Eradication therapy in Gastritis

Mohammad Rafiqul Islam. Assistant Professor of Medicine.

Dhaka Medical College.

The broad spectrum of gastritis

• General agreement on morphological aspects

• Great variety of names resulting in confusion • Many controversies caused by semantics

Gastritis is a histological diagnosis not a clinical diagnosis.

Michael Vieth. Diagnostic histopathology. June 2014.

Endoscopic findings such as erythema are frequently labeled as gastritis

Lack of evidence supporting a correlation between endoscopic features and histologic gastritis.

Sauerbructh Tchussler P et all. Endosc 1984; 16: 101–104

Epithelial or endothelial damage without

inflammation is Gastropathy

J Lindsay. Kumar and Clark’s clinical medicine. 2012

Original Sydney System (1990)

• Endoscopic and histological divisions • Histological arm: Combining topographical, morphological and etiological information Misiewicz JJ, J Gastroenterol Hepatol 1991 Price AB, J Gastroenterol Hepatol 1991

Updated Sydney System (1994)

General principles and grading retained Terminology improved to differentiate

between atrophic and nonatrophic stomach Provision of a visual analogue scale (Kappa value <0.5) Dixon MF, Am J Surg Pathol 1996 El-Zimaity HM, Hum Pathol 1996; 27:35-41

H.Pylori gastritis

1. Acute Gastritis 2. Chronic Gastritis Non atrophic gastritis Multifocal atrophic gastritis Autoimmune gastritis Atropic Gastritis Capella R. Gastritis. Philadelphia; 79–96. Rugge M. Hum Pathol; 36(3): 228–233.

H.pylori

Non-Helicobacter infectious gastritis

Bacterial: Mycobacterium tuberculosis, Mycobacterium avium-intracellulare, Treponema pallidum Viral: cytomegalovirus Fungal: Candida, Histoplasma capsulatum, Mucormycosis Parasitic: Cryptosporidium, giardiasis, Strongyloides stercoralis, Anisakis

CMV Gastritis

Non-infectious gastritis

• Acute gastritis -caustic gastritis -ulcero-haemorrhagic gastritis • Reactive gastropathy • Iatrogenic gastritis -drug related gastritis (iron, mucosal calcinosis, colchicine, …) -radiation gastritis • Autoimmune and other immunologically mediated gastritides -type A autoimmune gastritis -graft-versus-host disease -other forms of autoimmune and immunogical gastritis • Gastric manifestations of inflammatory bowel disease -Crohn’s disease -focally enhancing gastritis • Miscellaneous forms of gastritis with a distinctive histology -granulomatous gastritis -lymphocytic gastritis -collagenous gastritis -eosinophilic gastritis • Vascular gastropathies Srivastava A, Histopathology 2007

Caustic gastritis Haemorrhagic gastritis

Robin Warren and Barry Marshall 2005.

Helicobacter pylori

Major cause of non autoimmune chronic gastritis.

Acute gastritis and HP

H. Pylori induced acute gastritis is usually non erosive.

Acute gastritis encountered by H.pylori is usually asymptomatic.

Mohammad Wehbi, Acute Gastritis, Medscape 2016

Chronic Gastritis and HP

About 75% of patients with chronic gastritis have been found to have H.pylori infection compared to 10% in those without gastritis.

Zhang C et all. World J Gastroenterol 2005; 11: 791–796

Prevalence

The overall prevalence of H. pylori infection 28.7% in superficial gastritis, 57% in erosive gastritis, 63% in gastric erosion, 80% in gastric ulcer 52.4% in early gastric cancer Zhang C et all. World J Gastroenterol 2005; 11: 791–796

Perhaps up to 40% or more of patients with endoscopically normal mucosa have histological gastritis visible on biopsy.

Tytgat GNJ. J Gastroenterol Hepatol 1991; 6: 223–224.

What do we need for correct gastritis evaluation?

Two antral biopsies (highest number of H. pylori organism)

Two corpus biopsies (particularly valuable for finding H. pylori after treatment)

One biopsie from the incisura angularis (maximal degrees of atrophy and intestinal metaplasia)

Haematoxylin-eosin Special stain for H. pylori (modified Giemsa, Whartin-

Starry, Genta) Genta RM, Gastrointest Endosc 1994 Sugimura T, Mol Carcinog 1994

Biopsies needed for correct gastritis evaluation

Rapid Urease test

The rapid urease test (RUT) can detect H.pylori within one hour with a satisfactory accuracy

(>90%) and is acceptable to initiate eradication therapy. Malfertheiner P et all. Gut 2007; 56: 772–781

Treatment protocol of H. Pylori

• Seven days of concomitant treatment • 10 or 14 days of concomitant treatment, • 10 or 14 days of probiotic supplemented

triple treatment • 10 or 14 days of levofloxacin based triple

treatment • 14 days of hybrid treatment • 10 or 14 days of sequential treatment

Comparative effectiveness and tolerance of treatments for Helicobacter pylori: systematic

review and network meta-analysis • Through literature searches, 15 565 studies

were identified • 15 281 were excluded after screening of the

titles and abstracts. • The full texts of 284 remaining studies were

reviewed. • Overall, 143 studies were eligible and were

included

Bao-Zhu li et al. BMJ 2015

• In total, 14 treatments were successful of H pylori eradication

• presented in 143 studies, and • data were available for 32 056 patients

(intention to treat analysis). • All commonly used treatments were

assessed in at least one randomised controlled trial.

Bao-Zhu li et al. BMJ 2015

Network of eligible comparisons for treatment efficacy network meta-analysis. The width of lines is proportional to the number of studies compared in every pair of treatments, and the size of nodes is proportional to the total sample size of each treatment Bao-Zhu li et al. BMJ 2015

Bao-Zhu Li et al. BMJ 2015;351:bmj.h4052

©2015 by British Medical Journal Publishing Group

Ranking for effectiveness and tolerance of Helicobacter pylori treatments in network meta-analyses

Better outcome

• prolonging the duration of treatments enhance eradication rates

• 10 or 14 days of probiotic supplemented triple treatment

• 10 or 14 days of levofloxacin based triple treatment

• 14 days of hybrid treatment, and 10 or 14 days of sequential treatment

Bao-Zhu li et al. BMJ 2015

Difficult issue for Helicobacter pylori eradication treatment

The eradication rate of triple antibiotic

therapy is currently less than 80% in most parts of the world

Mei Zhang, World J Gastroenterol. 2015 Dec 28; 21(48): 13432–13437

H.Pylori eradication failure

H. pylori strain factors, Host factors, Environmental factors Inappropriate treatment.

Mei Zhang, World J Gastroenterol. 2015 Dec 28; 21(48): 13432–13437

HP Eradication.

Eradication of H. pylori in infected persons causes significant improvement of gastritis and gastric atrophy.

It also reduces the risks of malignancy and even causes complete remission of low grade MALT lymphoma.

Rokkas T et all. Helicobacter 2007; 12(Suppl. 2): 32–38. Moss SF, Malfertheiner P. Helicobacter 2007; 12(Suppl. 1): 23–30.