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Hépato-Gastro & Oncologie Digestive

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Revised french recommendations on the management of Helicobacter pylori infection Volume 19, issue 7, Septembre 2012

Authors
Hôpital Ambroise Paré, service d’hépato-gastroentérologie, 9 avenue Charles de Gaulle, 92104, Boulogne-Billancourt, France, CHU La Miletrie, service de bactériologie, Poitiers, France, Hôpital de Villeneuve Saint Georges, service hépato-gastroentérologie, CHU de Nancy - Hôpital Central, service de médecine interne H, Nancy, France, Hôpital H. Mondor, service d’hépato-gastroentérologie, Créteil, France, Groupe hospitalier de l’Institut Catholique de Lille, unité de pédiatrie, France, Institut Pasteur, Paris, France, Unité INSERM U853, Université Bordeaux Segalen, laboratoire de bactériologie, Bordeaux, France, Hôpital Cochin, service de bactériologie, Paris, France

The gastric and duodenal ulcers are indications of research and eradication of H. pylori. Eradication of H. pylori promotes healing and prevents recurrence of ulcers.

Eradication of H. pylori is part of the initial management of all gastric MALT lymphoma. Eradication may be sufficient to achieve lasting remission especially if the lesion is localized (stage I of the Ann Arbor classification) and in the absence of t (11 ; 18) translocation.

Search and eradication of H. pylori are justified in dyspepsia for patients having normal endoscopy. In patients issued from area with high prevalence of infection (> 50 %) the strategy of testing the presence of H. pylori and eradicate the bacterium without endoscopy remains an option if any risk factors for ulcer (history, age, NSAIDs) or gastric cancer are absent. In a country like France where the prevalence of infection is low but with high level of strains resistance to antibiotics, endoscopy should be considered first.

The eradication of H. pylori is not a treatment of gastroesophageal reflux. The indications for H. pylori search and treatment are not modified by the presence of gastroesophageal reflux. Eradication should be considered for patients with long term PPI therapy in order to reduce the progression toward atrophy and intestinal metaplasia.

The search and eradication of H. pylori are recommended prior treatment with NSAIDs, especially in prolonged treatment. The search and eradication of H. pylori are recommended in patient's receving NSAIDs or low-dose aspirin and who have history of complicated ulcer or not. The eradication does not exclude a PPI treatment in patients with high risks factors.

Infection with H. pylori should be sought and treated in patients with iron deficiency anemia without obvious cause or with a vitamin B12 deficiency or a Idiopathic thrombocytopenic purpura.

Infection with H. pylori should be sought and treated in patients with a family history of gastric cancer in the first degree, mutations in DNA mismatch repair genes (HNPCC), pre-neoplastic lesions: atrophy with or without intestinal metaplasia, previous limited resection for gastric cancer, a long-term treatment by PPI (at least 6 months) .

The prevention of gastric cancer justifies endoscopy for screening and H. pylori treatment of prior a gastric bypass for bariatric purpose. In case of severe or diffuse preneoplastic lesions, a surgical procedure without isolating the gastric cavity must be preferred.

The rapid urease test allows rapid diagnosis of infection with H. pylori. Its negativity does not exclude infection. The test is not recommended for the control and eradication in patients treated with PPIs or antibiotics.

Histological examination assesses the mucosal lesions and detects infection by H. pylori. If a gastroscopy was performed, a minimum of five biopsies is needed for diagnosis of infection and histological lesions: one of the angle of the lesser curvature, two from the gastric body (small and large curvature), two of the antrum (small and large curvature).

Culture of H. pylori with antibiotic sensitivity testing is recommended whenever possible and especially after failure of eradication therapy.

Gene amplification is an alternative to culture with antibiotic susceptibility testing. This technique must be developed.

Serology does not control eradication and can not be used alone for initial diagnosis. Serology is particularly recommended in situations where other tests have likewise failed: bleeding ulcer, glandular atrophy, MALT lymphoma, recent use of antibiotics or PPIs.

The 13C urea breath test can be used for diagnosis and is highly recommended for validate eradication, subject to its realization at least 4 weeks after discontinuation of antibiotics and at least two weeks after discontinuation of PPI therapy.

The search for bacterial antigens by monoclonal test is recommended for the diagnosis and validation of eradication, if the breath test is not feasible.

When endoscopy is required, the search for H. pylori and the study of resistance to antibiotics are recommended.

The infection must be proven by culture or histology associated with the rapid urease test.

Based triple therapy of clarithromycin should no longer be prescribed as first-line empirical treatment in France. The sequential therapy should be recommended as first line in France.

Subject to approval by the French health authorities, the empiric antibiotic quadruple therapy combining PPI, tetracycline, metronidazole and bismuth is the most interesting alternative especially in patients allergic to beta-lactams or in those having received previously macrolides.

Eradication control must be systematic 4 weeks after ending antibiotic treatment and 15 days after stopping PPIs.

After failure of eradication of H. pylori and in the absence of isolation of the strain, antibiotics already used in previous therapy must not be reused.

In patients who have not previously received clarithromycin sequential therapy should be offered. In patients who received clarithromycin, quadruple therapy combining PPI, tetracycline, metronidazole and bismuth is an alternative, subject to approval by the French health authorities.

After failure to eradicate the determination by PCR techniques of bacterial mutations associated with resistance to clarithromycin and levofloxacin is an alternative to prescribing guided combination.

After two failures to eradicate the practice of endoscopy for isolation and sensitivity testing is essential to guide further treatment.