Helicobacter pylori: New Thoughts and Practices

Research and thinking about Helicobacter pylori have recently experienced a paradigm shift. The Kyoto Consensus Conference on H pylori concluded that (a) H pylori gastritis was defined as an infectious disease even when patients have no symptoms and irrespective of complications such as peptic ulcers and gastric cancer, and (b) H pylori– infected individuals should be offered eradication therapy, unless there are competing considerations. H pylori is now recognized as the cause of the vast majority of gastric cancers, one of the major causes of cancer deaths worldwide. Recently, the World Health Organization published an IARC monograph entitled “ H pylori eradication as a strategy for preventing gastric cancer.” Japan approved global H pylori therapy along with a program of surveillance for those at high risk of gastric cancer, and pilot studies of mass H pylori eradication have been started in China, Taiwan, and Europe. The second aspect of the paradigm shift relates to H pylori eradication therapy. Until recently, identification of a new therapy, or study of the usefulness of a therapy in a new region, was largely done using a trial-and-error approach. It became clear that effective H pylori therapy, like that of other bacterial infectious diseases, must be susceptibility-based. The reasons therapy fails include the presence of resistant strains, poor choice of doses and/or duration of therapy, and poor patient adherence. There are a now a number of regimens that will reliably achieve 95% or greater cure rates with susceptible strains. As a general rule, they all contain a double dose of proton pump inhibitors (eg, 40 mg of omeprazole or an equivalent twice a day) and are for 14 days. In most regions, clarithromycin and fluoroquinolone resistance has increased sufficiently that they should no longer be used in empiric triple therapies.

This issue has several general themes. One theme is the modern approaches to the diagnosis and treatment of H pylori infections, which also includes an article on the current and future role of probiotics in therapy and in reducing side effects of current therapies. It remains a paradox that almost every hospital in the world offers culture and susceptibility testing for common infections and yet few extend this service to the culture of H pylori . The recognition of the importance of susceptibility data in choosing effective therapy prompted an article on the molecular approaches to identification of antimicrobial resistance. The article on H pylori diagnosis focuses on the problems the widespread use of proton pump inhibitors causes in the interpretation of currently available tests. There is also an article regarding when it is appropriate to follow up therapy with endoscopy.

There are four articles on H pylori in malignancy, three regarding gastric adenocarcinomas, and one on MALT lymphoma. These include an update on the role of H pylori in the molecular pathogenesis of gastric cancer, stratification of patients with H pylori in relation to risk of gastric cancer, and a discussion of the ground-breaking current Japanese approach to H pylori eradication and the elimination of gastric cancer. Finally, there is an up-to-date discussion of treatment strategies for the management of MALT lymphoma.

The final grouping consists of new information about H pylori in children based on recent experiences in Japan, the rationale for a test-and-treat strategy in patients with GERD, and an update on vaccination to prevent and potentially treat H pylori . Recent success in China with a vaccine strategy shows that vaccination is an option and potentially opens the way to eradication of H pylori in developing countries, where the prevalence of H pylori is high.

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