【原创】关于幽门螺旋杆菌处理治疗指南

关于幽门螺旋杆菌处理指南：
These are the guidelines from the American College of Gastroenterology (ACG) for managing infections caused by Helicobacter pylori. The following points are emphasized:

Conditions caused by H pylori include peptic ulcer disease, gastric malignancy, and dyspeptic symptoms. These represent the major indications for testing. Controversial areas include: functional dyspepsia, gastroesophageal reflux disease (GERD), patients taking nonsteroidal anti-inflammatory drugs (NSAIDs), iron deficiency anemia, and patients considered at risk for gastric cancer.

Diagnostic methods include endoscopic or nonendoscopic methods. The use depends to a large extent on availability, cost, and differences in test performance, including a distinction between tests used to establish the diagnosis vs establishing eradication of the pathogen.

Treatment considered "first line" includes a proton-pump inhibitor (PPI), clarithromycin, and amoxicillin. Eradication rates have decreased to 75% to 85% owing in part to a decrease in clarithromycin activity. The 14-day regimens are preferred to the 7-day treatment due to higher rates of eradication. The sequential regimen using a PPI plus amoxicillin for 5 days followed by a PPI plus clarithromycin and tinidazole for 5 days has shown good outcomes in Europe, but has not been tested in the United States. The usual salvage regimen with persistent H pylori is bismuth quadruple therapy.

The specific indications for diagnostic studies, types of tests, and FDA-approved regimens are listed below. Recommendations for first-line and salvage treatment are shown in Table 1 and Table 2 .


Indications for Diagnosis and Treatment of H pylori
Definite

Peptic ulcer disease (PUD)

History of PUD not previously treated for H pylori

Gastric mucosa-associated lymphoid tissue (MALT) lymphoma

Postendoscopic treatment of early gastric carcinoma

Uninvestigated dyspepsia (depending on H pylori prevalence)


Controversial

Nonulcer dyspepsia

GERD

Patients using NSAIDs

Unexplained iron deficiency anemia

Populations at high risk for gastric carcinoma


Diagnostic Testing
Endoscopic tests

Histology: sensitivity and specificity > 95%

Urease test: rapid, cheap, sensitive (> 95%), but sensitivity reduced posttreatment

Culture: specific, permits in vitro sensitivity testing but poor sensitivity, difficult to do, expensive, and often not available

Polymerase chain reaction (PCR): sensitive, specific, and permits antibiotic sensitivity testing, but methods not standardized and are considered experimental


Nonendoscopic tests

Antibody enzyme-linked immunosorbent assay (ELISA) or latex agglutination (LA): Both can be quantitative. Cheap, readily available, sensitivity 85%, specificity 79%, but antibody persists - not recommended post therapy.

Urea breath test (13C or radioactive 14C): Both have sensitivity and specificity > 95% and can be used posttreatment, but availability and reimbursement are variable.

Stool antigen: Sensitivity and specificity > 90% before and after treatment


FDA-Approved Regimens for The Treatment of H pylori
Bismuth 525 mg 4 times daily (QID) + metronidazole 250 QID, tetracycline 500 mg QID x 2 weeks + H2-receptor antagonist (H2RA) x 4 weeks

Lansoprazole* 30 mg twice daily (twice daily) + clarithromycin 500 mg twice daily + amoxicillin 1 g twice daily x 10 days


*Or substitute omeprazole 20 mg twice daily x 10 days or esomeprazole 40 mg once daily x 10 days or rabeprazole 20 mg twice daily x 7 days

附录：
Table 1. H pylori一线治疗方案

Recommended Treatment Comment
PPI* + clarithromycin (500 mg BID) + amoxicillin (1 g BID) x 10-14 days Eradication rate 70%-85%
PPI* + clarithromycin (500 mg BID) + metronidazole (500 mg BID) x 10 to 14 days Eradication rate 70%-85%, use in persons with penicillin allergy
Bismuth subsalicylate 525 mg QID + metronidazole 250 mg QID), tetracycline (500 mg BID), ranitidine 150 mg BID or PPI* x 10-14 days Eradication rate 75%-90%, use in persons with penicillin allergy
PPI* + amoxicillin (1 g BID) x 5 days, then PPI + clarithromycin 500 mg BID + tinidazole 500 mg BID x 5 days Eradication rates > 90%, efficacy shown only in European studies

BID = twice daily; PPI = proton pump inhibitor; QID = 4 times daily
*May substitute omeprazole 20 mg BID x 10 days or esomeprazole 40 mg QD x 10 days or rabeprazole 20 mg BID x 7 days

Table 2. 顽固性 H pylori推荐抢救治疗方案

Salvage Regimens Comment
PPI + tetracycline + Pepto Bismol + metronidazole x 7 days Eradicate rate 68%; cheap, high pill burden, and many side effects
PPI + amoxicillin 1 g BID + levofloxacin 500 mg BID x 10 days Eradication rate 87%

BID = twice daily; PPI = proton pump inhibitor