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Gastritis, peptic ulcer, and gastric cancer

Outline. H pylori and NSAIDS are two key causes of stomach ulcers; others are tobacco and alcohol, and medical/surgical stressTwo types of gastric cancerEpidemiology of H pyloriRole of H pylori in stomach cancerEradication of H pyloriTreatment of dyspepsia. What are the causes of stomach cancer?.

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Gastritis, peptic ulcer, and gastric cancer

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    1. Gastritis, peptic ulcer, and gastric cancer Roger Thomas MD PhD CCFP MRCGP Professor of Family Medicine Cochrane Collaboration Coordinator University of Calgary

    2. Outline H pylori and NSAIDS are two key causes of stomach ulcers; others are tobacco and alcohol, and medical/surgical stress Two types of gastric cancer Epidemiology of H pylori Role of H pylori in stomach cancer Eradication of H pylori Treatment of dyspepsia

    3. What are the causes of stomach cancer? 2nd cause of cancer deaths for males for 4th for females worldwide 10-fold variation world wide, highest rates Japan and Korea Incidence of gastric cancer has fallen last 30 years many Western countries Multifactorial causes: H pylori, diet high in salt and N-nitroso compounds and low in fruit and vegetables, tobacco (OR = 2.0), (and reflux and obesity for cardiac tumours) WHO classifies H pylori as Class I carcinogen

    4. What are the 2 types of stomach cancer? Proximal cardia tumours related to pangastritis without atrophy more common in developed countries and individuals with higher socio-economic status Gastroesophageal reflux and obesity are important causes; also H pylori

    5. Two types of stomach cancer Distal gastric cancer related to gastric atrophy and intestinal metaplasia predominates in developing countries and individuals with lower socieconomic status Main risk factor is H pylori

    6. What is the epidemiology of H pylori (Malaty’s review) Prevalence varies by country: 80% India, Saudi Arabia, Vietnam, Canada 30% Acquired in childhood from family. Low childhood socioeconomic status is key determinant (Russian children 30%, French 10%) Transmission: bodily fluids, vomit, water, food Increasing prevalence with age St. Petersburg and Japanese studies show individuals lose H pylori as socio-economic status and crowding improve

    7. What are the effects of H pylori on the stomach? (Reviews by Thomas) H pylori increase odds of stomach cancer by 2.1 to 16.7 in various studies (average 5.9) 3% of individuals with H pylori progress to gastric cancer in distal gastric cancer progression over 30 years is: chronic superficial gastritis atrophic gastritis intestinal metaplasia dysplasia

    8. What factors increase the risk of gastric cancer from H pylori? (review by Thomas) Patient polymorphisms that express higher levels of cytokine IL-1ß Higher level of TNF-? (suppresses gastric acid production) Histocompatibility genotypes upregulated by H pylori that affect how epithelium responds to infection H pylori with gene sequencs cag (allows bacterial proteins to enter host cells); and vacA and babA2 (permit adhesion of bacteria to cell surfaces)

    9. What factors decrease the risk of non-cardia gastric cancer? OR 95% CI NSAIDS 0.72 0.58 to 0.89 Aspirin 0.64 0.51 to 0.80 Hypothesis: use reduces production of Cox-1 and Cox 2 Note: There is more use of NSAIDS by H pylori patients

    10. Treatment of H pylori reduces intestinal metaplasia Wong randomised 1,630 patients with H pylori to eradication (0 gastric cancer after 7.5 years) ad placebo (6 gastric cancers) Leung randomised 587 patients to eradication or placebo and progression to intestinal hyperplasia was related to persistent H pylori infection, age > 45 years, alcohol abuse and drinking well water

    11. How sensitive and specific is Screening for H pylori? (Review by Thomas) Sensitivity specificity Urea breath tests 97% 95% Stool tests 93% 93% Treatment Clarithromycin 500 mg + Amoxicillin 1 g + PPI bid Duration of therapy: 7 days vs. 10 - 14 days

    12. What is the effect of treating H pylori on duodenal ulcers? (Cochrane review by Ford) H pylori is implicated in 90-95% of duodenal and 70% of gastric ulcers Risk of persisting duodenal ulcer RR 95%CI H pylori eradication 0.66 0.58 to 0.76 + ulcer healing drug vs. NNT 14 11 to 20 ulcer-healing drug

    13. What is the effect of treating H pylori on gastric ulcers? (Cochrane review by Ford) Risk of persisting gastric ulcer RR 95%CI H pylori eradication 1.25 0.88 to 1.76 + ulcer healing drug vs. ulcer-healing drug MODERATOR ANALYSIS: Intention to treat analysis, difference in loss from treatment arms < 10%, blinding, not being a multicentre study, all reduced this RR HOWEVER: we are interested in eradication of H pylori not just ulcer treatment so go ahead and treat

    14. What are the costs and benefits of screening for H pylori? A UK study showed that screening for H pylori in individuals who consulted for dyspepsia over two years reduced the costs of GI consultations enough to pay for the gastric cancer screening aspects of the H pylori screening

    15. Nonaspirin NSAIDS and upper GI bleeding and perforation (Hernández-Díaz review) Risk of upper GI bleed or perforation with NSAIDS RR 95%CI 3.8 3.6 to 4.1 Men 3.5 3.1 to 4.0 Women 5.1 4.6 to 5.7

    16. Risk of upper GI bleed or perforation with NSAIDS (Hernández-Díaz review) By age (25-49 is reference group, RR =1) Age 50-59 1.8 1.5 to 2.1 60-69 2.4 2.2 to 2.7 70-80 4.5 4.0 to 4.9 >80 9.2 7.6 to 11.1

    17. Risk of upper GI bleeding and perforation of with low to medium doses nonaspirin NSAIDS (Hernández-Díaz review) RR 95%CI Ibuprofen 1500 to 2400mg 2.1 1.6 to 2.7 Indomethacin 75 to 100 mg 3.0 2.2 to 4.2 Diclofenac 75 to 100 mg 3.1 2.0 to 4.7 Naproxen 500 to 1000mg 3.5 2.8 to 4.3 Piroxicam = 20 mg 5.6 4.7 to 6.7 Risks are similar across NSAIDS when daily equivalent doses are equalised except for piroxicam

    18. Conclusions H pylori and NSAIDS are the key causes of stomach ulcers. Other causes are alcohol, tobacco and stress ulcers H pylori is acquired in childhood from family members in situations of crowding (up to 80% incidence in some developing countries) In 3% of individuals with H pylori there is progression to stomach cancer (particularly distal non-cardia) H pylori should be treated with clarithromycin 500 mg and amoxicillin 1000 mg bid + a PPI x 7 days Reduction in the costs of treating dyspepsia over two years pays for H pylori screening programmmes NSAIDS should be given in low-intermediate doses and with caution in older individuals. (A stomach protector misprostol 200 mcg qid reduces risks of bleeding but 17 % will complain of diarrhea)

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