Probiotics for the treatment of Helicobacter pylori infection in children

The combination of a proton pump inhibitor and two antibiotics(clarithromycin plus amoxicillin or metronidazole)has been the recommended first-line therapy since the first guidelines for Helicobacter pylori(H.pylori)infection in children were published.In recent years,the success of eradication therapies has declined,in part due to the development of H.pylori resistant strains.Alternative anti-H.pylori treatments are currently becoming more popular than the traditional eradication methods.Components that may be used either as a monotherapy or,in combination with antimicrobials,resulting in a more effective anti-H.pylori therapy have been investigated in depth by several researchers.One of the potential therapies is probiotic cultures;promising results have been observed in initial studies with numerous probiotic strains.Nevertheless,many questions remain unanswered.In this article,we comprehensively review the possible mechanisms of action of probiotics on H.pylori infection,and present the results of published studies using probiotics as possible agents to control H.pylori infection in children.The effect of the addition of probiotics to the standard H.pylori eradication therapy for the prevention of antibiotic associated side-effects is also discussed.     

Helicobacter pylori infection in older people

Since the discovery of Helicobacter pylori(H.pylori)infection as the major cause of gastroduodenal disorders three decades ago,H.pylori has been the focus of active research and debate in the scientific community.Its linkage to several diseases,such as peptic ulcer disease,gastritis and gastric malignancy is incontestable.In particular,it has been noticed that,as the aged population is increasing worldwide,older people are at increased risk of developing several gastroduodenal diseases and related complications.At the same time,gastric cancer is definitely more frequent in elderly than in adult and young people.In addition,it has been showed that peptic ulcer and related complications occur much more commonly in aged individuals than in young people,resulting in a significantly higher mortality.Although this infection plays a crucial role in gastrointestinal disorders affecting all age groups and in particular older people,only a few studies have been published regarding the latter.This article presents an overview of the epidemiology,diagnosis,clinical manifestations and therapy of H.pylori infection in elderly people.     

Furazolidone-based triple and quadruple eradication therapy for Helicobacter pylori infection

AIM: To evaluate the efficacy of furazolidone-based triple and quadruple therapy in eradicating Helicobacter pylori (H. pylori) in a multi-center randomized controlled trial.METHODS: A total of 720 H. pylori positive patients with duodenal ulcer disease were enrolled at 10 different hospitals in Jiangxi province in China. The patients were randomly assigned to four treatment groups as follows: patients in Groups 1 and 3 received rabeprazole (10 mg), amoxicillin (1000 mg) and furazolidone (100 mg) twice daily for 7 and 10 d, respectively; patients in Groups 2 and 4 received rabeprazole (10 mg), bismuth (220 mg), amoxicillin (1000 mg) and furazolidone (100 mg) twice daily for 7 and 10 d, respectively. The primary outcome measure was H. pylori eradication rate 4 wk after treatment by intention-to-treat and per protocol analysis, while the secondary outcome measures were symptom and sign changes at the end of treatment and 4 wk after the end of treatment, as well as the proportion of patients who developed adverse events.RESULTS: The demographic data of the four groups were not significantly different. Overall, 666 patients completed the scheme and were re-assessed with the ¹³C-urea breath test. The intention-to-treat analysis of the H. pylori eradication rates in Groups 1, 2, 3 and 4 were 74.44%, 82.78%, 78.89% and 86.11%, respectively. The H. pylori eradication rate in Group 4 was significantly higher than that in Group 1. According to the per protocol analysis, the H. pylori eradication rates in Groups 1, 2, 3 and 4 were 81.21%, 89.22%, 85.54% and 92.26%, respectively. The H. pylori eradication rate in Group 4 was significantly higher than that in Group 1. The number of adverse events was 15 (8.3%), 16 (8.9%), 15 (8.3%) and 17 (9.4%) in Groups 1, 2, 3 and 4, respectively, including dizziness, vomiting, diarrhea, nausea, skin rash, itchy skin, and malaise. The symptoms were relieved without special treatment in all of the patients.CONCLUSION: Both 7- and 10-d quadruple furazolidone-based therapies achieve satisfactory H. pylori eradication rates.     

Helicobacter pylori infection following partial gastrectomy for gastric cancer

Gastric remnants are an inevitable consequence of partial gastrectomy following resection for gastric cancer.The presence of gastric stumps is itself a risk factor for redevelopment of gastric cancer.Helicobacter pylori(H.pylori)infection is also a well-known characteristic of gastric carcinogenesis.H.pylori colonization in the remnant stomach therefore draws special interest from clinicians in terms of stomach cancer development and pathogenesis;however,the H.pylori-infected gastric remnant is quite different from the intact organ in several aspects and researchers have expressed conflicting opinions with respect to its role in pathogenesis.For instance,H.pylori infection of the gastric stump produced controversial results in several recent studies.The prevalence of H.pylori infection in the gastric stump has varied among recent reports.Gastritis developing in the remnant stomach presents with a unique pattern of inflammation that is different from the pattern seen in ordinary gastritis of the intact organ.Bilerefluxate also has a significant influence on the colonization of the stomach stump,with several studies reporting mixed results as well.In contrast,the elimination of H.pylori from the gastric stump has shown a dramatic impact on eradication rate.H.pylori elimination is recognized to be important for cancer prevention and considerable agreement of opinion is seen among researchers.To overcome the current discrepancies in the literature regarding the role of H.pylori in the gastric stump,further research is required.     

Simple animal model of Helicobacter pylori infection

Helicobacter pylori(H.pylori)has become accepted as a human pathogen for the development of gastritis and gastroduodenal ulcer.To develop a simple rat model of chronic H.pylori infection,male Sprague-Dawley rats were pretreated with streptomycin suspended in tap water(5 mg/mL)for 3 d.The rats were inoculated by gavage at 1 mL/rat with H.pylori suspension(5×108-5×1010 CFU/mL)twice daily at an interval of 4 h for three consecutive days.Two weeks after inoculation,rats were sacrificed and the stomachs were removed.Antral biopsies were performed for urease test and the stomachs were taken for histopathology.Successful H.pylori inoculation was defined as a positive urease test and histopathology.We reported a 69.8%-83.0%success rate for H.pylori infection using the urease test,and hematoxylin and eosin staining confirmed the results.Histopathological analysis detected bacteria along the mucous lining of the surface epithelium and crypt lumen and demonstrated mild to moderate gastric inflammation in successfully inoculated rats.We developed a simple rat model of chronic H.pylori infection for research into gastric microcirculatory changes and therapy with plant products.     

Diagnostic performance of gastric imprint smear for determination of Helicobacter pylori infection

BACKGROUND:

Despite the availability of several methods (invasive and noninvasive) for the diagnosis of Helicobacter pylori infection, no test is considered to be the ‘gold standard’. Endoscopy-based tests are regarded as the reference method in most studies.

OBJECTIVE:

To evaluate the diagnostic performance of imprint cytology smears of antral biopsies compared with Gram-stained smears, the rapid urease test and culture methods, separately and in combination.

METHODS:

Antral biopsies were obtained from consecutive patients undergoing upper gastrointestinal endoscopy at a single centre. The biopsies were examined for the presence of H pylori by Gram-stained smear, the rapid urease test, culture methods and imprint cytology smear.

RESULTS:

A total of 273 biopsies were studied. All tests were positive in 36% of the patients. Of 252 biopsies tested, 73% were positive using the imprint cytology technique. Using Gram-stained smear, the rapid urease test and culture methods individually, the sensitivity and specificity of imprint cytology smears for the detection of H pylori were found to be 92.7% and 50%; 92.7% and 49%; and 92.4% and 38.5%, respectively. Combining the three microbiological methods resulted in a sensitivity of 92.1%, a specificity of 51.0% and an efficiency of 71.7% for imprint cytology smears.

CONCLUSIONS:

Endoscopic examination provides useful clinical information. Imprint gastric cytology can be used as a rapid test to establish the diagnosis of H pylori infection at the time endoscopy is performed, enabling the endoscopist to start treatment with immediate effect.     

Meta-analysis of the efficacy of probiotics in Helicobacter pylori eradication therapy

AIM: To evaluate the role of probiotics in the standard triple Helicobacter pylori therapy.METHODS: In this meta-analysis, we investigated the efficacy of probiotics in a standard triple H. pylori therapy in adults. Searches were mainly conducted in MEDLINE/PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials. Fourteen studies met our criteria, and the quality of these studies was assessed using the Jadad scale. We used STATA version 12.0 to extract data and to calculate the odds ratios (ORs), which are presented with the corresponding 95% confidence intervals (CIs). The data are presented as forest plots.RESULTS: The pooled ORs for the eradication rates calculated by intention-to-treat analysis and per-protocol analysis in the probiotic group vs the control group were 1.67 (95%CI: 1.38-2.02) and 1.68 (95%CI: 1.35-2.08), respectively, using the fixed-effects model. The sensitivity of the Asian studies was greater than that of the Caucasian studies (Asian: OR = 1.78, 95%CI: 1.40-2.26; Caucasian: OR = 1.48, 95%CI: 1.06-2.05). The pooled OR for the incidence of total adverse effects was significantly lower in the probiotic group (OR = 0.49, 95%CI: 0.26-0.94), using the random effects model, with significant heterogeneity (I² = 85.7%). The incidence of diarrhea was significantly reduced in the probiotic group (OR = 0.21, 95%CI: 0.06-0.74), whereas the incidence of taste disorders, metallic taste, vomiting, nausea, and epigastric pain did not differ significantly between the probiotic group and the control group.CONCLUSION: Supplementary probiotic preparations during standard triple H. pylori therapy may improve the eradication rate, particularly in Asian patients, and the incidence of total adverse effects.     

Diagnosing Helicobacter pylori infection in vivo by novel endoscopic techniques

Infection with Helicobacter pylori (H. pylori) is a worldwide problem. Endoscopic observation of H. pylori infection in vivo would be helpful to obtain an immediate diagnosis. The aim of this review is to describe recent advances in endoscopic technology and to review the available literature pertaining to its clinical application in H. pylori infection. Endoscopic visualization of H. pylori infection is not always feasible using conventional endoscopy. Thus, advanced endoscopic techniques have been developed with the aim of providing a precise and ‘‘real-time’’ endoscopic diagnosis. Recently, new endoscopic techniques such as magnifying endoscopy, narrow band imaging, I-Scan, endocytoscopy and endomicroscopy help focus examination of the stomach to diagnose disease in a time-efficient manner, and the analysis of mucosal surface details is beginning to resemble histologic examination. The new detailed images have enabled endoscopists to observe microscopic structures, such as gastric pit patterns, microvessels and cell morphology. Accordingly, endoscopic prediction of H. pylori infection is possible by analysis of surface architecture of the mucosa, which influences the clinical management. These endoscopic techniques might lead us to easier diagnosis and treatment of H. pylori-related diseases.     

Pharmacological therapy used in the elimination of Helicobacter pylori infection:A review

The optimal therapy for Helicobacter pylori(H.pylori) infection should combine a high cure rate and a short treatment duration with a favorable side-effect profile and should maintain a low cost.Several strategies have been proposed to increase the H.pylori eradication rate,including the extension of the treatment duration to 14 d,the use of a four-drug regimen(quadruple,sequential,and concomitant treatments),and the use of novel antibiotics,such as levofloxacin.However,triple therapy remains the most widely accepted firstline treatment regimen in Brazil and the United Statesand throughout Europe.Because this therapy is limited by resistance to clarithromycin,other therapeutic regimens have been investigated worldwide.This review describes the current literature involving studies directly comparing these different therapies and their efficacies.     

Sero-prevalence and factors associated with Helicobacter pylori infection in Eastern Sudan

Objective

To investigate the prevalence of Helicobacter pylori (H. pylori) among patients with dyspepsia and to evaluate the correlation between H. pylori infection and socio-demographic factors.

Methods

This cross-sectional hospital-based study, which ran from June to August 2012, determined seroprevalence of H. pylori among adult patients in Eastern Sudan. The presence of H. pylori was determined using ELISA.

Results

A total of 225 adult Sudanese patients were enrolled in the study. Of these, 148 (65.8%) tested positive for H. pylori. In logistic regression analysis, rural residency (OR=3.933, CI=1.337-11.26, P=0.01) was the only socio-demographic factor that was associated with H. pylori infection. The most common symptoms among seropositive patients were heartburn (OR=30.442, CI=9.478-97.776, P≤0.001) and/or epigastria pain (OR=28.225, CI=4.365-182.508, P≤0.001).

Conclusions

Clinical suspicion can facilitate the detection of H. pylori among patients with dyspeptic symptoms in a geographic area with high prevalence of H. pylori infection.     

Probiotics in Helicobacter pylori eradication therapy: A systematic review and meta-analysis

AIM: To summarize the evidence from randomized controlled trials(RCTs) regarding the effect of probiotics by using a meta-analytic approach.METHODS: In July 2013, we searched PubM ed, EMBASE, Ovid, the Cochrane Library, and three Chinese databases(Chinese Biomedical Literature Database, Chinese Medical Current Content, and Chinese Scientific Journals database) to identify relevant RCTs. We included RCTs investigating the effect of a combination of probiotics and standard therapy(probiotics group) with standard therapy alone(control group). Risk ratios(RRs) were used to measure the effect of probiotics plus standard therapy on Helicobacter pylori(H. pylori) eradication rates, adverse events, and patient compliance using a random-effect model. RESULTS: We included data on 6997 participants from 45 RCTs, the overall eradication rates of the probiotic group and the control group were 82.31% and 72.08%, respectively. We noted that the use of probiotics plus standard therapy was associated with an increased eradication rate by per-protocol set analysis(RR = 1.11; 95%CI: 1.08-1.15; P < 0.001) or intention-totreat analysis(RR = 1.13; 95%CI: 1.10-1.16; P < 0.001). Furthermore, the incidence of adverse events was 21.44% in the probiotics group and 36.27% in the control group, and it was found that the probiotics plus standard therapy significantly reduced the risk of adverse events(RR = 0.59; 95%CI: 0.48-0.71; P < 0.001), which demonstrated a favorable effect of probiotics in reducing adverse events associated with H. pylori eradication therapy. The specific reduction in adverse events ranged from 30% to 59%, and this reduction was statistically significant. Finally, probiotics plus standard therapy had little or no effect on patient compliance(RR = 0.98; 95%CI: 0.68-1.39; P = 0.889).CONCLUSION: The use of probiotics plus standard therapy was associated with an increase in the H. pylori eradication rate, and a reduction in adverse events resulting from treatment in the general population. However, this therapy did not improve patient compliance.     

Role of Helicobacter pylori infection on nutrition and metabolism

Helicobacter pylori (H. pylori) is a gram-negative pathogen that is widespread all over the world, infecting more than 50% of the world’s population. It is etiologically associated with non-atrophic and atrophic gastritis, peptic ulcer and shows a deep association with primary gastric B-cell lymphoma and gastric adenocarcinoma. Recently, the medical research focused on the modification of the gastric environment induced by H. pylori infection, possibly affecting the absorption of nutrients and drugs as well as the production of hormones strongly implicated in the regulation of appetite and growth. Interestingly, the absorption of iron and vitamin B12 is impaired by H. pylori infection, while infected subjects have lower basal and fasting serum levels of ghrelin and higher concentration of leptin compared to controls. Since leptin is an anorexigenic hormone, and ghrelin stimulates powerfully the release of growth hormone in humans, H. pylori infection may finally induce growth retardation if acquired very early in the childhood and in malnourished children. This review is focused on the nutritional effects of H. pylori infection, such as the reduced bioavailability or the malabsorbption of essential nutrients, and of gastrointestinal hormones, as well as on the relationship between H. pylori and the metabolic syndrome.     

Stool antigen tests for the management of Helicobacter pylori infection

Stool antigen tests(SATs)are noninvasive diagnostic modules for Helicobacter pylori(H.pylori)infection.Two types of SATs exist for the diagnosis of H.pylori infection,one based on enzyme immunoassay(EIA)and another on immunochromatography(ICA).SATs do not require expensive chemical agents or specified equipment;hence,they are less expensive compared with the urea breath test.Both European and Japanese guidelines have shown that EIA-based SATs using monoclonal antibodies are useful for primary diagnosis as well as for the assessment of eradication therapy.ICA-based tests do not require particular equipment and are therefore useful in developing countries.SATs are also useful for the diagnosis of H.pylori infection in children and post gastric surgery patients.SATs performed via EIA can assess H.pylori infection in a large number of subjects,almost as well as serology.Thus,SATs would be useful or detecting current infection in such a survey to identify and eradicate H.pylori infection.The accuracy of SATs is lower when the stool samples are unformed or watery,because H.pylorispecific antigens in the stool samples are diluted.Temperature and the interval between stool sample collection and measurement also affect the results of SATs.The choice of test kit depends on the sensitivity and specificity in each region and the circumstances of each patient.     

Management of Helicobacter pylori infection after gastric surgery

The Maastricht IV/Florence Consensus Report and the Second Asia-Pacific Consensus Guidelines strongly recommend eradication of Helicobacter pylori(H.pylori)in patients with previous gastric neoplasia who have undergone gastric surgery.However,the guidelines do not mention optimal timing,eradication regimens,diagnostic tools,and follow-up strategies for patients undergoing gastrectomy and do not indicate if eradication of H.pylori reduces the risk of marginal ulcer or stump cancer in the residual stomach after gastrectomy.The purpose of this review is to provide an update which may help physicians to properly manage H.pylori infection in patients who have undergone gastric surgery.This review focuses on(1)the microenvironment change in the stomach after gastrectomy;(2)the phenomenon of spontaneous clearance of H.pylori after gastrectomy;(3)the effects of H.pylori on gastric atrophy and intestinal metaplasia after gastrectomy;(4)incidence and clinical features of ulcers developing after gastrectomy;(5)does eradication of H.pylori reduce the risk of gastric stump cancer in the residual stomach?(6)does eradication of H.pylori reduce the risk of secondary metachronous gastric cancer in the residual stomach?and(7)optimal timing and regimens for H.pylori eradication,diagnostic tools and follow-up strategies for patients undergoing gastrectomy.     

Helicobacter pylori infection is associated with gallstones: Epidemiological survey in China

AIM: To elucidate the prevalence and risk factors for gallstones, primarily focusing on Helicobacter pylori(H. pylori) infection. METHODS: A total of 10016 Chinese subjects, who had undergone physical examination, fasting 13 C urea breath test and abdominal ultrasonography, had sufficient blood test data, and had finished a questionnaire, were included in this cross-sectional study. Participants(n = 1122) who had previous eradication of H. pylori were studied separately. RESULTS: Gallstones were discovered in 9.10% of men and 8.58% of women, with no significant sex difference. Multivariate analyses displayed that age, aspartate aminotransferase, total cholesterol, H. pylori infection, hepatitis C virus(HCV) infection, and fattyliver had a significant association with gallstones(P 0.05). Successive multiple logistic regression analysis including index of odds ratio(OR) and standardized coefficient(β) indicated that older age(OR/β = 1.056/0.055), H. pylori infection(OR/β = 1.454/0.109), HCV infection(OR/β = 1.871/0.123), and fatty liver(OR/β = 1.947/0.189) had a significant positive association with gallstones. After age stratification, H. pylori infection and fatty liver still had a significant positive association with gallstones in any age-specific groups, whereas HCV infection had a significant positive association in patients aged 40 years. The prevalence of gallstones among H. pylori-positive, H. pylori-eradicated, and H. pylori-negative subjects was 9.47%, 9.02%, and 8.46%, respectively. The matched analysis showed that gallstones among H. pylori eradicated subjects was significantly lower compared with H. pylori-positive subjects(P 0.05).CONCLUSION: H. pylori infection and fatty liver have a significant positive association with gallstones. H. pylori eradication may lead to prevention of gallstones.     

Fluoroquinolone-based protocols for eradication of Helicobacter pylori

Helicobacter pylori (H. pylori) is a widespread pathogen infecting about 40% of people living in urban areas and over 90% of people living in the developing regions of the world. H. pylori is well-documented as the main factor in the pathogenesis of peptic ulcer disease, chronic gastritis, and gastric malignancies such as cancer and mucosa-associated lymphoid tissue-lymphoma; hence, its eradication is strongly recommended. The Maastricht IV consensus, which focused on the management of H. pylori infection, set important new strategies in terms of treatment approaches, particularly with regards to first- and second-line treatment protocols and led to improved knowledge and understanding of H. pylori resistance to antibiotics. In recent years, various fluoroquinolone-based protocols, mainly including levofloxacin, have been proposed and effectively tested at all therapeutic lines for H. pylori eradication. The aim of the present paper is to review the scientific literature focused on the use of fluoroquinolones in eradicating H. pylori.     

Moxifloxacin-containing triple therapy after non-bismuth quadruple therapy failure for Helicobacter pylori infection

AIM: To assess the efficacy of moxifloxacin-containing triple therapy after non-bismuth quadruple therapy failure for Helicobacter pylori(H. pylori) eradication.METHODS: Between January 2010 and December 2012,we screened individuals who were prescribed non-bismuth quadruple therapy for H. pylori eradication. Among them,a total of 98 patients who failed non-bismuth quadruple therapy received 1-wk or 2-wk moxifloxacin-containing triple therapy(400 mg moxifloxacin once daily,and 20 mg of rabeprazole and 1 g of amoxicillin twice daily). H. pylori status was evaluated using the 13C-urea breath test 4 wk later,after treatment completion. The eradication rates were determined by intention-to-treat and per-protocol analyses.RESULTS: In total,60 and 38 patients received 1-wk and 2-wk moxifloxacin-containing triple therapy,respectively. The intention-to-treat and per-protocol eradication rates were 56.7%(95%CI: 45.0-70.0) and 59.6%(95%CI: 46.6-71.7) in the 1-wk group and 76.3%(95%CI: 63.2-89.5) and 80.6%(95%CI: 66.7-91.9) in the 2-wk group(P = 0.048 and 0.036,respectively). All groups had good compliance(95% vs 94.9%). Neither group showed serious adverse events,and the proportions of patients experiencing mild side effects were not significantly different(21.1% vs 13.9%). Clinical factors such as age,sex,alcohol and smoking habits,comorbidities,and presence of gastric or duodenal ulcer did not influence the eradication therapy efficacy. The efficacy of second-line eradication therapy did not differ significantly according to the firstline regimen.CONCLUSION: Two-week moxifloxacin-containing triple therapy showed better efficacy than a 1-wk regimen after non-bismuth quadruple therapy failure.Key words: Helicobacter pylori; Moxifloxacin-based triple; Non-bismuth quadruple; Second-line; Eradication     

Helicobacter pylori infection in gastric mucosa-associated lymphoid tissue lymphoma

Gastrointestinal lymphoma is the most common type of extranodal lymphoma,and most commonly affects the stomach.Marginal zone B-cell lymphoma of the mucosa-associated lymphoid tissue(MALT)and diffuse large B-cell lymphoma are the most common histologic types of gastric lymphoma.Despite its increasing incidence,diagnosis of gastric lymphoma is difficult at an earlier stage due to its nonspecific symptoms and endoscopic findings,and,thus,a high index of suspicion,and multiple,deep,repeated biopsies at abnormally and normally appearing sites in the stomach are needed.In addition,testing for Helicobacter pylori(H.pylori)infection and endoscopic ultrasonography to determine the depth of tumor invasion and involvement of regional lymph nodes is essential for predicting response to H.pylori eradication and for assessment of disease progression.In addition,H.pylori infection and MALT lymphoma development are associated,and complete regression of low-grade MALT lymphomas after H.pylori eradication has been demonstrated.Radiotherapy and/or chemotherapy can be used in cases that show poor response to H.pylori eradication,negativity for H.pylori infection,or high-grade lymphoma.