Gastritis is an inflammatory reaction of the gastric mucosa and can be divided into acute gastritis and chronic gastritis. Among them, chronic gastritis is related to Helicobacter pylori (Hp) infection, so based on the cause, gastritis can be divided into Hp gastritis and non-Hp gastritis.
Hp gastritis is an infectious disease and is currently recommended for treatment in a quadrant of bismuth + proton pump inhibitor (PPI) + 2 antimicrobials. Most patients with Hp gastritis are asymptomatic, and the clinical manifestations include fullness or pain in the upper gastrointestinal part, belching, discomfort or tenderness of epigastric compression, and bad breath. Eradication of Hp can not only alleviate clinical symptoms and facilitate the repair of gastric mucosa, but also improve, reverse or eliminate lesions such as gastric mucosal inflammation, atrophy, intestinal metaplasia, etc., and reduce the risk of gastric cancer.
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One. Hp eradication treatment
Standard dose PPI + standard dose bismuth (2 times/day, orally half an hour before meals) + 2 antibacterial drugs (orally after a meal) is recommended (Table 1).
The standard dose PPI is omeprazole 20 mg, pantoprazole 40 mg, lansoprazole 30 mg, rabeprazole 10 mg (or 20 mg), esomeprazole 20 mg, and the standard dose bismuth potassium citrate 220 mg (the standard dose of bismuth pectin is to be determined).
Most empiric bismuth quadruple regimens are recommended for a 14-day duration, but a 10-day course is an option if local studies confirm that the 10-day treatment is effective (eradication rate >90%).
In addition, the "Clinical Expert Consensus on Gastrointestinal Mucosal Protection (2021, Fuzhou)" (2021) pointed out that mucosal protectors containing bismuth, zinc and other elements have a certain inhibitory effect on Hp, and the addition of polyprecline zinc to the triple regimen of eradicating Hp can significantly improve the eradication rate.
Table 1. Hp eradication of antimicrobial combinations, dosages, and usage in the quadruple regimen
The combined antimicrobial regimen recommended in the Guidelines for the Primary Diagnosis and Treatment of Helicobacter pylori Infection (2019) (2020) and the Fifth National Consensus Report on the Management of Helicobacter pylori Infection (2017).
At present, Hp has a high rate of resistance to clarithromycin, levofloxacin, and metronidazole, and a low rate of resistance to amoxicillin, tetracycline, and furazolidone (<5%), so regimens containing levofloxacin (high and widely used) and furazolidone (only for difficult-to-eradicate Hp infections) are not recommended for the general population undergoing hp eradication for the first time.
Clarithromycin can prolong the QT interval, induce myocardial pleus abnormalities, and may cause torsades de pointes, torsades de pointes, or even ventricular fibrillation or sudden death. Levofloxacin can cause Q-T interval prolongation, ventricular arrhythmias, and occasionally torsades de pointes (TdP), and there is a risk of aortic aneurysm and aortic dissection. Bismuth tetratherapy with clarithromycin and levofloxacin is not recommended for those who are at risk of Q-T interval prolongation or who are at risk of Q-T interval prolongation.
The serious adverse reactions of furazolidone are mainly severe skin reactions (such as serum disease-like urticaria, etc.) and polyneuroitis (irreversible). Avoid foods rich in tyramine (such as fish, shrimp, chicken, cheese, preserved and smoked meat products, broad beans, etc.) and other foods that are easy to induce allergies during the medication, and prohibit alcohol consumption and alcoholic beverages. Patients with glucose-6-phosphate dehydrogenase (G-6PD) deficiency are prone to hemolytic anemia with furazolidone, so they are contraindicated in patients with G-6PD deficiency.
Two. Treatment after hp eradication
The symptoms of indigestion of Hp gastritis are mostly relieved after successful eradication of Hp therapy, and those who still have symptoms can use gastric mucosal protectors, prokinetic drugs, digestive enzyme preparations and other symptomatic treatment, and those whose symptoms persist or recur within 6 months may be combined with functional dyspepsia.
Gastric mucosal protector can protect the gastric mucosa, neutralize gastric acid, promote mucosal epithelial repair and healing of mucosal damage, enhance gastric mucosal defense, regulate submucosal blood flow, etc., and can also combine bile acids to alleviate or eliminate gastric mucosal damage caused by bile reflux, suitable for gastritis patients with gastric mucosal erosion or heartburn, acid reflux, noisiness, epigastric burning sensation, epigastric pain and other symptoms, or gastritis patients with gastric mucosal bleeding.
Prokinetic drugs can promote gastric emptying, reduce the high sensitivity of internal organs, reduce bile and acid reflux, shorten the residence time of reflux in the stomach, reduce the damage to the gastroesophageal mucosa, and can also play an antiemetic role, which can improve bloating, early satiety, belching, dyspepsia and other symptoms, suitable for gastritis with symptoms such as upper abdominal fullness, early satiety, nausea, vomiting, belching and other symptoms or with bile reflux.
Digestive enzyme preparations such as compound azimid, mitrix pancreatic enzyme, pancreatin, compound digestive enzyme, etc., in order to help digestion drugs, can improve the mid-upper abdominal fullness associated with eating, sodium difference, etc., and the effect of the combined pro-pro-propulsive drug can be more obvious, suitable for gastritis patients with symptoms such as low stomach acid or loss of appetite, low digestion function (there is obvious eating-related bloating, na poor) and other symptoms. Compound azimid enteric-coated tablets are contraindicated in patients with liver dysfunction, acute hepatitis, biliary obstruction and biliary colic. Pancreatic enzyme enteric-coated capsules and Mitrex pancreatic enzyme tablets are contraindicated in the early stages of acute pancreatitis and the acute onset of chronic pancreatitis. Compound digestive enzyme capsules are contraindicated in patients with acute hepatitis and complete biliary obstruction.