Houston Consensus Conference on Testing for Helicobacter pylori Infection in the United States
2018; Elsevier BV; Volume: 16; Issue: 7 Linguagem: Inglês
10.1016/j.cgh.2018.03.013
ISSN1542-7714
AutoresHashem B. El–Serag, John Y. Kao, Fasiha Kanwal, Mark A. Gilger, Frank LoVecchio, Steven F. Moss, Sheila E. Crowe, Adam Elfant, Thomas Haas, Ronald Hapke, David Y. Graham,
Tópico(s)Gastrointestinal disorders and treatments
ResumoDespite guidelines for detection and treatment of Helicobacter pylori infection, recommendations to test patients before and after therapy are commonly not followed in the United States. At the Houston Consensus Conference, 11 experts on management of adult and pediatric patients with H pylori, from different geographic regions of the United States, met to discuss key factors in diagnosis of H pylori infection, including identification of appropriate patients for testing, effects of antibiotic susceptibility on testing and treatment, appropriate methods for confirmation of infection and eradication, and relevant health system considerations. The experts divided into groups that used a modified Delphi panel approach to assess appropriate patients for testing, testing for antibiotic susceptibility and treatment, and test methods and confirmation of eradication. The quality of evidence and strength of recommendations were evaluated using the GRADE system. The results of the individual workshops were presented for a final consensus vote by all panel members. After the Expert Consensus Development meeting, the conclusions were validated by a separate panel of gastroenterologists, who assessed their level of agreement with each of the 29 statements developed at the Expert Consensus Development. The final recommendations are provided, on the basis of the best available evidence, and provide consensus statements with supporting literature to implement testing for H pylori infection at health care systems across the United States. Despite guidelines for detection and treatment of Helicobacter pylori infection, recommendations to test patients before and after therapy are commonly not followed in the United States. At the Houston Consensus Conference, 11 experts on management of adult and pediatric patients with H pylori, from different geographic regions of the United States, met to discuss key factors in diagnosis of H pylori infection, including identification of appropriate patients for testing, effects of antibiotic susceptibility on testing and treatment, appropriate methods for confirmation of infection and eradication, and relevant health system considerations. The experts divided into groups that used a modified Delphi panel approach to assess appropriate patients for testing, testing for antibiotic susceptibility and treatment, and test methods and confirmation of eradication. The quality of evidence and strength of recommendations were evaluated using the GRADE system. The results of the individual workshops were presented for a final consensus vote by all panel members. After the Expert Consensus Development meeting, the conclusions were validated by a separate panel of gastroenterologists, who assessed their level of agreement with each of the 29 statements developed at the Expert Consensus Development. The final recommendations are provided, on the basis of the best available evidence, and provide consensus statements with supporting literature to implement testing for H pylori infection at health care systems across the United States. Since 2015, 4 major Helicobacter pylori consensus documents have been published.1Malfertheiner P. Megraud F. O'Morain C.A. et al.Management of Helicobacter pylori infection-the Maastricht V/Florence Consensus Report.Gut. 2017; 66: 6-30Crossref PubMed Scopus (1763) Google Scholar, 2Chey W.D. Leontiadis G.I. Howden C.W. et al.ACG Clinical Guideline: treatment of Helicobacter pylori infection.Am J Gastroenterol. 2017; 112: 212-239Crossref PubMed Scopus (751) Google Scholar, 3Fallone C.A. Chiba N. van Zanten S.V. et al.The Toronto consensus for the treatment of Helicobacter pylori Infection in Adults.Gastroenterology. 2016; 151: 51-69Abstract Full Text Full Text PDF PubMed Scopus (500) Google Scholar, 4Sugano K. Tack J. Kuipers E.J. et al.Kyoto global consensus report on Helicobacter pylori gastritis.Gut. 2015; 64: 1353-1367Crossref PubMed Scopus (941) Google Scholar The stimulus for this consensus conference was that, despite previous guidelines, recommendations regarding appropriate testing before therapy were commonly not followed, and testing after therapy was also not recommended for practitioners in the United States.5Chey W.D. Wong B.C. American College of Gastroenterology guideline on the management of Helicobacter pylori infection.Am J Gastroenterol. 2007; 102: 1808-1825Crossref PubMed Scopus (1044) Google Scholar For example, a large 2007 retrospective study of US pharmacy claims involving 1.9 million health plan members showed serology to be the most common H pylori test used.6Howden C.W. Blume S.W. de Lissovoy G. Practice patterns for managing Helicobacter pylori infection and upper gastrointestinal symptoms.Am J Manag Care. 2007; 13: 37-44PubMed Google Scholar A more recent study, performed between 2010 and 2013, analyzed first-time H pylori diagnostic tests among more than 100 million individuals and reported that serology was used in ∼70% of 515,700 tests, of which 4.2% were positive.7Theel E.S. Johnson R.D. Plumhoff E. et al.Use of the Optum Labs Data Warehouse to assess test ordering patterns for diagnosis of Helicobacter pylori infection in the United States.J Clin Microbiol. 2015; 53: 1358-1360Crossref PubMed Scopus (9) Google Scholar Serology was used in ∼70%; 15,495 tests (4.2%) were positive.7Theel E.S. Johnson R.D. Plumhoff E. et al.Use of the Optum Labs Data Warehouse to assess test ordering patterns for diagnosis of Helicobacter pylori infection in the United States.J Clin Microbiol. 2015; 53: 1358-1360Crossref PubMed Scopus (9) Google Scholar Despite the need to confirm the results of serologic tests in low prevalence populations,8Vecchio T.J. Predictive value of a single diagnostic test in unselected populations.N Engl J Med. 1966; 274: 1171-1173Crossref PubMed Scopus (705) Google Scholar only a minority of patients with positive serology had confirmatory testing (ie, urea breath test [UBT] in ∼16% and stool antigen immunoassay [HpSAg] testing in 11%) within the 14-day window allowed by the study. Although reimbursement potentially influences practice patterns, the Centers for Medicare and Medicaid Services reimburses all methods of H pylori testing and at that time reimbursed $19.80 for serology, $91.89 for UBT, and $19.62 HpSAg. Since that time, several commercial insurance companies have designated serology as not medically necessary and no longer reimburse for that test.7Theel E.S. Johnson R.D. Plumhoff E. et al.Use of the Optum Labs Data Warehouse to assess test ordering patterns for diagnosis of Helicobacter pylori infection in the United States.J Clin Microbiol. 2015; 53: 1358-1360Crossref PubMed Scopus (9) Google Scholar A 2017 study among practicing gastroenterologists reported gastric biopsy as the most common diagnostic method (59%) followed by HpSAg (20%)9Murakami T.T. Scranton R.A. Brown H.E. et al.Management of Helicobacter pylori in the United States: Results from a national survey of gastroenterology physicians.Prev Med. 2017; 100: 216-222Crossref PubMed Scopus (24) Google Scholar; the predominance of biopsy likely reflected the fact that specialist practice often consists of referrals. The most common therapy prescribed was standard triple therapy, and among these 53% were for 14 days and 30% were for 7 or 10 days. This regimen has continued to be used despite data that the cure rates with standard triple therapy had fallen below 80% by 2000.10Shiotani A. Lu H. Dore M.P. Graham D.Y. Treating Helicobacter pylori effectively while minimizing misuse of antibiotics.Cleve Clin J Med. 2017; 84: 310-318Crossref PubMed Scopus (40) Google Scholar, 11Graham D.Y. Lee Y.C. Wu M.S. Rational Helicobacter pylori therapy: Evidence-based medicine rather than medicine-based evidence.Clin Gastroenterol Hepatol. 2014; 12: 177-186Abstract Full Text Full Text PDF PubMed Scopus (249) Google Scholar, 12Graham D.Y. Fischbach L.A. Empiric therapies for Helicobacter pylori infections.CMAJ. 2011; 183: E506-E508Crossref PubMed Scopus (16) Google Scholar, 13Rimbara E. Fischbach L.A. Graham D.Y. Optimal therapy for Helicobacter pylori infections.Nat Rev Gastroenterol Hepatol. 2011; 8: 79-88Crossref PubMed Scopus (168) Google Scholar The issue of falling cure rates was not incorporated into the guidelines until 201214Malfertheiner P. Megraud F. O'Morain C.A. et al.Management of Helicobacter pylori infection–the Maastricht IV/ Florence Consensus Report.Gut. 2012; 61: 646-664Crossref PubMed Scopus (1881) Google Scholar and not explicitly until 2017.1Malfertheiner P. Megraud F. O'Morain C.A. et al.Management of Helicobacter pylori infection-the Maastricht V/Florence Consensus Report.Gut. 2017; 66: 6-30Crossref PubMed Scopus (1763) Google Scholar Moreover, despite declining eradication rates with standard triple therapy, gastrointestinal physicians report confirming H pylori eradication in only 58% of cases.9Murakami T.T. Scranton R.A. Brown H.E. et al.Management of Helicobacter pylori in the United States: Results from a national survey of gastroenterology physicians.Prev Med. 2017; 100: 216-222Crossref PubMed Scopus (24) Google Scholar Clearly, a knowledge gap regarding best practices for H pylori diagnosis and therapy exists even among physicians most likely to be considered experts by their colleagues, and despite regularly updated guidelines, many gaps persist in practice. The guidelines developed by this consensus group focused on identifying the target populations for diagnosis and therapy with the aim of providing practical advice for US practitioners and recommendations for guidelines and to be adopted by US health care systems. Clearly, performance gaps exists in the practice of H pylori diagnosis and therapy even among expert physicians, and despite regularly updated guidelines. We convened a consensus conference to develop a set of recommendations for appropriate diagnostic testing and treatment strategies focusing on eradication of active H pylori infections. These recommendations would provide practical advice for US practitioners, and also guidelines to be adopted by US health care systems. The first step was to identify areas that would potentially be discussed at the meeting and to develop a set of draft consensus statements. This was done by the meeting leaders, Drs Graham and El-Serag, who compiled a list of important unresolved issues that included: (1) the impact of H pylori on gastric pathology if left untreated; (2) the amount of unnecessary hospitalizations due to H pylori–related gastric pathology; (3) the ability to reduce antibiotic overuse (or misuse) through active infection testing; and (4) the role of a test-treat-test strategy for H pylori diagnosis and eradication confirmation in the outpatient setting. We prepared draft consensus statements for the following 4 key topics related to H pylori management: (1) Who are the appropriate patient groups for testing?; (2) What is the impact of antibiotic susceptibility on testing and treatment of H pylori infection; (3) What are the appropriate testing methods for confirmation of eradication?; and (4) What are the health system considerations that are relevant to H pylori testing? We used a modified Delphi panel approach, which is an iterative, evidence-based process that combines the best available scientific data with the collective judgment of experts to develop the consensus statements. For each of the draft consensus statements, key references were identified, and with the assistance of a commercial vendor (Hospicom, Cold Spring, NY) draft consensus statements were developed. We identified an 11-member, multidisciplinary, expert panel consisting of opinion leaders in H pylori management from different geographic regions of the United States to assess the appropriateness of the candidate statements. Participants included adult and pediatric gastroenterologists, family and internal medicine practitioners, and experts in laboratory medicine. The group was sufficiently large to provide geographic, practice setting, and knowledge/attitude/belief diversity, and small enough to allow the dynamic exchange in a group discussion.15The Rand/UCLA appropriateness method user's manual. RAND Corporation, Santa Monica, CA2001Google Scholar The panel members met in a 1-day face-to-face meeting. Before the meeting, copies of the draft statements were sent to the invited panel members and the invitees were instructed to review, revise, and modify the draft consensus statements. Invitees were also instructed to review the available evidence and to be able to present the evidence and debate the issues at the face-to-face meeting designed to result in a consensus among the group for each statement. Each invitee was directed to prepare their point of view on each statement they were assigned and to state whether they agreed with the statement as written or to propose revisions and to provide the evidence in both cases. All invitees were asked to vote on all the statements for group consensus results. The Expert Consensus Development Meeting was held in Houston, Texas, on October 28, 2016, to refine and vote on the statements. The quality of evidence and strength of recommendations were evaluated using the GRADE system (Table 1).16Guyatt G.H. Oxman A.D. Vist G.E. et al.GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.BMJ. 2008; 336: 924-926Crossref PubMed Google Scholar, 17Guyatt G.H. Oxman A.D. Kunz R. et al.Going from evidence to recommendations.BMJ. 2008; 336: 1049-1051Crossref PubMed Google Scholar Voting was done using ballots which were immediately tabulated and the levels of agreement were shown on the screen using a 5-point Likert-type scale with responses ranging from 1 (strongly disagree) to 5 (strongly agree).Table 1GRADE: Quality of Evidence and Strength of RecommendationsQuality of evidenceA. High qualityFurther research is very unlikely to change our confidence in the estimate of effectB. Moderate qualityFurther research is very unlikely to have an important impact on our confidence in the estimate of effect and may change the estimateC. Low qualityFurther research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimateD. Very low qualityAny estimate of effect is very uncertainStrength of recommendation1. Strong Recommendation:Strong recommendation for using an intervention/strong recommendation against using an intervention2. Weak recommendationWeak recommendation for using an intervention/weak recommendation against using an intervention Open table in a new tab The attendees were divided into 3 work groups: (1) identification of appropriate patients for testing; (2) antibiotic susceptibility testing and treatment of H pylori infection; and (3) testing methods and confirmation of eradication. The teams refined and revised the statements and either agreed with the statement as written or provided a revised statement. Additionally, they were also asked to provide key references and to assign a grade and level of evidence for each statement. The statements and rationale were then presented to the full meeting participants and all statements were assigned a score using the 5-point Likert-type scale regarding the level of agreement. The statements either achieved consensus, when 80% or more indicated they strongly agreed or agreed with the statement, or achieved no consensus. Those statements failing to achieve consensus underwent postvote revision with full group discussion followed by a second and final vote to attempt to reach consensus. After the Expert Consensus Development meeting at which the statements were refined or revised, and the consensus was reached, an external validation was done where the statements were posed to a separate panel of gastroenterologists to assess their level of agreement with statements designed by the expert panel. Validation was tested using an online survey that assessed the level of agreement with each of the 29 statements previously developed at the Expert Consensus Development Meeting was assessed using a 5-point Likert-type scale with responses ranging from 1 (strongly disagree) to 5 (strongly agree). The validation group was identified by an expert contract group (SERMO, New York, NY) who identified 100 respondents who met all the criteria listed in Supplementary Tables 1 and 2 from a panel of 4100 U.S.-based gastroenterologists. Each respondent received a nominal incentive of $15 to complete the survey. The results of their responses were then tabulated and compared with those of the expert panel. The consensus conference was sponsored by Otsuka America Pharmaceutical, Inc (OAPI). Each conference participant received an honorarium from OAPI. Members of OAPI’s Medical Device Division were present and made brief introductions, but were not involved in substantive discussions or drafting of the manuscript. The final draft of the manuscript was reviewed by OAPI. Planning for the meeting including meeting logistics and coordination of travel was done by Hospicom. Additionally, Hospicom helped to identify the appropriate references, provided a scribe for each working group, managed the details of blinded voting, and assisted in preparing the slides used to present the drafts of the statements. The 11 members of the working group met in Houston, Texas, for an all-day meeting to discuss, debate, and revise the statements drafted in advance of the meeting. The original topics were: (1) identification of appropriate patients for testing (14 statements); (2) antibiotic susceptibility testing and treatment of H pylori infection (5 statements); and (3) testing methods and confirmation of eradication (11 statements; 1 statement was duplicated and in 2 groups). The group achieved consensus (defined as 80% or more agreed or strongly agreed) for 27 of the 29 statements. All 29 statements were submitted to the external review panel, and 6 statements, including the 2 not agreed upon by the expert panel, did not achieve consensus when reviewed by the external panel. All 6 of the statements that did not achieve consensus were within the “Identification of Appropriate Patients for Testing” topic. Finally, the statements were reformatted as recommendations using published guidelines.18Andrews J. Guyatt G. Oxman A.D. et al.GRADE guidelines: 14. Going from evidence to recommendations: the significance and presentation of recommendations.J Clin Epidemiol. 2013; 66: 719-725Abstract Full Text Full Text PDF PubMed Scopus (820) Google Scholar Identification of appropriate patients for testing approved by both the panel and the external group•Statement 1: We recommend that all patients with active H pylori infection be treated (100% agree/strongly agree, Grade 1A).•Statement 2: All patients with current or past gastric or duodenal ulcers should be tested for H pylori infection (100% agree/strongly agree; Grade 1A).•Statement 3: We recommend that all patients with uninvestigated dyspepsia be tested for H pylori infection (100% agree/strongly agree, Grade 1A).•Statement 4: We recommend routine testing for H pylori infection in patients with reflux symptoms only if they are at high risk for H pylori-related disease (91% agree/strongly agree, Grade 1C).•Statement 5: We recommend that patients with gastric mucosa-associated lymphoid tissue (MALT) lymphoma be tested for H pylori infection (100% agree/strongly agree, Grade 1B).•Statement 6: We recommend that individuals with family history of gastric cancer be tested for H pylori infection (100% agree/strongly agree, Grade 1B).•Statement 7: We recommend that patients who are first-generation immigrants from high prevalence areas be tested for H pylori infection (82% agree/strongly agree, Grade 1B).•Statement 8: We suggest that patients of Latino and African American racial or ethnic groups may be considered for H pylori testing due to their high risk of infection (91% agree/strongly agree, Grade 2C). The underlying principles regarding testing for H pylori are that H pylori infection is associated with a significant risk of important clinical outcomes, and that risk is not predictable for a given individual. The infection causes chronic progressive damage to the gastric mucosa that in 20%–25% of individuals will result in life-threatening clinical outcomes such as peptic ulcer or gastric cancer.19Graham D.Y. Can therapy ever be denied for Helicobacter pylori infection?.Gastroenterology. 1997; 113: S113-S117Abstract Full Text PDF PubMed Google Scholar, 20Axon A. Forman D. Helicobacter gastroduodenitis: a serious infectious disease.BMJ. 1997; 314: 1430-1431Crossref PubMed Google Scholar, 21Reddy K.M. Chang J.I. Shi J.M. et al.Risk of gastric cancer among patients with intestinal metaplasia of the stomach in a US integrated health care system.Clin Gastroenterol Hepatol. 2016; 14: 1420-1425Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar, 22Rugge M. Genta R.M. Di Mario M.F. et al.Gastric cancer as preventable disease.Clin Gastroenterol Hepatol. 2017; 15: 1833-1843Abstract Full Text Full Text PDF PubMed Scopus (138) Google Scholar H pylori infection differs from other chronic infections with long latent periods and clinically important outcomes such as tuberculosis and syphilis in that H pylori remains transmissible (Statement 1).19Graham D.Y. Can therapy ever be denied for Helicobacter pylori infection?.Gastroenterology. 1997; 113: S113-S117Abstract Full Text PDF PubMed Google Scholar Therefore, the Kyoto consensus guideline defined H pylori as an infectious disease that when diagnosed should be cured unless there are extenuating circumstances.4Sugano K. Tack J. Kuipers E.J. et al.Kyoto global consensus report on Helicobacter pylori gastritis.Gut. 2015; 64: 1353-1367Crossref PubMed Scopus (941) Google Scholar While in the United States the prevalence of H pylori infection is relatively low in the overall general population, there are large subpopulations (eg, African Americans, Hispanics, Korean Americans, Chinese Americans) with high H pylori prevalence and increased risk of important clinical outcomes such as peptic ulcer or gastric cancer.21Reddy K.M. Chang J.I. Shi J.M. et al.Risk of gastric cancer among patients with intestinal metaplasia of the stomach in a US integrated health care system.Clin Gastroenterol Hepatol. 2016; 14: 1420-1425Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar, 23Grad Y.H. Lipsitch M. Aiello A.E. Secular trends in Helicobacter pylori seroprevalence in adults in the United States: evidence for sustained race/ethnic disparities.Am J Epidemiol. 2012; 175: 54-59Crossref PubMed Scopus (104) Google Scholar, 24Dong E. Duan L. Wu B.U. Racial and ethnic minorities at increased risk for gastric cancer in a regional US population study.Clin Gastroenterol Hepatol. 2017; 15: 511-517Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar H pylori is etiologically related to gastric and duodenal ulcers, gastric cancer, and MALT lymphoma.25Graham D.Y. Helicobacter pylori update: Gastric cancer, reliable therapy, and possible benefits.Gastroenterology. 2015; 148: 719-731Abstract Full Text Full Text PDF PubMed Scopus (314) Google Scholar Peptic ulcer disease is one of the most common and important clinical manifestations of H pylori infection. Patients with a current or past history of a gastroduodenal ulcer should be considered to be at risk of peptic ulcer disease until the cause of the disease is eliminated (Statement 2). The natural history of peptic ulcers in patients with uncured H pylori ulcer disease is complicated with potentially life-threatening complication, most often bleeding in approximately 25% of the infected individuals.19Graham D.Y. Can therapy ever be denied for Helicobacter pylori infection?.Gastroenterology. 1997; 113: S113-S117Abstract Full Text PDF PubMed Google Scholar, 20Axon A. Forman D. Helicobacter gastroduodenitis: a serious infectious disease.BMJ. 1997; 314: 1430-1431Crossref PubMed Google Scholar Cure of the infection results in healing of peptic ulcers and prevention of recurrence and ulcer complications such as bleeding or rebleeding.26Ford A.C. Delaney B.C. Forman D. et al.Eradication therapy in Helicobacter pylori positive peptic ulcer disease: systematic review and economic analysis.Am J Gastroenterol. 2004; 99: 1833-1855Crossref PubMed Scopus (152) Google Scholar Dyspepsia has been defined as predominant epigastric pain lasting at least 1 month.27Moayyedi P.M. Lacy B.E. Andrews C.N. et al.ACG and CAG Clinical Guideline: management of dyspepsia.Am J Gastroenterol. 2017; 112: 988-1013Crossref PubMed Scopus (271) Google Scholar Patients with uninvestigated dyspepsia represent a special problem because their clinical presentation overlaps with the presenting symptoms of H pylori–related peptic ulcer disease (Statement 3). H pylori is one of the causes of dyspepsia in the absence of peptic ulcer. However, the number needed to treat for H pylori to achieve 1 symptomatic response has been estimated at 8,28Vakil N.B. Howden C.W. Moayyedi P. et al.White Paper AGA: functional dyspepsia.Clin Gastroenterol Hepatol. 2017; 15: 1191-1194Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar perhaps due to the delayed or exaggerated response of the functional components of the patient’s symptomatology. The recommendation to test and treat those with dyspepsia and H pylori infection has been included in the Kyoto, Maastricht, American College of Gastroenterology, and Canadian consensuses.1Malfertheiner P. Megraud F. O'Morain C.A. et al.Management of Helicobacter pylori infection-the Maastricht V/Florence Consensus Report.Gut. 2017; 66: 6-30Crossref PubMed Scopus (1763) Google Scholar, 2Chey W.D. Leontiadis G.I. Howden C.W. et al.ACG Clinical Guideline: treatment of Helicobacter pylori infection.Am J Gastroenterol. 2017; 112: 212-239Crossref PubMed Scopus (751) Google Scholar, 4Sugano K. Tack J. Kuipers E.J. et al.Kyoto global consensus report on Helicobacter pylori gastritis.Gut. 2015; 64: 1353-1367Crossref PubMed Scopus (941) Google Scholar, 27Moayyedi P.M. Lacy B.E. Andrews C.N. et al.ACG and CAG Clinical Guideline: management of dyspepsia.Am J Gastroenterol. 2017; 112: 988-1013Crossref PubMed Scopus (271) Google Scholar Although H pylori eradication may not resolve the clinical problem of dyspepsia in most patients, successful H pylori eradication therapy will reduce significantly the long-term risk of developing either peptic ulcer or gastric cancer.29Lee Y.C. Chiang T.H. Liou J.M. et al.Mass Eradication of Helicobacter pylori to prevent gastric cancer: Theoretical and practical considerations.Gut Liver. 2016; 10: 12-26Crossref PubMed Scopus (39) Google Scholar While many infected patients remain asymptomatic and may never develop complications, there are no predictors to determine which patients with nonatrophic H pylori-associated gastritis that, if left untreated, will not progress.4Sugano K. Tack J. Kuipers E.J. et al.Kyoto global consensus report on Helicobacter pylori gastritis.Gut. 2015; 64: 1353-1367Crossref PubMed Scopus (941) Google Scholar Gastroesophageal reflux disease (GERD) is typically a manifestation of robust acid secretion and an abnormal esophagogastric antireflux barrier. In the US population, where H pylori is infrequent, there is an inverse correlation between the prevalence of H pylori and erosive esophagitis or Barrett’s esophagus.30Raghunath A. Hungin A.P. Wooff D. et al.Prevalence of Helicobacter pylori in patients with gastro-oesophageal reflux disease: systematic review.BMJ. 2003; 326: 737Crossref PubMed Scopus (271) Google Scholar Thus, the recommendation not to routinely use noninvasive testing for H pylori in patients with GERD unless they are at high risk for H pylori disease (eg, on the basis of ethnic group; Statement 4). While this may seem to conflict with the recommendation that H pylori eradication be considered for patients who use proton pump inhibitors (PPIs), that recommendation is limited to the subset of GERD patients in whom longer term PPI use is planned (Statement 10). High acid output is also associated with antral predominant H pylori gastritis and with duodenal ulcer disease. If endoscopy is done for any reason such as to evaluate heartburn symptoms, it would be prudent to include gastric biopsy to exclude H pylori infection. Treatment of H pylori in patients with GERD does not alter the course or treatment of that disease.1Malfertheiner P. Megraud F. O'Morain C.A. et al.Management of Helicobacter pylori infection-the Maastricht V/Florence Consensus Report.Gut. 2017; 66: 6-30Crossref PubMed Scopus (1763) Google Scholar, 31Moayyedi P. Bardhan C. Young L. et al.Helicobacter pylori eradication does not exacerbate reflux symptoms in gastroesophageal reflux disease.Gastroenterology. 2001; 121: 1120-1126Abstract Full Text Full Text PDF PubMed Scopus (206) Google Scholar Gastric B cell lymphoma (also known as MALT lymphoma) and gastric cancer are both etiologically related to H pylori infection.32Wotherspoon A.C. Gastric lymphoma of mucosa-associated lymphoid tissue and Helicobacter pylori.Annu Rev Med. 1998; 49: 289-299Crossref PubMed Scopus (95) Google Scholar Because MALT lymphoma is often responsive to H pylori eradication, it is recommended that all patients with gastric MALT lymphoma be tested for H pylori with the idea that treatment will usually produce a remission or even a cure (Statement 5).33Nakamura S. Matsumoto T. Treatment strategy for gastric mucosa-associated lymphoid tissue lymphoma.Gastroenterol Clin North Am. 2015; 44: 649-660Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar First-degree relatives of those with symptomatic H pylori disease such as peptic ulcer or gastric cancer are usually raised in the
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