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Inicio Gastroenterología y Hepatología Enfermedades relacionadas con Helicobacter pylori: dispepsia, úlcera y cáncer ...
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Vol. 34. Issue S2.
Jornada de Actualización en Gastroenterología Aplicada
Pages 15-26 (October 2011)
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Vol. 34. Issue S2.
Jornada de Actualización en Gastroenterología Aplicada
Pages 15-26 (October 2011)
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Enfermedades relacionadas con Helicobacter pylori: dispepsia, úlcera y cáncer gástrico
Helicobacter pylori-related diseases: dyspepsia, ulcers and gastric cancer
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Javier P. Gisbert
Servicio de Aparato Digestivo, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria Princesa (IP), Madrid, España
Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD)
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Resumen

A continuación se resumen las principales conclusiones derivadas de las comunicaciones presentadas este año (2011) en la Digestive Disease Week relacionadas con la infección por Helicobacter pylori. En los países desarrollados, la prevalencia de infección por H. pylori ha disminuido, aunque parece haberse estabilizado en una cifra todavía relevante. Las resistencias antibióticas están aumentando en diversos países. La erradicación de H. pylori no favorece la aparición de enfermedad por reflujo gastroesofágico ni empeora su curso. La frecuencia de úlceras pépticas idiopáticas parece estar incrementándose. La erradicación de H. pylori elimina la práctica totalidad de las recidivas hemorrágicas por úlcera péptica; no obstante, la ingesta de antiinflamatorios no esteroideos o la reinfección por H. pylori puede originar una recidiva hemorrágica. Los pacientes con hemorragia digestiva por úlcera péptica H. pylori negativos tienen más recidivas hemorrágicas y mayor mortalidad. Existe una estrecha correlación entre la prevalencia de infección por H. pylori en una población determinada y su incidencia de cáncer gástrico. La erradicación de H. pylori se asocia a una mayor y más rápida cicatrización de la lesión ulcerosa originada por la disección submucosa endoscópica. La erradicación de H. pylori en los pacientes sometidos a una resección mucosa endoscópica de un cáncer gástrico precoz reduce la incidencia de tumores metacrónicos. La erradicación de H. pylori induce la regresión del linfoma MALT en un elevado porcentaje de casos y las recidivas tumorales a largo plazo son excepcionales. El narrow-band imaging (NBI) permite visualizar, durante la propia exploración endoscópica, los diferentes patrones mucosos y vasculares en los pacientes infectados por H. pylori. Las propiedades electroquímicas de H. pylori permiten su detección en biopsias gástricas con una elevada precisión y rapidez. La eficacia de las terapias triples “tradicionales” deja mucho que desear actualmente. La superioridad de la terapia “secuencial” sobre la triple estándar debería confirmarse en distintos medios. La terapia cuádruple “concomitante” parece ser igualmente efectiva que la “secuencial”, pero con la ventaja de ser más sencilla. Tanto el tratamiento “secuencial” como el “concomitante” son relativamente eficaces incluso cuando existe resistencia a la claritromicina. El tratamiento de rescate de segunda línea durante 10 días con levofloxacino es eficaz y además es más sencillo y mejor tolerado que la cuádruple terapia. En los pacientes alérgicos a la penicilina, una combinación con levofloxacino y claritromicina representa una prometedora alternativa de rescate. Las quinolonas de nueva generación, como el moxifloxacino y el sitafloxacino, podrían ser útiles como tratamiento erradicador. Tras el fracaso de 2 tratamientos erradicadores, la administración empírica de un tercero constituye una opción válida en la práctica clínica. Incluso tras el fracaso de 3 tratamientos erradicadores, una cuarta terapia de rescate empírica (con rifabutina) puede ser efectiva.

Palabras clave:
Cáncer gástrico
Diagnóstico
Dispepsia
Helicobacter pylori
Hemorragia digestiva
Tratamiento
Úlcera péptica
Abstract

This article summarizes the main conclusions drawn from the presentations on Helicobacter pylori infection at Digestive Disease Week 2011. In developed countries, the prevalence of H. pylori infection has decreased, but seems to have reached a plateau at a fairly high level. Antibiotic resistance is increasing in several countries. H. pylori eradication does not contribute to the development of gastroesophageal reflux disease or worsen its course. The frequency of idiopathic peptic ulcers seems to be increasing. H. pylori eradication eliminates almost all episodes of peptic ulcer rebleeding; nevertheless, the use of non-steroidal anti-inflammatory drugs or H. pylori reinfection can lead to bleeding recurrence. H. pylori-negative patients with peptic ulcer bleeding more frequently have bleeding recurrences and higher mortality. In each particular population, there is a close correlation between the prevalence of H. pylori infection and the incidence of gastric cancer. H. pylori eradication is associated with a higher and faster healing rate of ulcerous lesions caused by endoscopic submucosal dissection. In patients undergoing endoscopic submucosal dissection for early gastric cancer, H. pylori eradication decreases the incidence of metachronous tumors. In a high proportion of cases, H. pylori eradication induces MALT lymphoma regression, and long-term tumoral recurrences are exceptional. Narrow-band imaging allows visualization of the mucous and vascular pattern in H. pylori-infected patients during the endoscopic examination. The electrochemical properties of H. pylori allow these lesions to be rapidly and accurately detected in gastric biopsies. The efficacy of “traditional” triple therapies currently leaves much to be desired. The superiority of “sequential” therapy over the standard triple therapy should be confirmed in distinct environments. The “concomitant” quadruple therapy seems to be as effective as “sequential” therapy, but with the advantage of being simpler. Both the “sequential” and the “concomitant” regimens are relatively effective even when clarithromycin resistance is present. Second-line rescue therapy with levofloxacin for 10 days is effective and is simpler and better tolerated than quadruple therapy. In patients allergic to penicillin, a combination with levofloxacin and clarithromycin is a promising rescue alternative. The new-generation quinolones, such as moxifloxacin and sitafloxacin, could be useful as eradication treatment. After two eradication treatment failures, an empirical third-line rescue therapy may be a valid option in clinical practice. Even after three previous H. pylori eradication failures, an empirical fourth-line rescue treatment with rifabutin may be effective.

Keywords:
Gastric cancer
Diagnosis
Dyspepsia
Helicobacter pylori
Gastrointestinal bleeding
Treatment
Peptic ulcer
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