Clinical study
The association between CagA status and the development of esophagitis after the eradication of helicobacter pylori

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Abstract

BACKGROUND: Strains of Helicobacter pylori with the cytotoxine-associated gene A (cagA) are linked to severe forms of gastroduodenal disease. Although eradication of H. pylori may predispose to the development of reflux esophagitis, the effects of CagA status on risk of esophagitis after successful H. pylori treatment are not known.

METHODS: We studied 50 consecutive patients without esophagitis in whom H. pylori was eradicated successfully. CagA status was determined by immunoblotting sera from patients against H. pylori antigens. Patients underwent upper gastrointestinal endoscopy before eradication and 6, 12, 18, and 24 months after eradication or when reflux symptoms occurred. Biopsy specimens of the antrum and corpus were evaluated for gastritis before H. pylori eradication and at the end of the study. The sum of the scores for acute and chronic inflammation (both measured on a 0 [absent] to 3 [severe] scale) comprised the total gastritis severity score.

RESULTS: In a multivariate proportional hazards regression analysis, positive CagA serology (hazard ratio [HR] = 10, 95% confidence interval [CI]: 1.3 to 81) and moderate-to-severe corpus gastritis (total severity score ≥4) before eradication (HR = 2.3, 95% CI: 1.2 to 6.1) were independent risk factors for the development of esophagitis after H. pylori eradication.

CONCLUSION: Patients infected with strains of H. pylori that are cagA-positive are at increased risk of developing esophagitis after eradication of H. pylori.

Section snippets

Sample

We studied consecutive H. pylori–positive patients who did not have symptoms of gastroesophageal reflux disease (ie, heartburn, regurgitation, dysphagia, or chest pain) and who had normal esophageal mucosa and no evidence of hiatus hernia at endoscopy immediately before H. pylori treatment. None of the patients had regularly used antisecretory drugs (eg, proton pump inhibitors) for the previous 3 months, to avoid the possibility of prior antisecretory therapy masking gastroesophageal reflux

Results

Fifty H. pylori-positive patients (30 men; median age 42 years, range 21 to 57)], including 25 with duodenal ulcer, completed the study (Table). No relapses of H. pylori infection or peptic ulcer were observed during follow-up. Twenty-two (44%) of the patients were CagA-positive. During follow-up, symptoms of gastroesophageal reflux disease (heartburn) developed in 12 (24%) patients; at endoscopy, esophagitis was found in all 12 of these patients (7 with stage I and 5 with stage II esophagitis).

Discussion

H. pylori eradication is the treatment of choice to cure peptic ulcer and H. pylori-related gastritis. Eradication may not be free of adverse consequences, however, especially the development of gastroesophageal reflux disease. The hypothesis that patients infected with H. pylori might have a lower risk of gastroesophageal reflux disease (15) is supported by the observation that cagA-positive strains of H. pylori may protect against complications of gastroesophageal reflux disease, such as

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