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Vol. 34. Núm. S1.
Jornada de Actualización en Gastroenterología Aplicada
Páginas 16-27 (Enero 2011)
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Vol. 34. Núm. S1.
Jornada de Actualización en Gastroenterología Aplicada
Páginas 16-27 (Enero 2011)
Enfermedades relacionadas con el ácido
DOI: 10.1016/S0210-5705(11)70003-6
Acceso a texto completo
Enfermedades relacionadas con Helicobacter pylori: dispepsia, úlcera y cáncer gástrico
Helicobacter pylori-related diseases: dyspepsia, ulcer and gastric cancer
Visitas
...
Javier P. Gisbert
Servicio de Aparato Digestivo, Hospital Universitario de la Princesa, 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 en la Digestive Diseases Week relacionadas con la infección por Helicobacter pylori. Las resistencias antibióticas están aumentando en diversos países. Hay una relación inversa entre H. pylori y enfermedad por reflujo gastroesofágico (ERGE), aunque ello no implica que la erradicación del microorganismo favorezca la aparición de ERGE. El beneficio del tratamiento erradicador en la dispepsia no investigada parece confirmarse a largo plazo. La erradicación de H. pylori mejora los síntomas de un subgrupo de dispépticos funcionales. 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 (AINE) o la reinfección por H. pylori puede originar una recidiva hemorrágica. Los métodos diagnósticos de H. pylori basados en la biopsia gástrica poseen una reducida sensibilidad en pacientes con hemorragia digestiva. Incluso los pacientes que presentan una hemorragia digestiva mientras reciben AINE están frecuentemente infectados. El origen filogenético de la cepa de H. pylori predice el desarrollo de lesiones gástricas preneoplásicas. Las propiedades electroquímicas de H. pylori permiten su detección en biopsias gástricas con una elevada precisión y rapidez. La realización del test rápido de la ureasa conjuntamente a partir de una biopsia de antro y otra de cuerpo incrementa la sensibilidad y disminuye el tiempo en obtener el resultado. Aunque actualmente se recomienda confirmar la erradicación de H. pylori, en la práctica clínica esta recomendación frecuentemente no se cumple. El narrow-band imaging permite comprobar el cambio del patrón mucoso y vascular tras la erradicación. Se ha sugerido una relación entre infección por H. pylori y anemia ferropénica, arteriosclerosis, obesidad y adenomas/tumores colorrectales, aunque esta asociación no está suficientemente establecida. La eficacia de las terapias triples “tradicionales” deja mucho que desear actualmente, aunque el empleo de dosis elevadas de inhibidores de la bomba de protones y de antibióticos, y/o su duración más prolongada, pueden mejorar la eficacia. La nueva preparación que combina en una única cápsula bismuto, tetraciclina y metronidazol facilita la administración de la terapia cuádruple. La superioridad de la terapia “secuencial” sobre la triple estándar debería confirmarse en distintos medios. Un tratamiento híbrido secuencial-concomitante representa una prometedora alternativa. Las nuevas formulaciones antibióticas de liberación sostenida han obtenido resultados esperanzadores. El tratamiento de rescate de segunda línea 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 sitafloxacino, podrían ser útiles en el tratamiento erradicador de tercera línea. Puesto que la infección por H. pylori no confiere protección, los individuos se pueden reinfectar más de una vez con su propia cepa, lo que podría permitir el empleo de esta bacteria como vector para la administración de diversas vacunas en múltiples ocasiones.

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

This article summarizes the main conclusions drawn from the presentations on Helicobacter pylori infection at Digestive Disease Week 2010. Antibiotic resistance is increasing in several countries. There is an inverse relationship between H. pylori and gastroesophageal reflux disease (GERD), although this association does not imply that H. pylori eradication favors the development of GERD. The benefit of eradication therapy in uninvestigated dyspepsia seems to be confirmed in the long term. H. pylori eradication improves symptoms in a subgroup of patients with functional dyspepsia. 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 (NSAIDS) or H. pylori reinfection can lead to bleeding recurrence. Diagnostic methods for H. pylori based on gastric biopsy have reduced sensitivity in patients with gastrointestinal bleeding. Even patients showing gastrointestinal hemorrhage while receiving NSAIDs are frequently infected. The phylogenetic origin of the H. pylori strain predicts the development of preneoplastic gastric lesions. The electrochemical properties of H. pylori allow these lesions to be rapidly and accurately detected in gastric biopsies. The rapid urease test, including biopsies from both antrum and body, increases sensitivity and allows results to be obtained more quickly. Although confirmation of H. pylori eradication is recommended, in clinical practice, this recommendation is frequently not carried out. Narrow-band imaging allows the change in mucous and vascular pattern after eradication to be confirmed. An association between H. pylori infection and iron deficiency anemia, arteriosclerosis, obesity and adenomas/colorectal tumors has been suggested but remains to be confirmed. The efficacy of “traditional” triple therapies currently leaves much to be desired but could be increased by the use of high-dose proton pump inhibitors and antibiotics and/or increased duration of therapy. The new single-capsule preparation combining bismuth, tetracycline and metronidazole simplifies administration of quadruple therapy. The superiority of “sequential” therapy over the standard triple therapy should be confirmed in different environments. A hybrid sequential-concomitant therapy is a potentially useful alternative. The new sustainedrelease formulation antibiotics have shown promising results. Second-line rescue therapy with levofloxacin is effective and is also 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 sitafloxacin, could be useful in third-line eradication therapy. Because H. pylori infection does not confer protection, reinfection can occur more than once with the same strain, which could allow the use of this bacterium as a vector for the administration of various vaccines on multiple occasions.

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