The Influence of Helicobacter Pylori Infection on Early Rebleeding Rate in Patients with Peptic Ulcer Bleeding

 

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We read with great interest the article by Schilling et al. [1], investigating the influence of Helicobacter pylori infection and the use of nonsteroidal anti-inflammatory drugs (NSAIDs) on the early rebleeding rate in patients who had undergone successful primary endoscopic hemostasis procedures for peptic ulcer bleeding. The highly interesting paper mainly focuses on the question of whether H. pylori infection has any influence on rebleeding episodes during the 3-week period after initial hemostasis. The authors concluded that H. pylori infection does not affect the early rebleeding rate after successful endoscopic hemostasis in patients with peptic ulcer bleeding, and therefore early eradication therapy may not be necessary in order to improve the prognosis in the acute phase. We agree with these conclusions, which accord well with our own results; however we have some suggestions and comments about the study design and data.

A total of 344 patients with bleeding ulcer were enrolled into the study, and primary hemostasis was achieved in 75 % by injection therapy alone. Supposing that endoscopic hemostatic procedures were performed at least in the 89 patients with active bleeding (Forrest Ia and Ib groups), it is a strong probability that immediate surgery was offered for some patients in whom primary hemostasis was attempted without success. Furthermore we also suppose that in this subgroup of patients assessment of H. pylori status was not carried out, because the protocol indicates that H. pylori was done only after hemostasis had been achieved. With these considerations, the question arises of whether the authors’ calculations, based on a total of 344 patients regarding H. pylori infection and rebleeding rates, are completely accurate? Rebleeding and H. pylori-positivity rates might have been calculated only in those patients whose bleedings were successfully treated with injection therapy, but the number of these patients was not clearly indicated in the paper.

The authors used different types of hemostatic procedure, including epinephrine and fibrin injection, hemoclipping, or a combination of all of these methods, depending on the individual situation. Although there is much evidence that rebleeding rates are similar for all methods [2] [3] [4], the use of a combination may have led to some differences. To avoid the possible influence on rebleeding rate of using different combinations of hemostatic procedures, it would have been more convenient to use identical hemostatic methodology for all patients.

The main goal of the study was to test whether H. pylori infection had any effect on the early rebleeding rate within a 3-week period after emergency endoscopy. However, all H. pylori-positive patients received eradication therapy immediately after the first 3-day proton pump inhibitor (PPI) treatment period. It is highly probable that within a 1-2-week interval many patients had already become negative for H. pylori due to the success of eradication efforts. Therefore it is uncertain, that the rebleeding results for the whole 3-week observation period reflect the influence of the initial H. pylori status. To overcome this protocol bias it would have been more practical to shorten the observation period for early rebleeding to 72 hours. The 43-hours and 40-hours rebleeding times after the index endoscopy might indicate that a 72-hour interval is long enough to check for early rebleeding episodes. To assess the real influence of eradication therapy on the early rebleeding rate among H. pylori-positive patients with bleeding ulcers, we might suggest immediate intravenous PPI treatment with two antibiotics, in a randomized fashion.

The main conclusions of the study accord well with our results, as well as with some data in the literature. The presence of H. pylori does not necessarily inhibit ulcer healing in the acute phase [5]. Therefore a beneficial effect of early eradication is at least controversial. Campbell et al. showed, by prospective analysis of two identical double-blind, multicenter studies, that gastric ulcer healing with an antisecretory agent in patients receiving NSAIDs was significantly enhanced in the presence of H. pylori infection [6]. Leodolter et al. evaluated the short-term effect of omeprazole therapy on gastric pH in patients with peptic ulcer bleeding with and without H. pylori infection [7]; they concluded that acid secretion was more rapidly and more effectively inhibited in the H. pylori-infected patients.

In our own unpublished prospective study we investigated, whether previous NSAID treatment or H. pylori infection can influence the early rebleeding rate after initial hemostasis has been achieved in bleeding peptic ulcer. Previous NSAID treatment was checked on the basis of the medical history and H. pylori status was evaluated by means of the rapid urease test and/or histological investigation. Data were analysed from a total of 292 patients who had received successful initial endoscopic treatment (duodenal ulcer 189, gastric ulcer 103). Rebleeding within the first 72 hours occurred in 14.7 % of duodenal ulcer patients and 11.8 % of gastric ulcer patients. Rebleeding rates in the NSAID-user and nonuser groups were 12.1 % versus 14.9 %, while those in the H. pylori-positive and H. pylori-negative patients were 11.9 % versus 15.6 %. Interestingly, rebleeding occurred in only 3 % of the H. pylori-positive and NSAID-treated patients, while the rebleeding rate among patients who were H. pylori-negative and nonusers of NSAIDs was 16.2 %. We concluded that neither previous NSAID treatment, nor H. pylori infection are risk factors for early rebleeding in ulcer patients after successful initial hemostasis.

Comparing our data with the observations of Schilling et al., we found the same tendency. The lowest early rebleeding rate occurred in the H. pylori-positive NSAID-user group, while the highest risk for rebleeding was detected among the H. pylori-negative patients without previous NSAID consumption. We might address the important question of whether H. pylori infection has any real protective role against the risk of ulcer rebleeding during the acute phase, or whether its presence is simply irrelevant at that time. To answer this question, further investigation is needed in large multicenter studies.

References

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I. Rácz, M. D. PhD

Department of Gastroenterology
Petz AladÄr County and Teaching Hospital

Vasvári Pál út 2
9024 Győr
Hungary

Fax: +36-96-519066

Email: raczi@petz.gyor.hu