H. pylori should be eradicated before
beginning the treatment with these
drugs. A proton pump inhibitor (PPI)
should also be taken during long term
therapy with NSAID.
5
Maastricht IV Guidelines
A report delivered by experts at the
Maastricht IV/Florence Consensus
Conference included the following
statements
6
for the management of
H. pylori  infection:
•
A test-and-treat strategy is appro-
priate for uninvestigated dyspepsia
in populations where the H. pylori
prevalence is high (
M
20%). This
approach is subject to local cost–
benefit considerations and is not
applicable to patients with alarm
symptoms – weight loss, dysphagia,
GI bleeding, abdominal mass and
iron deficient anaemia.
•
The main non-invasive tests that
can be used for the test-and-treat
strategy are the UBT and mono-
clonal stool antigen tests (Evidence
level: 2a).
•
H. pylori  eradication produces
long-term relief of dyspepsia in one
of 12 patients with H. pylori  and
functional dyspepsia; this is better
than any other treatment (Evidence
level: 1a).
•
On average, H. pylori  status has no
effect on symptom severity, symp-
tom recurrence and treatment ef-
ficacy in GORD (gastro-esophageal
reflux disease) (Evidence level: 1a).
•
Long-term treatment with PPIs in
H. pylori-positive patients is asso-
ciated with the development of a
corpus-predominant gastritis. This
accelerates the process of loss of
specialised glands, leading to
atrophic gastritis (Evidence level: 1c).
•
Eradication of H. pylori  in patients
receiving long-term PPIs heals
gastritis and prevents the progres-
sion to atrophic gastritis (Evidence
level: 1b).
Test and Treatment Strategy
Infected individuals at high risk to de-
velop gastric cancer should undergo
an eradication of H. pylori. These in-
clude:
•
first degree relatives of patients
with a stomach carcinoma. These
individuals have a 2- to 3-fold high-
er risk of developing a carcinoma.
This risk increases to greater than
10-fold if more than one family
member is affected.
•
patients who have undergone pre-
vious treatment for neoplasia.
•
patients with advanced pan-gastri-
tis, and in particular, if the gastritis
primarily affects the corpus and is
accompanied by a severe atrophy.
•
individuals with chronic hydrochlo-
ric acid inhibition >1 year.
•
in cases of high tobacco consump-
tion, or exposure to dust, coal or
cement.
•
patients with a H. pylori  infection
desiring eradication.
In addition to an infection with Helico-
bacter pylori, treatment with non-ster-
oidal anti inflammatory drugs (NSAID)
and aspirin represents an additional,
independent risk for developing a gas-
trointestinal ulcer. A test for H. pylori
is therefore required in cases of long
term treatment with NSAID or aspirin.
2
High Infection Rates in the Population
Type B: Bacterial gastritis with H. pylori infection
3 Phenotypes of H. pylori infection
Mild
Pan-Gastritis
Corpus-dominant
Gastritis
Antrum-dominant
Gastritis
No real disturbance
of stomach physiology
or significant illness
Gastric cancer type
with atrophy and
hypochlorhydria
Duodenal ulcer
type with
hypochlorhydria
Gastric ulcer
(approx. 70–90%)
Gastric carcinoma
(approx. 60–90%)
There is a correlation between H. pylori infection and gastric/duodenal ulcer
and malignant gastric illnesses.
H. pylori colonies
Duodenal ulcer
(80–95%)
H. pylori infection and gastrointestinal illnesses
HP+
HP-
Gastric
lymphoma
Gastric
carcinoma
Gastric
ulcer
1% p.a.
Duodenal ulcer
1 3,4,5,6,7,8