• Helicobacter pylori
• gastro-oesophageal reflux disease
• gastritis
• atrophy
• gastric cancer
• omeprazole

Should Helicobacter pylori infection be eradicated in patients requiring maintenance proton pump inhibitor therapy for gastro-oesophageal reflux disease? This question has stimulated heated debate and contention over the past few years. The issue first came to prominence in 1996 when Kuipers et al published their study purporting to demonstrate that omeprazole accelerated the development of corpus atrophic gastritis in H pylori infected subjects.¹ This rung alarm bells due to the fact that atrophic gastritis is a well recognised risk factor for gastric cancer in H pylori infected subjects. There was therefore concern that proton pump inhibitor therapy was modifying the inflammatory response to H pylori infection in such a way as to increase the risk of gastric cancer. For this reason, some experts have recommended that H pylori infection should be eradicated prior to long term proton pump inhibitor therapy.²

The original paper by Kuipers et al was widely criticised due to weaknesses in its design,³ and its claim that proton pump inhibitor therapy accelerated atrophy in H pylori infected subjects was not supported by the FDA Gastrointestinal Drugs Advisory Committee.⁴ In 1999, Lundell et al published a study claiming that proton pump inhibitor therapy did not accelerate the development of corpus atrophy in H pylori infected subjects.⁵ However, their conclusion was challenged because there was evidence of accelerated development of moderate and severe atrophy in the H pylori infected group on proton pump inhibitor therapy and the size of this effect was similar to that reported by Kuipers and colleagues.^6–8 The paper by Kuipers and colleagues⁹ in the current issue of Gut confuses the issue further as they did not observe any …