HPylori
Helicobacter pylori is a spiral bacteria. It is only present in humans and locates exclusively in the stomach cavity. It resists a very acidic environment. ′′ The incidence of Helicobacter pylori infection is different in adults and children. In France, it is lower among children under 30 (20 % of people are infected at age 20) and more frequent after the age of 50 (about one in two people ))
In developing countries, 80 % of the population is infected before the age of 20 due to adverse socio-economic conditions (faulty and promiscuity).
Contamination
Contamination occurs mainly in childhood during the first five years of life and goes unnoticed. In the vast majority of cases, this infection is asymptomatic. The identification of this germ in Australia in the 1990 s completely questioned the physiopathology of the gastro-duodenal ulcer that has become an infectious disease. The two doctors who discovered Helicobacter pylori received the Nobel Prize in Medicine. There is currently no organized screening for Helicobacter pylori infection.
′′ Most of the time inflammation is silent ′′
Symptoms: gastritis or ulcers
The main protests related to the presence of bacteria are gastritis and a stomach or duodenal ulcer. ′′ Helicobacter pylori infection can be complicated by chronic gastritis (chronic inflammation of the stomach) that persists throughout life if the infection is not treated ", says the specialist. In rare cases, chronic carrying this bacteria can be responsible for a certain type of stomach cancer (called MALT lymphoma) that can cure by treating this infection. ′′ Most of the time, inflammation is silent, causing no symptoms. Seven out of 10 stomach ulcers are directly related to Helicobacter pylori infection and 9 duodenal ulcers out of 10 ′′
Diagnosis: biopsy, urease test
The GEFH (Group of French Studies of Helicobacter) has given recommendations to seek this infection in several situations. Diagnosis and treatment of Helicobacter pylori infection is currently recommended in the following cases:
chronic dyspepsia without visible injury at high digestive endoscopy;
stomach ulcer or recidivism, duodenal ulcer with or without complications;
history of ulcer with NSAID or low dose aspirin;
Atrophic gastritis;
presence of pre-neoplastic stomach lesions;
patients with cancer stomach resection;
patients with a 1st degree family history of stomach cancer;
patients requiring long-term non-steroidal anti-inflammatory treatment or associated with proton pump inhibitor treatment;
iron or vitamin B12 deficiency anemia;
immunological thrombocene purpura;
stomach lymphoma;
Lynch syndrome (HNPCC);
before obesity surgery like a stomach bypass.
Direct diagnostic methods are carried out using the stomach biopsy (fundus and den biopsies) performed during the endoscopic examination. The examination of these biopsies by microscope (anatomopathological examination) allows you to assess the characteristics of gastritis and its intensity and to visualize the bacteria. The urease test allows for a rapid diagnosis (transformation of urea into ammonia and CO2 by urease produced by Helicobacter pylori). The cultivation of stomach biopsies is interesting to perform an antibiogram, especially to guide treatment in the event of a therapeutic failure.
Indirect diagnostic methods are carried out most often to verify the efficacy of Helicobacter pylori treatment.
These methods are:
Urea breathing test marked with 13 C or HELIKIT;
the search for bacterial antigens in the saddles using immunozyme tests;
and serology of Helicobacter pylori (antibody search) during a blood test.
Treatments
′′ The treatment of Helicobacter pylori and its eradication is recommended in several situations such as the presence of a gastro-duodenal ulcer, chronic gastritis associated with the bacteria, MALT lymphoma, dyspepsia (after endoscopic exploration), a long-term IPP treatment, from a personal or family background to the first degree of stomach cancer ′′
There are several therapeutic strategies that will be ideally proposed by gastroenterologist, some of which are mentioned below
Sequential treatment for 10 days
The Helicobacter Study Group recommends the prescription of antisecretory treatment with double dose proton pump inhibitors (morning and evening) associated with amoxicillin at 1 gram morning and evening dose for 5 days … For the following five days, antisecretory treatment will be continued in the same way with Metronidazole at 500 mg morning and evening dose and Clarithromycin at 500 mg morning and evening dose in case of a sensitive strain or at Clarithromycin and Levofloxacin at 500 mg dose morning and evening in case of a Clarithromycin-resistant strain sensitive to quinolones. In case of resistance to both antibiotics, a tritherapy including double dose proton pump inhibitors - amoxicillin - metronidazole 500 mg at the dose of two tablets per day can be offered with an optimal duration of 14 days.
In all cases, there will be a need to ensure that there is no contraindication to the use of antibiotics, including allergies.
Regarding the dosage of proton pump inhibitors:
Omeprazole, Esomeprazole, Rabeprazole: 20 mg morning and evening,
Lansoprazole: 30 mg morning and evening,
Pantoprazole: 40 mg morning and evening.
Bismuthée quadritherapy for 10 days
It is based on the prescription of 3 capsules of Pylera ® 4 times a day (after breakfast, lunch, dinner and at bedtime) and Oméprazole 20 mg morning and evening. Each Pylera capsule contains: 140 mg bismuth citrate, 125 mg metronidazole,
125 mg tetracycline.
After, a test of control
According to GEFH, eradication rates with sequential treatment or bismuthée quadritherapy on the front line are 90 %. Therefore, the treatment used to eradicate Helicobacter pylori is not effective at 100 %. GEFH recommends an eradication control test by respecting a deadlines without antibiotics at least 4 weeks and without 2 weeks proton pump inhibitors to avoid false negatives. This check test is a ¹³ C urea breathing test. The test requires two collections of air expired at the lab with 30 minutes interval. Two prescriptions must be given to the patient: one for the pharmacy (′′ Respiratory test with urea marked ¹³ C ′′), the other for the laboratory (′′ collection and analysis of expired air ′′).