Pump 'til the fire in your belly's out

Simultaneous H pylori eradication and
withdrawal of PPI therapy can worsen GERD

By Marlene Busko

Fifty-year-old Mike Beilstein is a trucker who loves life out on the open road. Along with the odd hitchhiker, Mike's picked up some pretty bad eating habits on the job. Unfortunately, the chili fries and burger diet has finally caught up with him. He's on proton pump inhibitor (PPI) therapy for GERD and was just prescribed some antibiotics to get rid of an H pylori infection that's given him an ulcer. A few weeks later, Mike's free of the bug but his GERD has returned in a big way. Should he have stayed on the PPI a little longer?

A small study by Scottish investigators published in the April issue of Gastroenterology confirms the possibility of a rebound increase in stomach acid in patients when H pylori eradication and withdrawal of PPI therapy are done at the same time.

Dr Derek Gillen at the Aberdeen Royal Infirmary and colleagues studied 20 patients who were infected with H pylori and 12 who didn't have the infection. All received 40mg/day omeprazole for 56 days. During the last week of omeprazole treatment, half of the H pylori-positive patients, chosen at random, received antibiotic therapy to eradicate the bug: 1g amoxicillin and 500mg clarithromycin twice a day. Stomach acid output was recorded before, during, and up to two months after omeprazole therapy. Surprisingly, in patients with no H pylori infection, stomach acid secretions after PPI treatment were almost double that seen in the H pylori-positive patients.

Apparently, H pylori eradication seems to result in higher acid secretion that "may aggravate or induce GERD," according to Dr Gillen. He concludes, however, that "the clinical significance of these interactions [betweenH pylori and PPI therapy] remains to be determined."

In Canada, doctors are split on whether they should eradicate H pylori in GERD. "Basically, H pylori eradication in GERD is probably not a big thing," says Dr Arni Sekar, a gastroenterologist at Ottawa Civic Hospital. "In GERD patients who need endoscopy, I don't look for H pylori routinely. Not all H pylori infections cause disease, yet others feel that an infection is an infection and should be dealt with."

Dr RH Hunt, a gastroenterologist and professor at McMaster University has a different view. He admits that "the more severe the GERD, the less likely we are to find H pylori, so this phenomenon is unlikely to influence management of the more difficult cases." However, he stresses that "current guidelines remain unchanged and the infection should be eradicated when found to be present." He explains that this is because of the "acceleration of gastritis and atrophy in patients infected with H pylori who are on long-term antisecretory therapy."