Should we eradicate Helicobacter pylori in patients with recurrent gastro-oesophageal reflux disease?

Abstract

The 1998 Guidelines of the American College of Gastroenterology recommend that diagnostic testing for Helicobacter pylori infection should only be performed if treatment is intended, and that testing for H. pylori is not indicated in patients on long-term treatment with a proton pump inhibitor (PPI) for gastro-oesophageal reflux disease (GORD). Moreover, a recent evidence-based workshop evaluating major clinical strategies for the management of GORD reported, with an 'A' category (maximum of evidence), that eradication of H. pylori does not heal or prevent relapse of GORD. In detail, it seems that H. pylori infection per se has no effect on the pathogenic mechanisms determining either reflux or its complications. The relationship between H. pylori and oesophagitis is mediated by the effect of H. pylori on gastric acid secretion; in particular, by the proximal extension of gastritis and related impairment of gastric secretory function. In general, if the corpus is infected, the amount of acid available for reflux is less and the probability of excessive oesophageal acid exposure leading to oesophagitis reduced. However, the clinical relevance of corpus H. pylori infection as a biological antisecretory agent (and of H. pylori eradication) seems small or absent, at least in the long run. Conversely, the previous claim of an increased risk of atrophic gastritis in H. pylori-infected patients treated long term with PPI drugs appears not to be confirmed by subsequent studies. In conclusion, H. pylori infection may, in some circumstances, be moderately favourable and, in other circumstances, it may be neutral, with respect to the management of GORD.