Unformatted text preview: Gastroesophageal
Reflux Disease and
By Salim A. Itani M.D.
Beirut-Lebanon Helicobacter Pylori
The discovery of H. pylori in
gastric mucosa has changed the
understanding and management
of several gastroduodenal
Benefits of the eradication of H. pylori
have been reported from patients
.Peptic ulcer disease
Peptic * Mucosa associated lymphoid tissue
. (MALT) lymphoma
.Gastric adenocarcinoma *
Gastric * H.Pylori &GERD
However the improvement of
symptoms in patients with
GERD after the eradication of
the bacteria remains
Questions 1- Is there any association between
GERD and H.Pylori infection ?
GERD 2-What is the reflection of presence of
H.Pylori infection on GERD ?
H.Pylori 3-What is the reflection of eradication
of H.pylori on GERD ?
of H.pylori and GERD
?a confusing issue
confusing Several studies showed a number
of controversies .
The role of H. pylori infection in
GERD remains controversial.
controversy The controversy is important because
GERD and its complications appear to be
increasing , whereas H.Pylori is
decreasing Evidence for an association
Clinical Studies :
-mostly retrospective and not designed to address
-did not have effect of eradication on GERD as a
primary outcome measure.
-variable results in
.Barrett’s No convincing evidence to indicate: … a causal relationship between GERD and
…that this organism has a significant
deleterious effect on any of the major
pathophysiological factors in GERD.
STUDY In a prospective ,double blind study ,
(*)demonstrates ,using excellent GERD
quantifying measures including validated
symptom severity scores, endoscopy, and24hrs
PHmetry,that there exist NO clinically significant
differences in clinical or laboratory related GERD
manifestations between H.Pylori infected and
non infected GERD patients.
non (*)Fallone et al (Aliment.Pharma. Therapy, 20(7) (761-768 ),2004) Hypothesis
The previous hypothesis that H. pylori
infection protects from the development of
GERD is thought to be an erroneous
concept Factors that influence the outcome
of studies of this relationship
of Prevalence of GERD and H.pylori,
H.pylori The pathological severity of GERD at the
time of presentation and investigation,
time The coexistence of peptic ulceration ,
peptic And the pathogenicity of the organism.
pathogenicity Chronic antrum –predominant
Hypergastrinemia and increased secretion
of acid leads to gastritis and Duodenal
ulcer In the presence of GERD ,reflux
esophagitis becomes more common .
esophagitis By treating the D.U. and eradicating
H.pylori, The acid load in stomach will
decrease to Normal without a change in
the parietal cell sensitivity to gastrin.
the Corpus predominant gastritis
Inverse relationship between the
prevalence H.pylori ,and that of Barrett’s
esophagus and its complications.
esophagus Corpus predominant gastritis, esp. those
who are cagA positive leads to gastric
atrophy and hypochlorhydria,thus
reducing the esophageal acid load and
CagA The presence of the CagA+ gene in
H.pylori has been implicated as a marker
of more severe histological gastritis,
CagA+ association with GERD has been
evaluated in several studies with
There is no evidence that infection with
cagA+ strains of H. pylori reduces risk of
Esophageal & gastric cardia
Studies confirm the positive association
between risk of distal gastric cancer and
infection with H.pylori infection , esp. CagA+
Strains. Corpus- predominating gastritis
CorpusEradication therapy of H.pylori will lead to
normal acid secretion.
normal For GERD patients, there in no evidence
that eradication exacerbates GERD
symptomatology or pathology.
symptomatology In any event , any exacerbation
(esophagitis) will be minor and can be
dealt with by PPI therapy.
It has been recommended to eradicate
H.pylori infection in those patients with
GERD needing long term treatment with
PPIs, as some studies have reported that
these drugs induce , in presence of the
organism, atrophic gastritis with the
consequent risk of gastric cancer.
gastric Eradication Therapy
When H.pylori eradication is
Indicated in a particular patient,
the concomitant diagnosis of
GERD should not change our
attitude. Take Home Message
Take There is, indeed, evidence to
indicate that eradication of H.
Pylori benefits the GERD
patient. THANK YOU
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- Fall '11
- Helicobacter pylori, h.pylori