HELICOBACTER PYLORI

Current concepts in the management of Helicobacter pylori infection: the Maastricht III Consensus Report

P Malfertheiner¹, F Megraud², C O’Morain³, F Bazzoli⁴, E El-Omar⁵, D Graham⁶, R Hunt⁷, T Rokkas⁸, N Vakil⁹, E J Kuipers¹⁰ The European Helicobacter Study Group (EHSG)

¹ Otto-von-Guericke University of Magdeburg, Magdeburg, Germany
² INSERM U853, Bordeaux, France
³ Adelaide and Meath Hospital, Trinity College, Dublin, Ireland
⁴ University of Bologna, Bologna, Italy
⁵ Aberdeen University, Aberdeen, UK
⁶ VA Medical Center Houston, Texas, USA
⁷ McMaster University, Hamilton, Ontario, Canada
⁸ Henry-Dunant Hospital, Athens, Greece
⁹ University of Wisconsin Medical School, Milwaukee, USA
¹⁰ Erasmus MC University Medical Center, Rotterdam, Netherlands

Correspondence to:
Professor P Malfertheiner
Otto-von-Guericke-Universität Magdeburg, Medizinische Fakultät, Zentrum für Innere Medizin, Klinik für Gastroenterologie, Hepatologie und Infektiologie, Leipziger Straße 44, D-39120 Magdeburg, Germany; peter.malfertheiner{at}medizin.uni-magdeburg.de

Background: Guidelines on the management of Helicobacter pylori, which cover indications for management and treatment strategies, were produced in 2000.

Aims: To update the guidelines at the European Helicobacter Study Group (EHSG) Third Maastricht Consensus Conference, with emphasis on the potential of H pylori eradication for the prevention of gastric cancer.

Results: Eradication of H pylori infection is recommended in (a) patients with gastroduodenal diseases such as peptic ulcer disease and low grade gastric, mucosa associated lymphoid tissue (MALT) lymphoma; (b) patients with atrophic gastritis; (c) first degree relatives of patients with gastric cancer; (d) patients with unexplained iron deficiency anaemia; and (e) patients with chronic idiopathic thrombocytopenic purpura. Recurrent abdominal pain in children is not an indication for a "test and treat" strategy if other causes are excluded. Eradication of H pylori infection (a) does not cause gastro-oesophageal reflux disease (GORD) or exacerbate GORD, and (b) may prevent peptic ulcer in patients who are naïve users of non-steroidal anti-inflammatory drugs (NSAIDs). H pylori eradication is less effective than proton pump inhibitor (PPI) treatment in preventing ulcer recurrence in long term NSAID users. In primary care a test and treat strategy using a non-invasive test is recommended in adult patients with persistent dyspepsia under the age of 45. The urea breath test, stool antigen tests, and serological kits with a high accuracy are non-invasive tests which should be used for the diagnosis of H pylori infection. Triple therapy using a PPI with clarithromycin and amoxicillin or metronidazole given twice daily remains the recommended first choice treatment. Bismuth-containing quadruple therapy, if available, is also a first choice treatment option. Rescue treatment should be based on antimicrobial susceptibility.

Conclusion: The global burden of gastric cancer is considerable but varies geographically. Eradication of H pylori infection has the potential to reduce the risk of gastric cancer development.

Abbreviations: BabA2, blood group antigen binding adhesin 2; CagA, cytotoxin associated gene A; EHSG, European Helicobacter Study Group; GORD, gastro-oesophageal reflux disease; IDA, iron deficiency anaemia; ITP, idiopathic thrombocytopenic purpura; MALT, mucosa associated lymphoid tissue; NSAIDs, non-steroidal anti-inflammatory drugs; OipA, outer inflammatory protein A; PPIs, proton pump inhibitors; RCT, randomised controlled trial; SabA, sialic acid binding adhesion; UBT, ¹³C-urea breath test; VacA, vacuolating associated gene A

Keywords: H pylori; diseases; diagnosis; treatment; prevention

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