immunogenic in humans. There is an increasing evidence that infection with CagA-positive strains is related to the development of peptic ulcer disease, atrophic gastritis, or gastric cancer. The aim of our study was to assess seropositivity to CagA in a group of 95 clinically symptomatic adults who underwent gastroduodenoscopy and to correlate results to their disease characteristics. METHODS AND RESULTS: Serum immunoglobulin G antibodies to CagA detected by ELISA kit (Helicobacter p120, Viva Diagnostika, Germany) were compared to standard IgG specific antibodies against a pool of H. pylori antigens Synelisa Pin plate, ELIAS, Germany). Immunoglobulin G antibodies to CagA were present in 5/31 (16%) serum samples from H. pylori negative persons and 10/28 (36%) serum samples from H. pylori positive patients without peptic ulcer disease compared with 8/11 (73%) H. pylori positive patients with peptic ulcer disease in the past, 11/13 (85%) H. pylori positive patients with duodenal ulcers or duodenitis and 4/5 (80%) H. pylori positive (1/7, 14% H. pylori negative) serum samples from patients with gastric resection for peptic ulcers in the past. Serum levels of antibodies to CagA in the groups of patients with peptic ulcer disease in the past, with present duodenal ulcers of duodenitis and in H. pylori infected patients with gastric resection were significantly higher then those of H. pylori infected patients without peptic ulcer disease (P < 0.05). On the other hand, there was no significant difference in the presence of the specific antibodies against at pool of H. pylori antigens between these four groups. CONCLUSIONS: These data suggest that serologic response to the CagA antigen is more prevalent in H. pylori positive persons with present or past peptic ulceration than among infected persons without peptic ulcer disease. The presence of antibodies to CagA in H. pylori positive persons may be useful for the identification of patients with higher risk or more severe disease.     

Beneficial effects of Helicobacter pylori eradication on migraine

BACKGROUND/AIMS: Migraine is a commonly unilateral throbbing headache, which has been associated with disorders of the vascular tone. Helicobacter pylori, the most relevant cause of gastritis and peptic ulcer, has been recently associated with a typical functional vascular disorder such as primary Raynaud phenomenon. The aim of this study was to assess the prevalence of H. pylori for patients affected by migraine and the effects of H. pylori eradication on migraine symptoms. METHODOLOGY: Two-hundred and twenty-five patients were consecutively enrolled between October 1996 and January 1997. H. pylori was assessed by 13C-urea breath test. Infected subjects were eradicated of the bacterium; frequency, intensity and duration of attacks of migraine were assessed during a 6 month follow-up period. RESULTS: H. pylori was detected in 40% of the patients. Eighty-three percent of the patients who underwent therapy were eradicated. Intensity, duration and frequency of attacks of migraine were significantly reduced in all eradicated patients. CONCLUSIONS: H. pylori is common in subjects with migraine. Bacterium eradication causes a significant decrease in attacks of migraine. The reduction of vasoactive substances produced during infection may be the pathogenetic mechanism underlying the phenomenon.     

The impact of Helicobacter pylori eradication on peptic ulcer healing

OBJECTIVE: Current literature was reviewed analyzing the outcome of peptic ulcer healing in relation to the results of the posttherapeutic Helicobacter pylori (HP) status. METHODS: Literature was reviewed along with an analysis of 60 studies, comprising a total of 4329 patients. RESULTS: Successful Helicobacter pylori eradication was found to induce a better response in peptic ulcer healing, regardless of diagnosis: gastric ulcer 88% vs 73% (odds ratio [OR] 2.7, p < 0.01), duodenal ulcer 95% vs 76% (OR 5.6, p < 0.0001), and peptic ulcer 95% vs 76% (OR 6.6, p < 0.0001), for patients having their HP infection successfully cured versus those remaining HP-positive, respectively (Fisher's exact test). For all evaluated time points (< or = 6, 7-8, and 10-12 wk after beginning treatment), HP-negative patients had higher healing rates than HP-positive patients (95% vs 82%, 94% vs 69%, and 96% vs 78% with corresponding OR of 4.2, 6.5, and 7.4, all p < 0.0001, Fisher's exact test). The use of concomitant acid suppression therapy during initial HP eradication provided a benefit on peptic ulcer healing only for patients with persistent HP infection (improved healing rates of 78% vs 67%; otherwise rates were 94-96%). Likewise, prolonged acid inhibition in HP treatment failures after the initial HP treatment phase resulted in 7-20% improved healing rates, whereas patients becoming HP-negative did not profit. CONCLUSION: Successful HP eradication therapy accelerates peptic ulcer healing even without concomitant acid suppression.     

Diseases of the upper segment of the gastrointestinal tract and Helicobacter pylori infection

Helicobacter pylori infection is the most frequent infection in humans. It is assumed that over 50% of total world population suffer from this infection. Chronic gastritis is the most usual consequence of this infection. Development of peptic ulcer appears in case of 10 to 20 percent of infected people with the increased risk of malignancy. In the group of 819 examined patients at the Clinic for gastroenterology and hepatology of the Institute for internal diseases, the presence of helicobacter pylori was confirmed in case of 69.18% of patients. The infection was equally observed in both sexes and its frequency was higher with the increase of age, reaching its peak in the sixth decade of life (75.24%). The highest frequency was found in patients with duodenal ulcer (84.85%) and hyperplastic stomach polyp (81.82%) and lowest in case of resected stomach (56.52%). We also establish the dependence of the type and degree of pathohistological changes and the Helicobacter pylori infection.     

Survey on Helicobacter pylori and peptic ulcer in Spain

OBJECTIVE: The goal of this study is to determine, through a national survey, the degree of acceptance among gastroenterologists of the relationship between Helicobacter pylori and peptic ulcer, and how they manage their patients according to this association. STUDY DESIGN: An observational study through a self-administered questionnaire. PARTICIPANTS: The questionnaire was distributed to 690 gastroenterologists from all over Spain. The questionnaire was answered by 687 specialists. RESULTS: Most (98.1%) Spanish specialists accept the relationship, 1.5% are reluctant, and 0.3% are irresolute. Eradication treatments are prescribed by 96.4% of the gastroenterologists, mainly omeprazole+amoxicillin, in 1994, though only 40.8% of gastroenterologists always prescribe it for H. pylori positive peptic ulcer. A control of the effectiveness of the treatment is undertaken by 84.3% of gastroenterologists. CONCLUSIONS: The relationship between H. pylori and ulcer is accepted by Spanish gastroenterologists, as well as eradication therapy.     

Preparation of yttrium-90-labeled human macroaggregated albumin for regional radiotherapy

Helicobacter pylori and non-steroidal anti-inflammatory drugs are two of the most common causes of peptic ulceration. The aim of this review is to assess the possible inter-relationships between Helicobacter pylori and non-steroidal anti-inflammatory drugs in the pathogenesis of gastric and duodenal erosions and ulcers, with the aim of assessing if the presence of Helicobacter pylori is likely to increase the likelihood of non-steroidal anti-inflammatory drug-related gastroduodenal symptoms and lesions, and if eradication of Helicobacter pylori may reduce or prevent non-steroidal anti-inflammatory drug lesions. There appears to be more likelihood of dyspeptic symptoms in patients on long-term non-steroidal anti-inflammatory drugs when Helicobacter pylori is present. The balance of evidence also suggests that peptic ulcers and erosions in patients on long-term non-steroidal anti-inflammatory drugs may be more likely to occur in patients who are Helicobacter pylori positive compared to those who are Helicobacter pylori negative. Although Helicobacter pylori and non-steroidal anti-inflammatory drugs both increase the risk of peptic ulcer bleeding, the risk does not appear to be additive. There is increasing evidence from prospective studies that eradication of Helicobacter pylori may reduce the incidence of ulcers in patients on non-steroidal anti-inflammatory drugs. More prospective long-term studies are required. If Helicobacter pylori is confirmed to be a factor in this respect, it will aid in the targeting of patients at greatest risk of developing ulcers in patients on long-term non-steroidal anti-inflammatory drugs. Those at greatest risk are elderly patients, especially females, smokers, patients with a previous ulcer history, severe or debilitating arthritis or who have other chronic diseases. The addition of Helicobacter pylori to this list and its subsequent eradication may improve the outlook for these patients and help in the effective targeting of patients at greatest risk who are on long-term non-steroidal anti-inflammatory drugs.     

Treatment of Helicobacter pylori infection

Since acceptance of the association between Helicobacter pylori and peptic ulcer disease, eradication of H. pylori has become the standard of care in the treatment of peptic ulcer disease. Unfortunately, eradication therapy is no easy task, especially when one is faced with a myriad of drug combinations with varying degrees of efficacy and tolerability. The following is a review of the literature regarding the drugs and drug combinations used to eradicate H. pylori and their effectiveness both as single agents and in combination.     

Effectiveness of an ambulatory care clinical pharmacist: a controlled trial

Medical therapy for duodenal or gastric ulcer disease has traditionally involved gastric acid antisecretory therapy for 4 to 8 weeks to promote initial healing and indefinitely to prevent recurrences of ulcer. The discovery of Helicobacter pylori in most patients with peptic ulcer disease has led to a change in this approach. Therapy designed to eradicate H pylori may facilitate ulcer healing with acid antisecretory agents and, more important, may greatly reduce the incidence of ulcer recurrence, obviating the need for maintenance antisecretory therapy. Regimens designed to eradicate H pylori are difficult to comply with, however, and are associated with adverse effects in some patients. In this article we review the diagnosis and treatment of H pylori infection in patients with peptic ulcer disease and make recommendations regarding the use of conventional ulcer therapies and therapies designed to eradicate H pylori.     

Helicobacter pylori in 1997

In this review Helicobacter pylori (H. pylori) infection and its relation to different diseases is presented. H. pylori doesn't cause inconvenience to most infected people, though all infected persons have chronic active gastritis. The 10 year risk of peptic ulcer for people infected with H. pylori is about 10%. Randomized double-blinded trials have shown that eradication of H. pylori can cure most patients with peptic ulcer disease. Some people infected with H. pylori develop atrophic gastritis which is a risk factor for development of gastric cancer. It is not known if H. pylori screening and eradication would have a prophylactic effect against gastric cancer. It is also unknown if persons with non-organic dyspepsia and persons in long-term treatment with proton-pump-inhibitors would benefit from H. pylori eradication.     

The impact of peptic ulcer disease and infection with Helicobacter pylori on life expectancy

OBJECTIVE: Knowledge about the influence of H. pylori-related disease on life expectancy might affect physician behavior in dealing with such disease. The aim of this study was to assess how life expectancy is influenced by H. pylori infection and peptic ulcer disease. METHODS: The declining exponential approximation of life expectancy was used to model the effects of H. pylori and various peptic ulcer disease conditions on life expectancy. Deaths from peptic ulcer and gastric cancer were determined from the Vital Statistics of the United States. H. pylori prevalence rates were derived from the existing literature. RESULTS: Cure of active peptic ulcer increases life expectancy by 2.3 yr in persons aged 40-44 yr and 121 days in persons aged 70-74 yr. More substantial impact occurs in complicated ulcer, with increases in life expectancy ranging between 26.1 and 6.3 yr. Primary prevention of H. pylori could increase life expectancy by 190 days in those aged 40-44 yr and 26 days in 70-74-yr-old subjects. CONCLUSION: The benefit of ulcer cure or H. pylori prevention diminishes as age advances. Cure of ulcers in young patients or in those who have sustained complications results in an appreciable increase in life expectancy. Successful primary prevention of H. pylori in selected populations could substantially increase life expectancy.     

Rapid recurrence of Helicobacter pylori infection in Peruvian patients after successful eradication. Gastrointestinal Physiology Working Group of the Universidad Peruana Cayetano Heredia and The Johns Hopkins University

Helicobacter pylori is associated with gastritis, peptic ulcer disease, and gastric cancer. Since gastric cancer is common in Peru, eradication of H. pylori may help to reduce the occurrence of gastric cancer. This study involved three randomized trials to determine the efficacy of four different triple-drug therapy regimens. The most successful regimen was furazolidone combined with bismuth subsalicylate and amoxicillin, which eradicated infection in 82% of patients. Patients successfully treated were followed every 2-3 months to determine the recurrence rate of H. pylori infection. Of 105 patients with H. pylori eradication documented by pathology and culture, 52% (55) returned for follow-up endoscopy, and in 73% (40) of these 55 the infection recurred during the 8-month follow-up period. Thirty-five patients from whom H. pylori was eradicated and who were tested for antibodies to H. pylori remained consistently seropositive. Rapid recurrence of H. pylori infection after successful eradication suggests that measures other than antimicrobial therapy are needed to fight H. pylori in developing countries.