Factors Affecting Helicobacter pylori Diagnosis & Eradication

1. NHÂN MỘT TRƯỜNG HỢP Viêm dạ dày, nhiễm vi khuẩn Helicobacter pylori Bs. Lê Đình Tín Phòng Khám Tiêu Hóa – Gan Mật

12. Bàn luận

13. False-negative results …There is firm evidence to implicate that recent use of proton pump inhibitors (PPI) (within 2 weeks) or antimicrobials (within 4 weeks) may lead to a decrease in the gastric bacterial load causing falsenegative results. Bleeding can also reduce the sensitivity of both UBT and SAT. Data from a systematic review suggests repeating diagnostic tests in patients with bleeding ulcer after at least 4 weeks in case of a negative result. In patients with precancerous conditions (e.g. atrophic gastritis, intestinal metaplasia) or gastric cancer, as well as in patients with partial gastrectomy, diagnostic tests may have lower accuracy. False-positive results …Apart from false-negative results listed above, UBT also gives false-positive results, which have received more attention during the past 10 years. These false-positive results are typical to patients with acid-free stomach (due to AG or a long term use of PPIs), where urease-positive bacterial species or yeast-like organisms colonize. http://www.mathewsopenaccess.com/PDF/Gastroenterology/M_J_Gast_1_1_007.pdf

14. Bàn luận • Successful eradication of H. pylori is defined as negative H. pylori status in a previously H. pylori‐infected patient at least 4 weeks after treatment. Recurrence is defined as evidence of an active H. pylori infection in a patient with previously confirmed H. pylori eradication. Recurrence can occur either by recrudescence or reinfection. • Recrudescence is defined as reappearance of the original infection that was temporarily suppressed leading to false results tests regarding eradication. • Reinfection is defined as infection with a new strain of H. pylori or recurrence of infection after an as yet undefined period (eg, 6 months to 2 years). • https://onlinelibrary.wiley.com/doi/full/10.1111/apt.14319#apt14319-bib-0015 • Recrudescence reflects the reappearance of the originnal strain of H. pylori following its temporary suppression rather than successful eradication. Instead, true reinfection occurs when, after successful eradication, a patient becomes infected with either the original strain or a new strain of H. pylori. • http://mattioli1885journals.com/index.php/actabiomedica/article/view/7947/7707

15. …Recurrence of H pylori after eradication is rare in developed countries and more frequent in developing countries. The proportion of H pylori annual recurrence was 2.67% and 13.00% in developed and developing countries, respectively. …A different approach for follow-up after H pylori eradication is probably needed in patients of developing countries, since reinfection is highly prevalent. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2693738/

16. Aim: To evaluate the global recurrence rate following H. pylori eradication therapy and confirm its association with socioeconomic and sanitary conditions. • Methods: A systematic search of PubMed, EMBASE and the Cochrane library was performed to identify potentially relevant publications using the following keywords: “Helicobacter pylori” or “H. pylori” or “Hp” and “recurrence” or “recrudescence” or “reinfection” or “recurrent” or “recurred” or “re‐infect*” or “relapse*.” • Results: A total of 132 studies (53 934 patient‐years) were analysed. • The global annual recurrence, reinfection and recrudescence rate of H. pylori were 4.3% (95% CI, 4‐5), 3.1% (95% CI, 2‐5) and 2.2% (95% CI, 1‐3), respectively. • The H. pylori recurrence rate was inversely related to the human development index (HDI) (ie, 3.1% [95% CI, 2‐4], 6.2% [95% CI, 4‐8] and 10.9% [95% CI, 6‐18] in countries with a very high, high and medium or low HDI) (P <.01) • and directly related to H. pylori prevalence (10.9% [95% CI, 7‐16], 3.7% [95% CI, 3‐5], 3.4% [95% CI, 2‐5] and 1.6% [95% CI, 0.5‐3] in countries with a very high, high, medium or low local H. pylori prevalence) (P <.01). • Global recurrence rates remained relatively stable between 1990s, 2000s and 2010s but varied across different regions (P <.05). https://onlinelibrary.wiley.com/doi/full/10.1111/apt.14319

17. Helicobacter pylori, transmission routes and recurrence of infection: state of the art Stefano Kayali, Marco Manfredi, Federica Gaiani, Laura Bianchi, Barbara Bizzarri, Gioacchino Leandro, Francesco di Mario, Gian Luigi de’Angelis Many investigators have found that recurrence rates during the first 3-12 months after cure are due to late recrudescence. A documented H. pylori negativity for 1 year after treatment is a reliable indicator of successful eradication without recrudescence. Recrudescence rather than reinfection is likely to be responsible for most recurrent cases because the recurrences decrease with time, declining sharply after the first year, and identified strains (before and after therapy) are usually genetically identical. Intrafamilial transmission could be also involved in the reinfection of H. pylori. Genetic factors may also play a role, susceptible individuals who have eradicated H. pylori may be prone to reinfection when they are exposed to H. pylori-positive people The high prevalence of H. pylori infection may possibly be associated with high recurrence of infection after eradication because of the high risk of re-exposure. http://mattioli1885journals.com/index.php/actabiomedica/article/view/7947/7707

18. Bàn luận • Điều trị Tái phát và Tái nhiễm HP: • Chưa được đề cập đến trong đồng thuận Maastrich V. • Suy luận: • Tái phát (Recrudescence, Relapse): có thể xem như thất bại của lần điều trị trước đó, cần thay đổi phác đồ điều trị với các thuốc kháng sinh chưa dùng trước đó. • Tái nhiễm (Reinfection): có thể áp dụng các phác đồ như điều trị ban đầu. Có thể xét đến việc điều trị nguồn lây nhiễm là những người thân trong gia đình. • Thực tế: khó phân biệt chính xác Tái phát và Tái nhiễm vì thường không có xét nghiệm “dấu ấn AND” của các chủng H pylori trước và sau khi điều trị, nên dùng kháng sinh bệnh nhân chưa được dùng trước đó hay phác đồ 4 thuốc có Bismuth.

19. https://www.ncbi.nlm.nih.gov/pubmed/30811663

20. Bàn luận Trở lại bệnh nhân vừa trình bày: • Chẩn đoán: Viêm dạ dày, nhiễm vi khuẩn H pylori, nghi Tái nhiễm. • Điều trị: • Phác đồ 4 thuốc có Bismuth. • Xét đến yếu tố gia đình.

21. Kết luận • Tái phát hay Tái nhiễm sau khi điều trị tiệt khuẩn HP là vấn đề có thể gặp trong thực hành hằng ngày, việc phân biệt chính xác giữa chúng còn khó khăn và nhiều khi không có ý nghĩa thực tế. • Thu thập đầy đủ các thông tin về các lần điều trị trước đây như cách chẩn đoán, các thuốc đã dùng và tiền căn gia đình,…sẽ giúp có hướng chẩn đoán chính xác và chỉ định điều trị thích hợp.

22. Tài liệu tham khảo • https://www.ncbi.nlm.nih.gov/pubmed/18566138 • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4625746/ • http://www.mathewsopenaccess.com/PDF/Gastroenterology/M_J_Gast_1_1_007.pdf • https://www.sciencedirect.com/science/article/pii/S209012321830016X • https://www.sciencedirect.com/science/article/pii/S0264410X18300173 • http://ar.iiarjournals.org/content/39/3/1091.full • https://www.ncbi.nlm.nih.gov/pubmed/30811663 • https://www.infai.de/Helicobacter-Test-ENG.htm • https://onlinelibrary.wiley.com/doi/full/10.1111/apt.14319 • http://mattioli1885journals.com/index.php/actabiomedica/article/view/7947

23. CHÂN THÀNH CẢM ƠN SỰ CHÚ Ý CỦA QUÝ VỊ