Recurrent symptoms and gastro‐oesophageal reflux disease in patients with duodenal ulcer treated for Helicobacter pylori infection

Abstract

Background: Eradication of Helicobacter pylori has been shown to prevent relapse of endoscopically detected duodenal ulcers. There is controversy regarding symptom improvement after therapy. Some studies have suggested that a substantial number of patients remain symptomatic after eradication therapy. Other studies suggest that gastro‐oesophageal reflux disease (GERD) may develop as a result of H. pylori eradication. Aim: To determine the relationship between symptoms and H. pylori eradication and to determine whether H. pylori eradication results in symptoms or endoscopic findings of GERD. Methods: Two hundred and forty‐two patients with endoscopically documented duodenal ulcer disease and evidence of H. pylori infection by rapid urease testing and histology were studied in four randomized, placebo‐controlled, double‐blind trials of H. pylori eradication therapy. All patients underwent symptom assessment and endoscopy with biopsy before therapy and 1 and 6 months after completing therapy. The rapid urease test and histology were used to determine H. pylori status. Interviewers were blinded to H. pylori status after eradication and were unaware of the endoscopic findings (interviews were performed prior to repeat endoscopy). Results: The presence of epigastric pain was significantly associated with persistent H. pylori infection 1 month after therapy (odds ratio 2.3, 95% CI: 1.02–5.2; P=0.041), as was nausea (OR 7.1, 95% CI: 0.93–55.6; P=0.029). The presence of epigastric pain was significantly associated with ulcer relapse at 6 months (OR 7.5, 95% CI: 3.6–15.7; P < 0.001) as was nausea (OR 5.1, 95% CI: 1.7–16.0; P=0.002). Heartburn was not associated with eradication of H. pylori or ulcer relapse. New onset reflux symptoms were reported by 17% (17 of 101 patients) at 6 months and were not significantly different in patients with (15%) and without (22%) persistent H. pylori infection (P=0.47). Erosive oesophagitis was present at endoscopy in one of the 17 cases that developed new heartburn. Conclusions: One month after completion of therapy, the presence of epigastric pain or nausea is associated with persistent infection and these symptoms at 6 months are suggestive of duodenal ulcer relapse. The incidence of GERD is not increased in patients who have eradication of H. pylori.

Role of Corpus Gastritis and cagA -Positive Helicobacter pylori Infection in Reflux Esophagitis

“…Case-control studies (9,11,14) have shown that the eradication of H. pylori from patients with duodenal ulcers may provoke GERD. This finding, however, has not been confirmed by other investigators (23,24). Conflicting data have been also observed in studies evaluating the association between GERD and H. pylori infection.…”

Patterns of gastritis and the effect of eradicating Helicobacter pylori on gastro‐oesophageal reflux disease in Western patients with non‐ulcer dyspepsia

“…26 Two randomized controlled trials in 603 individuals reported on the development of oesophagitis. The development of reflux symptoms was uncommon, occurring in 6% of individuals undergoing eradication and 3% taking placebo (relative risk: 2, 95% CI: [1][2][3][4][5]. Differences between these studies are probably related to the small sample sizes, which make it difficult to detect an uncommon event, differences in the pattern of gastritis in the different populations studied and the lack of a randomized control group in others.…”

“…2 The incidence of symptomatic or endoscopic GERD developing in ulcer patients cured of the infection, however, has ranged widely in other reports. [3][4][5][6][7] The results of H. pylori eradication in non-ulcer dyspepsia have been mixed, with some studies showing no benefit and others demonstrating improvement in symptoms and prevention of future ulcer disease. [8][9][10] A recent meta-analysis demonstrated modest efficacy for H. pylori eradication in alleviating dyspeptic symptoms with a number needed to treat of 19. 11 A subsequent meta-analysis using individual patient data suggested that the benefit of eradication was similar whether patients with predominant epigastric pain or predominant heartburn were studied.…”

Neither genotype nor the gastric colonization site of Helicobacter pylori are predictive factors for the development of erosive esophagitis in patients with peptic ulcer disease, 1 year after eradication

“…Several studies made evident that the virulence of the CagA-positive H. pylori strains can determine a protector effect against the development of reflux esophagitis, especially that more severe (18,39) , including Barrett's esophagus (37) .…”