Discriminant analysis of factors distinguishing patients with functional dyspepsia from patients with duodenal ulcer

Patients with duodenal ulcer or functional dyspepsia do not differ on dyspeptic symptoms. The aim of the present study was to test the hypothesis that functional dyspepsia and duodenal ulcer are two different diagnostic entities by examining the discriminating power of several anamnestic, biological, and psychosocial variables. Ninety-four patients with duodenal ulcer and 86 patients with functional dyspepsia were included. Anamnestic data, global assessment,Helicobacter pylori status, blood group, Lewis^a+ phenotype, and several measures of psychological distress and somatic complaints were registered. Compared to patients with functional dyspepsia, the duodenal ulcer patients were more often infected byHelicobacter pylori and had their stomach discomfort more often relieved by eating. Compared to patients with duodenal ulcer, patients with functional dyspepsia had higher scores of depression, trait anxiety, general psychopathology and different somatic complaints (called somatization). They were also less satisfied with the health care system, their disorder had a greater negative impact on their quality of life, and their global assessment of own health was poorer. Discriminant analysis including age, smoking,Helicobacter pylori status, global assessment, and somatic complaint classified 86.1% of the patients correctly (77.9% of the patients with functional dyspepsia and 93.6% of the patients with duodenal ulcer). It is concluded that duodenal ulcer and functional dyspepsia are two separate diagnostic entities. Patients with duodenal ulcer are older, smoke more often, and almost all are infected withHelicobacter pylori, while patients with functional dyspepsia are characterized by somatization and a negative assessment of their own health.     

<Emphasis Type="Italic">Helicobacter pylori</Emphasis> infection status had no influence on upper gastrointestinal symptoms: a cross-sectional analysis of 3,005 Japanese subjects without upper gastrointestinal lesions undergoing medical health checkups

Background

This study aimed to evaluate the influence of Helicobacter pylori infection and its eradication on the upper gastrointestinal symptoms of relatively healthy Japanese subjects.

Methods

A total of 3,005 subjects (male/female: 1,549/1,456) undergoing medical health checkups were enrolled in the present study, at five hospitals in Saga, Japan, from January to December 2013. They had no significant findings following upper gastrointestinal endoscopy. All subjects completed a questionnaire that addressed a frequency scale for symptoms of gastroesophageal reflux disease. The questionnaire comprised seven questions regarding reflux symptoms and seven regarding acid-related dyspepsia, which were answered with a score based on the frequency of symptoms. Helicobacter pylori infection was identified by a rapid urease test and/or H. pylori antibody titer, and an eradication history was confirmed by the subjects’ medical records.

Results

Helicobacter pylori infection was positive in 894 subjects out of 3,005 (29.8%). Eradication of Helicobacter pylori was successfully achieved in 440 subjects of 458 treated. Helicobacter pylori infection had no influence on the acid-related dyspepsia evaluated by the questionnaire, whereas the mean reflux score was relatively high in the Helicobacter pylori native negative subjects compared to Helicobacter pylori native positive. Eradication of Helicobacter pylori and time span after the eradication had no effect on the upper gastrointestinal symptoms evaluated by the questionnaire.

Conclusion

Helicobacter pylori infection and history of eradication did not affect acid-related dyspepsia symptoms in Japanese healthy subjects.

     

Gastric accommodation in non-ulcer dyspepsia and the roles of Helicobacter pylori infection and vagal function

Background—Thepathophysiological mechanisms in non-ulcer dyspepsia are incompletely understood.
Aims—To compare gastric motor andsensory functions in Helicobacter pyloripositive or negative patients with non-ulcer dyspepsia.
Patients—Seventeen patients withnon-ulcer dyspepsia and 16 asymptomatic controls.
Methods—The following wereevaluated: gastrointestinal symptoms; gastric emptying and orocaecaltransit of solids; abdominal vagal function; gastric compliance;fasting and postprandial gastric tone and phasic contractions; symptomsduring ingestion of cold water and during the distension of anintragastric bag; and somatic sensitivity and personality profile(Minnesota Multiphasic Personality Inventory, MMPI).
Results—Gastric accommodation wasreduced in H pylori negative dyspepticsrelative to controls; the degree of accommodation was unrelated toH pylori status in dyspeptics. Increasedpostprandial gastric sensation was more frequent amongH pylori positive patients (4/5H pylori positive versus 4/12H pylori negative patients). Intragastricmeal distribution and orocaecal transit were normal; gastric emptyingat four hours was abnormal in 4/17 patients. Vagal dysfunction wasrare. Eight of 17 patients had somatisation or depression on MMPI.
Conclusion—Impaired gastricaccommodation is frequent in non-ulcer dyspepsia and seems to beunrelated to vagal efferent dysfunction. Hpylori infection does not seem to influence gastric accommodation, but is associated with heightened sensitivity in dyspeptics. Therapeutic approaches that restore normal postprandial accommodation and gastric sensitivity should be tested in non-ulcer dyspepsia.

Keywords:non-ulcer dyspepsia; Helicobacter pylori; vagal function

     

Assessment of symptomatic response as predictor of Helicobacter pylori status following eradication therapy in patients with ulcer

Background—Helicobacter pylorieradication therapy is routinely used for treating patients with pepticulcer disease.
Aims—To assess the value of symptomatic responseto H pylori eradication therapy as a marker ofpost-treatment H pylori status.
Patients and methods—One hundred and ninedyspeptic patients with active duodenal or gastric ulcerationassociated with H pylori infection had their symptomsmeasured by a validated questionnaire before and three months followingH pylori eradication therapy. The symptomatic response wascompared with post-treatment H pylori status as determinedby the ¹⁴C urea breath test.
Results—An eradication rate of 84% was achieved.Of the 92 patients eradicated of H pylori, 47%experienced complete or near complete resolution of dyspepsia. Of the17 patients in whom the infection was not eradicated, only one (6%)experienced resolution of dyspepsia. Resolution of dyspepsia wastherefore a powerful predictor of eradication of H pyloriwith a predictive value of 98%. In contrast, persistence of dyspepsiawas a weak predictor of persisting infection with a predictive value ofonly 25%. Excluding patients with endoscopic evidence of coexistingoesophagitis and/or retrosternal discomfort or reflux at initialpresentation did not increase the predictive value of persistingdyspepsia for persisting infection.
Conclusions—Complete resolution of dyspepticsymptoms is a powerful predictor of eradication of Hpylori infection in ulcer patients. Persistence of symptoms is aweak predictor of persisting infection and patients with persistingdyspepsia must have their H pylori status rechecked toguide future management.

Keywords:Helicobacter pylori; dyspepsia; ulcerdisease; eradication therapy; reflux disease

     

Symptom clusters cannot be used in distinguishing Helicobacter pylori positive or negative patients with functional dyspepsia

Background: A retrospective study was done in consecutive patients in order to seek out whether dyspepsia subgroups (reflux-like, ulcer-like, and, dysmotility-like dyspepsia) can be useful in describing Helicobacter pylori positive and negative functional dyspepsia.Methods: Consecutive patients who underwent upper gastrointestinal endoscopy were included if no macroscopic lesions in oesophagus, stomach or duodenum were seen. Antral biopsy specimens were taken for detection of H. pylori. A validated questionnaire was used. Results: Six hundred patients fulfilled the inclusion criteria. Three hundred were positive for H. pylori. In the H. pylori positive (HP+) patients only 3 (1.2%) had `pure' reflux-like dyspepsia, 17 (6.9%) had ulcer-like dyspepsia and 10 (4%) suffered from dysmotility-like dyspepsia. In the H. pylori negative (HP−) patients these figures were 6 (2.3%), 17 (6.6%) and 7 (2.7%), respectively (ns). The majority of patients had a combination of complaints belonging to the three subgroups. Reflux-like dyspepsia was present in 179 (73%) HP+ dyspeptics and 195 (76%) HP−'s (ns). Ulcer-like dyspepsia was present in 213 (88%) HP+ cases and 233 (92%) HP−'s (ns). Dysmotility-like dyspepsia was present in 197 (81%) HP+'s and 212 (82%) HP−'s (ns).Conclusions: It is concluded that it is not possible to identify patients suffering from H. pylori infection on basis of symptom clusters.     

Dyspepsie

Functional dyspepsia is a chronic and polymorphic disorder with a prevalence of approximately 10% in the adult population. Management of this disease represents a considerable economic burden worldwide. Functional dyspepsia is defined as a pain or a sensation of discomfort located in the upper abdomen, according to the Rome II criteria. A dyspepsia subgroup classification based on the predominant symptom has been proposed: dysmotility-like dyspepsia, ulcer-like dyspepsia and non-specific dyspepsia. In patients with alarm symptoms, upper endoscopy has to be performed. In the absence of alarm features, the patient needs to be reassured and psychotherapy must be discussed. Then, empirical therapy with proton pump inhibitors (ulcer-like dyspepsia) or domperidone (dysmotility-like dyspepsia) may improve symptoms in some cases. Efficacy of Helicobacter pylori eradication in dyspepsia is probably poor; on the other hand, treatment of Helicobacter pylori infection could reduce the prevalence of gastric cancer but further investigations are needed to clarify this point. Pathophysiology of dyspepsia remains unclear. The psychological factors are not the only involved in this functional disorder. The identification of the mechanisms that lead to symptom generation should facilitate the development of newer and more effective therapeutic strategies in functional dyspepsia.     

Dyspepsia in healthy blood donors

WhetherHelicobacter pylori is causally linked to dyspepsia remains controversial. The aims of this study were to assess in healthy blood donors the prevalence of dyspepsia and dyspepsia subgroups, determine ifH. pylori is associated with different categories of dyspeptic symptoms, and evaluate the association between dyspepsia and nicotine, alcohol, and analgesic use. Consecutive blood donors (N=180) who had no clinical evidence of organic disease were included. Abdominal symptoms were measured by means of a standardized questionnaire that has been previously validated. Subjects with dyspepsia (defined as pain localized to the upper abdomen) were further subdivided into those with ulcer-like, dysmotility-like, reflux-like, or nonspecific dyspepsia. A total of 65 subjects reported abdominal pain or discomfort during the prior 12 months [36.1%, 95% confidence interval (CI) 29.1–43.1]; 44 subjects (24.4%, 95% CI 18.2–30.7) had dyspepsia. Dysmotility-like, reflux-like, and ulcer-like symptoms were reported by 19.4% (95% CI 13.7–25.2), 17.2% (95% CI 11.7–22.7), and 16.7% (95% CI 11.2–22.1) of subjects with dyspepsia, respectively. Fifty-seven subjects (31.7%, 95% CI 24.9–38.5) wereH. pylori positive; 26% of subjects withH. pylori and 24% withoutH. pylori had dyspepsia (P>0.50). The seroprevalence ofH. pylori was also similar among the different categories of dyspepsia. We conclude that infection withH. pylori is not associated with abdominal complaints in otherwise healthy subjects.     

Helicobacter pylori: Evidence-Based Review with a Focus on Immigrant Populations

Helicobacter pylori has been causally linked to a number of diseases, including peptic ulcer disease, gastric adenocarcinoma, mucosa-associated lymphoid tissue lymphoma, and dyspepsia. It is the most prevalent bacterial pathogen in humans, and while the overall prevalence in the United States is about 30 %, the distribution is heterogeneous amongst different ethnic groups. Recent immigrants from high prevalence areas such as Korea, Japan, and China bear an increased burden of its disease and complications. There is clear evidence that treatment of H. pylori resolves peptic ulcer disease, and increasing evidence for protection against development of gastric adenocarcinoma. However, H. pylori treatment failure is common and alternative regimens may be necessary. The following case-based review will highlight these issues, including the epidemiology of H. pylori in the immigrant population, an approach to dyspepsia, and the role of H. pylori in gastric adenocarcinoma.     

Long-term prospective study ofHelicobacter pylori in nonulcer dyspepsia

Helicobacter pylori is present in up to 87% of patients with nonulcer dyspepsia. This study assessed the effect of eradicatingHelicobacter pylori infection on the symptoms of nonulcer dyspepsia at four weeks and one year after treatment. Dyspepsia was assessed on the frequency and severity of six symptoms [epigastric pain (night and day), nausea and vomiting, upper abdominal discomfort, and regurgitation] where each symptom was scored from 0 to 4.Helicobacter pylori status was assessed before treatment and four weeks after treatment with histology and microbiology, and at one year with a carbon-13 urea breath test. Eighty-three patients (23 males, 60 females; mean age 56.3 years; mean symptom duration 3.6 months) with nonulcer dyspepsia andHelicobacter pylori infection entered the study. Seventy-five were available at one year follow-up. Four weeks after treatment, the mean symptom score improved in those with eradication (6.95–2.3,P=0.01,N=41) or persistent infection (6.69–3.0,P=0.015,N=42). At one year, those with persistentHelicobacter pylori infection (N=38, score 5.24) had a higher score than those remaining clear of infection (N=24, score 1.4,P<0.0001) and those with reinfection (N=13, score 2.2,P<0.0001). In addition, persistentHelicobacter pylori infection was associated with more additional treatments than those with eradication (34/38 versus 4/37,P<0.001). These results suggest thatHelicobacter pylori plays an important role in the symptoms of nonulcer dyspepsia.     

Kyoto global consensus report on Helicobacter pylori gastritis and its impact on Chinese clinical practice

The Kyoto global consensus report on Helicobacter pylori (H. pylori) gastritis has had a great effect on the field of H. pylori studies worldwide. For the first time H. pylori gastritis was defined entirely as an infectious disease and H. pylori‐associated dyspepsia as a new category of organic dyspepsia apart from functional dyspepsia, together with a proposed diagnostic algorithm. Accordingly, the report states that the eradication of H. pylori should be regarded as the first‐line treatment for dyspepsia. Moreover, H. pylori eradication before the development of pre‐neoplastic changes is recommended to reduce the risk of more serious complications of H. pylori gastritis. Despite the recommendations of this new global consensus, the task of transforming them into feasible and practical recommendations for individual countries will require them to become region‐specific, which requires further discussion.     

Relation between Helicobacter pylori infection and gastrointestinal symptoms and syndromes

Background—Helicobacter pylori is ahuman pathogen that colonises the gastric mucosa and causes permanentgastric inflammation.
Aims—To assess the symptoms of Hpylori infection in an adult unselected population.
Subjects—A random sample of 3589 adult Danes whowere examined in 1982 and 1987 (n=2987).
Methods—Abdominal symptoms within the precedingyear were recorded at both attendances. Circulating IgG antibodiesagainst H pylori in serum samples drawn in 1982 weremeasured by using in-house indirect enzyme linked immunosorbent assays (ELISA).
Results—People with increased levels of IgGantibodies to H pylori were more likely than uninfectedindividuals to report heartburn (odds ratio (OR) = 1.26, 95%confidence interval (CI) 1.03-1.54) and abdominal pain characterisedby daily length (OR= 1.33, 95% CI 0.92-1.91), nocturnal occurrence(OR = 1.62, 95% CI 1.19-2.19), spring aggravation (OR = 1.68, 95% CI0.70-4.05), and no relation to meals (OR = 0.62, 95% CI 0.43-0.91)or stress (OR = 0.69, 95% CI 0.50-0.95). The inclusion of people withincreased levels of IgG antibodies to H pylori, butwithout upper dyspepsia, at study entry significantly increased thelikelihood of reporting upper dyspepsia at follow up (OR = 1.71, 95%CI 1.24-2.36). People with epigastric pain and increased levels of IgMantibodies to H pylori only indicative of acute Hpylori infection were more likely to report nocturnal pain,heartburn, nausea, and vomiting.
Conclusions—H pylori infection mayprecede the development of dyspepsia and is associated with a varietyof gastrointestinal symptoms in people with no history of peptic ulcer disease.

Keywords:epidemiology; Helicobacter pylori;non-ulcer dyspepsia; symptomatology; upper dyspepsia

     

Intragastric distribution and gastric emptying of solids and liquids in functional dyspepsia

The relative contributions of altered gastric motor function andHelicobacter pylori-associated active chronic gastritis to the pathogenesis of functional dyspepsia are controversial. We therefore evaluated scintigraphically the intragastric distribution and gastric emptying of a mixed solid-liquid meal in 75 patients with functional dyspepsia; patients were subdivided on the basis of both specific symptom clusters and the presence or absence ofH. pylori gastritis. Twenty-one (28%) patients displayed abnormal solid and/or liquid gastric emptying, with prolonged solid lag time the most prominent alteration detected. The number of patients with abnormal scintigraphic patterns increased to 36 (48%) when intragastric distribution parameters (fundal half-emptying time and antral maximal fraction) were examined. Although patients with reflux-like dyspepsia (N=36) demonstrated significantly slower rates of liquid emptying at 45 and 70 min and a higher prevalence of abnormal liquid intragastric distribution when compared to patients with motility-like dyspepsia (N=39) or to controls (N-34), the absolute differences were small and unlikely to be of clinical significance. Patients withoutH. pylori gastritis (N=50) demonstrated a significantly more prolonged solid lag time when compared to those withH. pylori gastritis (N=25), but the difference was small and there were no other differences between these two subgroups. We conclude that in patients with functional dyspepsia: (1) abnormal solid gastric emptying is present in less than one third; (2) assessment of parameters of intragastric distribution enables more subtle gastric motor dysfunction to be identified; and (3) neither dividing patients into symptom subgroups nor accounting for the presence or absence ofH. pylori gastritis has a major influence on the prevalence or type of gastric motor dysfunction.     

Helicobacter pylori in First Nations and recent immigrant populations in Canada

The diminishing prevalence of Helicobacter pylori infection among most segments of the Canadian population has led to changes in the etiologies and patterns of associated upper gastrointestinal diseases, including fewer peptic ulcers and their complications. Canadian Aboriginals and recent immigrants are among populations in which the prevalence of H pylori infection remains high and, therefore, the health risks imposed by H pylori remain a significant concern. Population-based strategies for H pylori eradication in groups with a low prevalence of infection are unlikely to be cost effective, but such measures are attractive in groups in which the prevalence rates of infection remain substantial. In addition to a lower prevalence of peptic ulcers and dyspepsia, the public health value of eradication may be particularly important if this leads to a reduction in the prevalence of gastric cancer in high prevalence groups. Therefore The Canadian Helicobacter Study Group held a conference that brought together experts in the field to address these issues, the results of which are reviewed in the present article. Canadians with the highest prevalence of H pylori infection are an appropriate focus for considering the health advantages of eradicating persistent infection. In Canadian communities with a high prevalence of both H pylori and gastric cancer, there remains an opportunity to test the hypothesis that H pylori infection is a treatable risk factor for malignancy.     

Prevalence of <Emphasis Type="Italic">Helicobacter pylori</Emphasis>infection among new outpatients with dyspepsia in Kuwait

Background  

Testing and treatment for Helicobacter pylori has become widely accepted as the approach of choice for patients with chronic dyspepsia but no alarming features. We evaluated H. pylori status among outpatients with uninvestigated dyspepsia in Kuwait.     

Functional dyspepsia

Functional dyspepsia is defined as persistent or recurrent upper abdominal pain or discomfort not explained by structural or biochemical abnormalities. In about half of the patients who present to their practitioner with chronic dyspepsia, no underlying disease is established after clinical investigation. Many clinical trials have been performed to demonstrate a certain relationship between functional dyspepsia and several pathogenic mechanisms like dysmotility, Helicobacter pylori infection, acid output and hypersensitivity to distension. Unfortunately, the conclusions of those studies are conflicting. Short-term follow-up, lack of consensus about diagnostic criteria for functional dyspepsia and unvalidated symptom measures make it difficult to interpret their results.     

Prevalence of non <Emphasis Type="Italic">Helicobacter pylori</Emphasis> species in patients presenting with dyspepsia

Background  

Helicobacter species associated with human infection include Helicobacter pylori, Helicobacter heilmannii and Helicobacter felis among others. In this study we determined the prevalence of H. pylori and non-Helicobacter pylori organisms H. felis and H. heilmannii and analyzed the association between coinfection with these organisms and gastric pathology in patients presenting with dyspepsia. Biopsy specimens were obtained from patients with dyspepsia on esophagogastroduodenoscopy (EGD) for rapid urease test, histology and PCR examination for Helicobacter genus specific 16S rDNA, H. pylori phosphoglucosamine mutase (glmM) and urease B (ureB) gene of H. heilmannii and H. felis. Sequencing of PCR products of H. heilmannii and H. felis was done.     

Lymphocytic duodenosis: aetiology and long-term response to specific treatment

BackgroundThe clinical significance of lymphocytic duodenosis remains unclear.AimTo prospectively assess the aetiology of lymphocytic duodenosis and the patterns of clinical presentation.MethodsNinety consecutive patients with lymphocytic duodenosis and clinical symptoms of the coeliac disease spectrum were prospectively included. All subjects underwent serological testing and HLA genotyping for coeliac disease, assessment of Helicobacter pylori infection, and parasite stool examination. Intake of non-steroidal anti-inflammatory drugs was also recorded. The final aetiology of lymphocytic duodenosis was evaluated on the basis of the long-term response to specific therapy.ResultsMore than one initial potential aetiology was observed in 44% of patients. The final diagnosis was gluten-sensitive enteropathy alone or associated with Helicobacter pylori infection in 43.3%, Helicobacter pylori infection (without gluten-sensitive enteropathy) in 24.4%, non-steroidal anti-inflammatory drugs intake in 5.5%, autoimmune disease in 3.3%, and parasitic infection in 2.2%. Among first degree relatives and patients with chronic diarrhoea, the most common final diagnosis was gluten-sensitive enteropathy. In contrast, in the group presenting with chronic dyspepsia the most common diagnosis was Helicobacter pylori infection (‘Diarrhoea’ vs ‘Dyspepsia’ groups, p = 0.008).ConclusionsLymphocytic duodenosis is often associated with more than one potential initial aetiology. Clinical presentation may be useful to decide the initial therapeutic approach with these patients.     

Increased reflux symptoms after calcium carbonate supplementation and successful anti-Helicobacter pylori treatment

We used data from a randomized placebo-controlled clinical trial to examine the relationship between Helicobacter pylori and reflux symptoms in nonulcer dyspepsia patients randomly assigned anti-Helicobacter pylori triple therapy alone, calcium carbonate alone, or in combination with triple therapy, tetracycline, or placebo. We compared risk differences for posttreatment Helicobacter pylori status and increased reflux symptoms from crude, multivariable and stratified multivariable analyses. In crude analyses, 54% of subjects without Helicobacter pylori after-treatment reported an increase in reflux compared to 41% of those with persistent infection (risk difference = 13%; P = 0.07). Only subjects with multifocal atrophic gastritis assigned to calcium carbonate reported an increase in reflux symptoms more frequently when Helicobacter pylori was absent versus when it persisted (risk difference = 52%; P = 0.0001). Therefore, the interaction of calcium carbonate use, chronic multifocal atrophic gastritis, and the absence of Helicobacter pylori may increase reflux symptoms.     

Does Helicobacter pylori gastritis affect motor function of proximal stomach in dyspeptic patients?

The role of Helicobacter pylori infection in proximal gastric motor function and its relation to symptoms in patients with functional dyspepsia is still unclear. We prospectively studied 26 patients with dyspepsia, no structural abnormalities found during endoscopy and biopsy-proven Helicobacter pylori-positive gastritis before and three months after Helicobacter pylori treatment. We used an 11-item score list to evaluate symptoms, gastric biopsies for histology, and a gastric barostat (isobaric inflation–deflation) for proximal gastric motility. Minimal distending pressure (MDP), mean gastric volume at operating pressure, AUC of inflation–deflation cycles, and hysteresis (difference in AUC during inflation and AUC during deflation) were calculated. After three months, Helicobacter pylori was eradicated in 96% of patients. MDP, mean gastric volume at operating pressure, gastric compliance, and hysteresis did not change significantly. Aggregate symptom score as well as histology scores in antrum and corpus decreased significantly. Reduction in postprandial pain correlated with a change in hysteresis (r = 0.567, P < 0.01), but other symptoms did not. Reduction of corpus inflammatory activity correlated with changes in hysteresis (r = 0.604, p < 0.005), suggesting that the stomach attains it original shape faster when inflammation is reduced. These observations suggest that inflammatory changes or release of inflammatory substances associated with Helicobacter pylori infection may influence proximal gastric motor characteristics.     

Helicobacter pylori

Helicobacter pylori is associated with various gastroduodenal diseases such as peptic ulcer, functional dyspepsia, MALT lymphoma and distal gastric cancer. Diagnosis of H. pylori can be established by non-invasive (^13Curea breath test, stool antigen test, serology) and invasive (histology, rapid urease test, culture) tests. In adults, culture and susceptibility testing should or must be performed after failing of first-line therapy in case of a control endoscopy and before third-line therapy, respectively. Peptic ulcer and gastric MALT lymphoma represent obligatory indications for eradication therapy. Other potential indications are functional dyspepsia, prevention of gastric cancer in individuals being at risk, and before starting treatment with traditional non-steroid antiphlogistics. First-line therapy is performed with a 7-days combination of proton pump inhibitor with clarithromycin and amoxicillin or metronidazole. In second-line therapy levofloxacin and rifabutin are good rescue antibiotics.