Gastroesophageal Reflux Disease and Helicobacter pylori Infection

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Gastroesophageal Reflux Disease and Helicobacter
pylori Infection

• By
• Salim A. Itani M.D.
• Beirut-Lebanon

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Helicobacter Pylori

• The discovery of H. pylori in gastric mucosa
  has changed the understanding and management of
  several gastroduodenal
• diseases.

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H.Pylori

• Benefits of the eradication of H. pylori have
  been reported from patients presenting
• Peptic ulcer disease.
• Mucosa associated lymphoid tissue (MALT)
  lymphoma.
• Gastric adenocarcinoma.

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H.Pylori GERD

• However the improvement of symptoms in patients
  with GERD after the eradication of the bacteria
  remains controversial .

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Questions

• 1- Is there any association between GERD and
  H.Pylori infection ?
• 2-What is the reflection of presence of H.Pylori
  infection on GERD ?
• 3-What is the reflection of eradication of
  H.pylori on GERD ?

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H.pylori and GERD a confusing issue?

• Several studies showed a number of controversies
  .
• The role of H. pylori infection in GERD remains
  controversial.

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controversy

• The controversy is important because
• GERD and its complications appear to be
• increasing , whereas H.Pylori is
• decreasing .

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Evidence for an association

• Clinical Studies
• -mostly retrospective and not designed to address
  this relationship
• -did not have effect of eradication on GERD as a
  primary outcome measure.
• -variable results in
• .GERD
• .Esophagitis
• .Barretts

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• No convincing evidence to indicate
• a causal relationship between GERD and
  H.pylori.
• that this organism has a significant
  deleterious effect on any of the major
  pathophysiological factors in GERD.

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STUDY

• In a prospective ,double blind study ,
  ()demonstrates ,using excellent GERD quantifying
  measures including validated symptom severity
  scores, endoscopy, and24hrs PHmetry,that there
  exist NO clinically significant differences in
  clinical or laboratory related GERD
  manifestations between H.Pylori infected and non
  infected GERD patients.
• ()Fallone et al (Aliment.Pharma. Therapy, 20(7)
  (761-768 ),2004)

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Hypothesis

• The previous hypothesis that H. pylori
• infection protects from the development of
• GERD is thought to be an erroneous
• concept recently.

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Factors that influence the outcome of studies of
this relationship

• Prevalence of GERD and H.pylori,
• The pathological severity of GERD at the time of
  presentation and investigation,
• The coexistence of peptic ulceration ,
• And the pathogenicity of the organism.

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Chronic antrum predominant gastritis

• Hypergastrinemia and increased secretion of acid
  leads to gastritis and Duodenal ulcer
• In the presence of GERD ,reflux esophagitis
  becomes more common.
• By treating the D.U. and eradicating H.pylori,
  The acid load in stomach will decrease to Normal
  without a change in the parietal cell sensitivity
  to gastrin.

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Corpus predominant gastritis

• Inverse relationship between the prevalence
  H.pylori ,and that of Barretts esophagus and its
  complications.
• Corpus predominant gastritis, esp. those who are
  cagA positive leads to gastric atrophy and
  hypochlorhydria,thus reducing the esophageal acid
  load and esophagitis.

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CagA

• The presence of the CagA gene in H.pylori has
  been implicated as a marker of more severe
  histological gastritis, CagA association with
  GERD has been evaluated in several studies with
  conflicting results.

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CagA

• There is no evidence that infection with
• cagA strains of H. pylori reduces risk of
• Esophageal gastric cardia
• adenocarcinoma.

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CagA

• Studies confirm the positive association
• between risk of distal gastric cancer and
• infection with H.pylori infection , esp. CagA
• Strains.

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Corpus- predominating gastritis

• Eradication therapy of H.pylori will lead to
  normal acid secretion.
• For GERD patients, there in no evidence that
  eradication exacerbates GERD symptomatology or
  pathology.
• In any event , any exacerbation (esophagitis)
  will be minor and can be dealt with by PPI
  therapy.

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Recommendations

• It has been recommended to eradicate H.pylori
  infection in those patients with GERD needing
  long term treatment with PPIs, as some studies
  have reported that these drugs induce , in
  presence of the organism, atrophic gastritis with
  the consequent risk of gastric cancer.

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Eradication Therapy

• When H.pylori eradication is
• Indicated in a particular patient, the
  concomitant diagnosis of GERD should not change
  our attitude.

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Take Home Message

• There is, indeed, evidence to indicate that
  eradication of H. Pylori benefits the GERD
  patient.

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• THANK YOU