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Helicobacter pylori: Diagnosis, treatment and risks of untreated infection
bB
Klaus MönkemüllerDepartment of Gastroenterology, Hepatology
und Infectius DiseasesOtto-von-Guericke University, Magdeburg
InvasiveInvasive Non invasiveNon invasive
Rapid urease testRapid urease test 1313C/C/1414CC--breath testbreath test
HistologyHistology Stool antigenStool antigen
MicrobiologyMicrobiology SerologySerology (serum(serum, , blood)blood)
(FISH, PCR)(FISH, PCR) (Urine)(Urine)
Helicobacter pylori Diagnosis
Rapid urease testRapid urease test
•• SensitivitySensitivity / / SpecificitySpecificity > 90%> 90%
•• One biopsy from each antrumOne biopsy from each antrum & &
corpuscorpus
•• Cost effectiveCost effective
LabenzLabenz et al. Digestion 1999et al. Digestion 1999Malfertheiner et al. Malfertheiner et al. EurEur J J GastroentereolGastroentereol Hepatol 1996Hepatol 1996
Helicobacter pylori Diagnosis
Maastricht 3-2005
Level of Evidence: 2 Grade of Recommendation: A
Statement:In patients presenting for endoscopy without pre-treatment, a positive RUT is sufficient to initiate a therapy.
95,7
4,30
25
50
75
100
I agree I don't agreeValues in percentage
Urea breath test 13CO²
13C-labeled urea
urease
ammonia 13CO²13CO²
Urea blood test
PPI decrease sensitivity of UBT for detection of H. pylori
• 13C-UBT turned negative in 50% of patients after 5 days therapy with 80 mg of Omeprazole
• Stoschus B et al. Eur J Gastroenterol 1996
• Mechanism: unknown– Inhibits Hp growth– Reduces the concentration of bacteria– Decreased urea entrance into bacteria
• Available UBT and stool Ag tests become reliable only 2-6 weeks after stopping antibiotics + PPIs
.
False negative due to PPI is dependent on PPI
• 179 patients• PPI x 14 days, then UBT
– (high dosage citric acid 4 gm)False negatives
Omeprazole 20m g/d 4.1%Pantoprazole 40 mg /d 2.2%Lansoprazole 30 mg/d 16.6%Esomperazole 40 mg/d 13.6%
.Levine et al APT 2005
50%55%60%65%70%75%80%85%90%95%
100%
FemtoLabH. pylori
Cnx
PremierPlatinum
HpSA
UreaBreathTest
Serology
SensitivitySpecificity
Malfertheiner et al. Gut 2001
European European MulticenterMulticenter Study to compare various nonStudy to compare various non--invasive invasive methods for the diagnosis of methods for the diagnosis of H. pyloriH. pylori
Helicobacter pylori Diagnosis
Maastricht 3-2005
Level of Evidence: 1 Grade of Recommendation: B
Question: Which are the non-invasive tests to be used in the test and treat strategy?
Statement:
The non-invasive tests that can be used for the test and treat
strategy are UBT and the stool antigen tests. Certain kits for
serology with high accuracy can also be applied.
76,2
23,8
0
25
50
75
100
I agree I don't agreeValues in percentage
Maastricht 3-2005
Level of Evidence: 1 Grade of Recommendation: A
Statement:PPI is a source of false negative diagnostic tests except serology. PPI should be stopped for at least 2 weeksbefore performing the diagnostic test.
92,9
7,1
0
25
50
75
100
I agree I don't agreeValues in percentage
Evaluation of Evaluation of eradicationeradication
–– 1313CC--breath test breath test –– Stool antigenStool antigen--test test
94 9794
100
80
85
90
95
100
%
HpSA 13C-UBT
Sensitvity Specificity
Vaira et al. Ann Intern Med 2002
Helicobacter pylori Diagnosis
Maastricht 3-2005
Level of Evidence: 1b Grade of Recommendation: A
Statement:It is recommended to follow up patients after H. pylori eradication with UBT if available. If not available a laboratory-based stool test, preferably using monoclonalantibodies, could be used.
83,7
16,3
0
25
50
75
100
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Maastricht 3-2005
• PPI Clarithromycin Amoxycillin2 x Stand. 2 x 500 mg 2 x1000 mg
(if clarithromycin resistance < 15%)
• PPI Clarithromycin Metronidazol2 x Stand. 2 x 500 mg 2 x 400 mg
(if metronidazole resistance , 40%)
• Bismuth based Quadruple Therapies
First line options
Duration of therapy: at least 7 days, max. 14 days
Primary clarithromycin resistance in Europe
% RESISTANCERESISTANCEMACH2 MACH2
Sweden, 1997 2.7Finland, 2004 2.0U.K., 2001-2004 4.4 - 7Ireland, 1996 4.5Germany, 1998-2001 2.0 - 4.9Belgium, 1992-1997 1.7 - 10.5France, 1997-2000 2.0 - 11.0Italy, 2000-2003 1.8 - 23.4 Spain, 1998 - 2000 5.7 - 6.2Bulgaria, 2004 11.9
Expected Eradication rates of PPI-CA and PPI -CM according to resistance rate to
Clarithromycin (C) and Metronidazole (M)
0
10
20
30
40
50
60
70
80
90
100
10 20 30 40 50
PPsCAPPsCM(M resistance 30%)PPsCM (M resistance 20%)PPsCM (M resistance 10%)
Megraud F. Current Infectious Disease Reports 2005
C resistance (%)
Era
dica
tion
(%)
Resistance acording to underlying diesease
0
5
10
15
20
25
30
35
%
Ulcer Gastritis Normal mucosa
MZ CLA MZ+CLA CIP
Patients not previously treated
Resinet, Professor Manfred Kist, Freiburg, Germany, Dec 2006
Smoking increases the therapeutic failure of H. pylori eradication
• Meta-Analysis: 22 Studies, 5538 patients• OR eradication failure: smoker versus
non-smoker: 1.95 (p<0.01)• Difference of eradication rates: 8.4%
Suzuki T et al. Am J Med 2006;119:217-24
Maastricht 3-2005
Level of Evidence: Grade of Recommendation:
Question: What is the recommended first line treatment?
Statement:•PPI – clarithromycin amoxicillin or metronidazole therapy remains the recommended first line therapy in populations with less than 15-20% clarithromycin resistance prevalence. In population with less than 40% metronidazole resistance prevalence PPI – clari – metro is preferable•Quadruple therapies are alternative first line therapies
94,6
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Efficacy of short and long therapiesfor H.pylori infection
6%10-14 vs 7Quadruple
2%14 vs 10
3%10 vs 7
9% - 12%14 vs 7
Triple
Increase in cure rateDuration (days)Therapy
Calvet X et al. APT 2000;14:603-9Fishbach LA et al APT 2004;20:1071-82
Ford A. et al. Can J Gastroenterol 2003; 17: 36-40
CYP2C19 Polymorphisms
0102030405060708090
100
Eradication PPI level
mt/mtmt/wtwt/wt
Schwab et al Clin Pharmacol Ther 2004
Maastricht 3-2005
Evidence: 2 Grade of Recommendation: B
Results (%)
Question: Which one is the second line therapy of choice?
Statement:• Wismut-based quadruple therapies remain the bestsecond line therapy, if available. If not PPI amoxicillinor tetracyclin and metronidazole are recommended
90.2
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0
25
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I agree I don't agree
PPI, PPI, RifabutinRifabutin and and LevofloxacinLevofloxacin versus Quadruple versus Quadruple Therapy as Second Line TreatmentTherapy as Second Line Treatment
PPI,LRPPI,LR
Erad
icat
ion
rate
(%)
Erad
icat
ion
rate
(%)
PPI,BMTPPI,BMT
Wong, Aliment Wong, Aliment PharmacolPharmacol TherTher 2003, 17: 5532003, 17: 553--560560
0
20
40
60
80
100ITTITTPPPP
Reserve therapies (1)
1. PPI-AM-Therapy („Englishe Therapy“) (14 days)
PPI 2 x SD/Amoxicillin 2x1g/Metronidazol 2x400mg
2. High dose-dual therapy (14 days)PPI (3x SD), Amoxicillin 3x1g
3. Rifabutin-based therapy (7 days)PPI 2 x SD/Amoxicillin 2 x 1g/Rifabutin 2 x 150mg
4. Bismuth-based quadruplePPI-Standard dosage + Bismutsubcitrat (2 x 240 mg) Tetrazyclin (4 x 500 mg) + metronidazol ( 4 x 500 mg) or furazolidone* (2 x 200 mg) x 7 - 14 days
5. Gyrase inhibitor &Amoxicillin (7 days)PPI 2 x SD/Amoxicillin 2 x 1g/Levofloxacin 1 x 500 mg or Moxifloxacin 1 x 400 mg
6. Rifabutin & gyrase inhbitor (if Penicillin-Allergy)( 7 days)
PPI 2 x SD/Rifabutin 2 x 150mg/ 1 x 500 mg orMoxifloxacin 1 x 400 mg
Reserve therapies (2)
Maastricht 3-2005
Level of Evidence: 2c Grade of Recommendation: B
Statement:The rescue therapy should be based on
antimicrobial suseptibility testing
92,7
7,3
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Development of Peptic Ulcer in NUD Patients
Placebo EradicationTherapy
Blum 4.0 % 0.6 %
Talley 5.0 % 0.2 %
Hsu 7.5 % 2.5 %
McColl 2.0 % 0 %Cochrane Library 2005
H. pylori H. pylori and and gastric cancergastric cancer
HpHp--AgAg
ILIL--8; 8; IL1IL1ββ
Macrophages
TT--helper helper cellscells
PMN
UreaseUreaseLPSLPS
CytotoxinCytotoxinVacAVacACagACagA
NONO
ROSROSIL1IL1ββ
↓ H+
↑ Atrophy
El Omar 2000El Omar 2000
Gastrin Gastrin ↑↑
SomatostatinSomatostatin ↓↓
Effects on gastric physiologyEffects on gastric physiology
H. pylori infection and gastric cancer: A prospective endoscopy study
•1526 patients with NUD, DU, GU or gastric hyperplasia (GH)
•Endoscopy: enrollment and every 1-3 years
•No antibiotic treatment
•Mean follow-up: 7.8 years
Uemura et al, N Engl J Med 2001; 345:784
Hp- Hp+ NUD GU GH DU 0
2.9
4.7
3.4
2.2
00
1
2
3
4
5Incidence of gastric cancer (%)
H. pylori Infection und stomach CAA prospective endoscopic studyUemuraUemura et al. N Eng J Med 2001et al. N Eng J Med 2001
Gastric Histology and cancer in non-ulcer dyspepsia
6.4 (2.6,16.1)6.5%464Intestinal metaplasia
4.9 (2.8-19.2)7.2%208Atrophy severe
1.7 (0.8-3.7)2.7%657Atrophy moderate
Relative risk
HP+ with gastric cancer n=36
NBaseline
Uemura N. New Engl J Med 2001;345:784-9
Impact of H. pylori infection on gastric cancer incidence
0
1
2
3
4
5
6
Hp+ Hp-
MaleFemale
731 Hp-
1171 Hp+Follow-up: 9 years
Relative risk of CA: 2.59 Yamagata Arch Int Med 2000
Maastricht 3-2005
Statement: H. pylori infection is the most common proven risk
factor for human non-cardia gastric cancer.
Level of Evidence: n.a. Grade of Recommendation: A
97,7
2,30
25
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75
100
I agree I don't agreeValues in percentage
H. pylori, NSAID use, and risk of peptic ulcer disease: Meta-analysis of 5 case control
studies
Huang et al, Lancet 2002; 359:14-22
49.2
OR=2.8
OR=16.5
26OR=5.7
H. pylori -positive
5.5
0
80
Peptic ulcer (%)
n = 307 308 344 242
H. pylori -negative
Non-NSAID takers
25
NSAID takers
OR=5.99
Maastricht 3-2005
Level of Evidence : 1b Grade of Recommendation: A
Statement:H. pylori eradication is of value in chronic NSAID users but is insufficient to completely prevent NSAID-related ulcer disease
90,5
9,5
0
25
50
75
100
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H. pylori und drug use; NSAIDs (and Cox2-Inhibitors)
Maastricht 3-2005
Level of Evidence: 1b Grade of Recommendation: A
Statement:Patients who are on long-term aspirin who bleed should be tested for H. pylori, and if positive receive eradication therapy.
H. pylori and drugs (aspirin)
93,5
6,5
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Conclusions
• Best tests for the diagnosis of H. pylori: RUT, UBT, antigen stool test
• Triple therapy remains standard eradication strategy– Choose regimen based on resistance patterns in your area– 14 days increase eradication rates but are not cost-effective– Smoking decreases eradication rates
• Rescue therapies ( > 2) should be based on susceptibility testing (antibiogram)
• Untreated H. pylori infection will lead (varying %) to peptic ulcer, atrophic gastritis, intestinal metaplasia, gastric cancer, etc.