|Year : 2021 | Volume
| Issue : 2 | Page : 40-46
Impact of quadruple eradication therapy on the elements of the Sydney system in chronic Helicobacter pylori gastritis in Abidjan (Ivory Coast)
Doffou Adjéka Stanislas1, Constant Assi2, Hamidine Illa3, Antonin Wilson Ndjitoyap Ndam2, Bangoura Aboubacar Demba4, Nigue Luc5, Attia Koffi Alain6
1 Department of Gastroenterology, Yopougon Teaching Hospital, Abidjan, Côte d’Ivoire; Department of Gastroenterology, Danga Medical Clinic, Abidjan, Côte d’Ivoire; Department of Gastroenterology, Rosette Medical Clinic, Abidjan, Côte d’Ivoire; Department of Gastroenterology, High Center Medical Clinic, Abidjan, Côte d’Ivoire; Officials Medical Service, Abidjan, Côte d’Ivoire
2 Department of Gastroenterology, Cocody Teaching Hospital, Abidjan, Côte d’Ivoire
3 Department of Gastroenterology, Yopougon Teaching Hospital, Abidjan, Côte d’Ivoire; Department of Gastroenterology, Oliviers Medical Center, Abidjan, Côte d’Ivoire; Department of Gastroenterology, Mamie Adjoua Medical Clinic, Abidjan, Côte d’Ivoire; Department of Biostatistics, University of Cocody, Abidjan, Côte d’Ivoire
4 Department of Gastroenterology, Oliviers Medical Center, Abidjan, Côte d’Ivoire; Department of Gastroenterology, Mamie Adjoua Medical Clinic, Abidjan, Côte d’Ivoire
5 Department of Biostatistics, University of Cocody, Abidjan, Côte d’Ivoire
6 Department of Gastroenterology, Yopougon Teaching Hospital, Abidjan, Côte d’Ivoire; Department of Gastroenterology, Danga Medical Clinic, Abidjan, Côte d’Ivoire
|Date of Submission||12-Jul-2021|
|Date of Acceptance||10-Dec-2021|
|Date of Web Publication||24-Feb-2022|
Dr. Constant Assi
Department of Gastroenterology, Cocody Teaching Hospital, Boulevard de l’université de Cocody, PO Box V 13 Abidjan.
Source of Support: None, Conflict of Interest: None
Background: The effect of eradicating Helicobacter pylori on the course of chronic gastritis (CG) is controversial. The aim of this study was to assess the impact of H. pylori eradication treatment on CG. Materials and Methods: This was a retrospective (January 2016 to December 2018) multicenter study. All medical records of patients treated with a quadruple therapy to eradicate H. pylori who were confirmed with histology at least 4 weeks after the end of treatment were included. The evolution of the CG ratings after treatment was analyzed. Results: The records of 170 patients (male/female ratio 0.95, average age 49.3 ± 12.2 years) were included. Respectively, inflammation and H. pylori levels decreased (P < 0.001) in antrum (2.09 to 1.45; 1.95 to 0.63) and fundus (1.82 to 1.27; 1.76 to 0.55). Gastric atrophy levels regressed in antrum (0.28 to 0.18; P = 0.0655) and fundus (0.19 to 0.09; P = 0.0096) on sequential quadruple therapy (0.42 to 0.26; P = 0.2384), with bismuth (0.27 to 0.1l8; P = 0.6232) or with concomitant therapy for 14 days (0.20 to 0.13; P = 0.1288). Gastric intestinal metaplasia progressed in the antrum (0.05 to 0.06; P = 0.5930) and the fundus (0.02 to 0.03; P = 0.2568); in sequential quadruple therapy (0.04 to 0.07; P = 0.3173) and in bismuth therapy groups (0.04 to 0.09; P = 0.5637) even after eradication of H. pylori (0.03 to 0.09; P = 0.0455). Conclusions: The eradication treatment for H. pylori improved elements of the Sydney CG system except for intestinal metaplasia.
Keywords: Abidjan, chronic gastritis, eradication of H. pylori, intestinal metaplasia, Sydney system
|How to cite this article:|
Stanislas DA, Assi C, Illa H, Ndjitoyap Ndam AW, Demba BA, Luc N, Alain AK. Impact of quadruple eradication therapy on the elements of the Sydney system in chronic Helicobacter pylori gastritis in Abidjan (Ivory Coast). Niger J Gastroenterol Hepatol 2021;13:40-6
|How to cite this URL:|
Stanislas DA, Assi C, Illa H, Ndjitoyap Ndam AW, Demba BA, Luc N, Alain AK. Impact of quadruple eradication therapy on the elements of the Sydney system in chronic Helicobacter pylori gastritis in Abidjan (Ivory Coast). Niger J Gastroenterol Hepatol [serial online] 2021 [cited 2022 May 25];13:40-6. Available from: https://www.njghonweb.org/text.asp?2021/13/2/40/338253
| Introduction|| |
Chronic gastritis (CG) is a chronic inflammatory disorder of the gastric mucosa, which can be atrophic or non-atrophic. Its diagnosis is based on histological evaluation of gastric biopsies performed during a gastroscopy. In sub-Saharan Africa, several studies have highlighted the high frequency of CG, its strong association with Helicobacter pylori infection, the precancerous and cancerous lesions.,,
Gastric atrophy and intestinal metaplasia are precancerous gastric lesions; they require endoscopic and histological monitoring. It is established that approximately 50% of patients with CG progressed to gastric atrophy, 8% of those with atrophy develop intestinal metaplasia and approximately 1% (of patients with GC) progressed to severe dysplasia and gastric cancer.Helicobacter pylori is responsible for 5.5% of all cancers worldwide, and two-thirds (2/3) of gastric cancers are attributed to it; thus, this bacterium has been classified since 1994 as a Type 1 carcinogen by the International Agency for Research on Cancer (IARC) under the aegis of the World Health Organization (WHO). Gastric cancer is one of the leading causes of death from cancer worldwide. Eradicating H. pylori is a means of preventing gastric cancer.,,, This eradication should lead to a reduction of mean scores of inflammation, atrophy, and intestinal metaplasia and consequently a reduction in the incidence of gastric cancer, after a long follow-up period.,[12-14] Nevertheless, the data in the literature on the regression of gastric atrophy and gastric intestinal metaplasia after eradication of H. pylori are controversial.,[15-19] In Ivory Coast, the prevalence of chronic atrophic gastritis in patients with H. pylori varies between 74.5% and 81.2% and that of intestinal metaplasia between 6.8% and 18.6%., Few data are available on the effect of H. pylori eradication treatment on the development of CG in Ivory Coast. The aim of our work was to assess the effect of quadruple eradication therapy on the evolution of histological scores for chronic H. pylori gastritis in Abidjan.
| Subjects and methods|| |
This was a retrospective study carried out from January 2016 to December 2018 in all hospital centers offering gastroenterology consultations (Teaching hospitals of Yopougon and Cocody and 6 private medical centers) in Abidjan. All medical records of patients of both sexes, aged over 18 years, and meeting the following three criteria were included:
- Have a histological diagnosis of chronic H. pylori gastritis from endoscopic gastric biopsies
- Be treated by quadruple eradication therapy protocol of H. pylori (10 or 14-days concomitant therapy (proton pump inhibitors [PPI], amoxicillin 1 g, clarithromycin 500 mg, and metronidazole 500 mg; all drugs b.i.d.) or 10-day bismuth therapy (daily doses of bismuth 300 mg, four times; PPI, twice; metronidazole 500 mg, three times; and tetracycline 500 mg, four times)
- Carry out a histological confirmation of the eradication from endoscopic gastric biopsies 4 weeks after the end of the quadruple therapy.
Incomplete or unusable records and those of patients who interrupted their quadruple therapy were excluded. The variables studied: age, sex, smoking, alcohol consumption, antibiotics use and/or anti-gastric secretory therapy in the 30 days preceding the eradication of H. pylori, non-steroidal anti-inflammatory drugs use, reason for gastroscopy, result of initial and control gastroscopy after quadruple therapy, gastric histological lesions before and after treatment, and type of quadruple therapy used. Data collection was carried out from the files of patients seen by gastroenterologists in Abidjan using a standardized questionnaire. Data entry was done on Excel 2007 and analysis by Pack office 2019 and Stata 14.2 software (Stata Corp, College Station, Texas). Qualitative variables were presented as a percentage, quantitative ones as median and average with their interquartile range and their standard deviation, respectively. The scores for each of the histological elements of the Sydney system of CG (inflammation, activity, lymphoid follicles, H. pylori, Gastric intestinal metaplasia, and gastric atrophy) were presented as follows: 0 = absent; 1 = slight; 2 = moderate; 3 = severe. The rating of the different histological parameters of CG according to the Sydney System after quadruple therapy was compared to that before treatment in series paired with the Wilcoxon test. All the statistical tests used were bilateral tests with an alpha significance threshold set at 5%. The study has been approved by the Ivory coast national ethic committee for life and health sciences regarding the Helsinki declaration of 1975, revised in 2000.
| Results|| |
During the study period, 700 records of patients with chronic H. pylori gastritis were found. Among them, 530 were excluded because of incomplete data. One hundred and seventy patients who met our study criteria were included. There was a slight female predominance (n = 87; 51.2%) with a sex ratio of 0.95. The overall eradication rate for H. pylori was 62.4%. The mean age of the patients was 49.3 ± 12.2 years with extremes of 12 and 81 years. [Table 1] shows the characteristics of the sample. Before treatment, glandular atrophy was present in 39 patients (22.9%) and gastric intestinal metaplasia in 8 patients (4.7%), respectively. Concomitant quadruple therapy of 14 days was the most prescribed (n = 84; 49.4%) [Table 1]. After quadruple eradication, the inflammation, activity, and H. pylori scores decreased significantly regardless of the gastric site (P < 0.001). Gastric atrophy regressed regardless of gastric topography. This regression is statistically significant in fundic only (P = 0.0096), but not when the location was diffuse (P = 0.0755) or only antrum (P = 0.0655). Irrespective of its gastric site, intestinal metaplasia progressed after eradication treatment, although not significantly [antral (P = 0.5930) or fundic (P = 0.2568) and diffuse (P = 0.328)]. [Table 2] and [Table 3] show the evolution of CG after quadruple therapy according to the gastric site. Inflammation decreased significantly after quadruple therapy (P < 0.0001), bismuth (P < 0.0430), and concomitant 14 days (P < 0.0001); this decrease was not significant for the concomitant quadruple therapy of 10 days (P = 0.0588). The density of H. pylori decreased significantly with the sequential quadruple therapies (P < 0.0001), bismuth (P = 0.0001), concomitant of 10 days (P = 0.0046) and 14 days (P < 0.0001). [Table 4] shows the evolution of chronic H. pylori gastritis according to the type of quadruple therapy performed. The evolution of intestinal metaplasia and gastric atrophy under each of the quadruple therapy is presented in [Table 5]. If H. pylori was successfully eradicated, inflammation (P < 0.0001), lymphoid follicles (P = 0.0263), and activity (P < 0.0001)) significantly regressed; gastric atrophy decreased without statistical significance (P = 0.1449); gastric intestinal metaplasia increased significantly (P = 0.0455). [Table 6] shows the effect of the outcome of the eradication treatment on the course of CG.
|Table 1: Clinical, endoscopic, and therapeutic characteristics of the sample (n = 170)|
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|Table 2: Evolution of the elements of chronic gastritis (inflammation, glandular atrophy, and activity) at different gastric sites based on the Sydney system after eradication treatment for H. pylori (n = 170)|
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|Table 3: Evolution of the elements of chronic gastritis (lymphoid follicles, intestinal metaplasia, and H. pylori) according to the Sydney system after eradication treatment for H. pylori (n = 170)|
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|Table 4: Evolution of chronic gastritis using the Sydney system (inflammatory, activity, and lymphoid follicles) according to the type of quadruple therapy of eradication of H. pylori (n = 170)|
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|Table 5: Evolution of chronic gastritis using the Sydney system (H. pylori, glandular atrophy, and intestinal metaplasia) according to the type of quadruple therapy of eradication of H. pylori (n = 170)|
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|Table 6: Evolution of chronic gastritis according to the effectiveness of H. pylori eradication|
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| Discussion|| |
The results of our study showed that the H. pylori eradication quadruple therapies had an impact in the evolution of H. pylori-associated CG. In general, the four eradication protocols studied resulted in a significant reduction in the density of H. pylori, irrespective of the gastric site, although the eradication rate of each quadruple therapy does not exceed 80%, with a significant drop in the inflammation and activity. The beneficial effect of eradication treatment on reducing the burden of H. pylori, on inflammation and gastric activity has been reported by several authors.,[22-24] However, after successful eradication of H. pylori, paradoxically, the score for gastric intestinal metaplasia increased in our study. According to Zhou et al., 5 years after an eradication treatment for H. pylori, antral intestinal metaplasia decreased or remained stable if successful but increased when failed., According to other authors, at this stage there was no regression after eradication treatment.,,,, The other gastric precancerous lesion studied, gastric atrophy, decreased after eradication of H. pylori, although the difference was not statistically significant. This regression after successful eradication had been described.,,, For some authors, there was a regression of metaplasia and atrophy,; for others, this regression only concerned atrophy but not gastric intestinal metaplasia, which constituted a point of no return.,,,, According to Leung et al, several factors are associated with the progression of gastric intestinal metaplasia: the persistence of an H. pylori infection after eradication treatment (37.6% in our case), age over 45 years (49.3 ± 12.2 years in our case), exposure to gastro toxic cofactors (alcohol: 25.3% in our case). Other factors, such as extension and importance of gastric intestinal metaplasia, the treatment used as first intention in our work, in the absence of knowledge on the level of resistance to antibiotics were in accordance with the recommendations of learned societies.,, These learned societies recommend quadruple therapies given the increasingly frequent emergence of resistance to basic antibiotics from conventional triple therapies, thus reducing their effectiveness. The overall H. pylori eradication rate in our study was 62.4%. Our overall eradication rate was certainly low compared to about 80% reported in the literature,,, but it was associated with a regression in the intensity of infection in non-eradicated patients which went from 31.8% to 5.2% of severe intensity and 35.9% to 10% of moderate intensity. In our study, the regression of histological lesions associated with chronic H. pylori gastritis was dependent on the eradication protocol used. In fact, gastric inflammation had regressed significantly with all protocols, except concomitant 10-day quadruple therapy, quadruple therapy not currently recommended. The probabilistic eradication treatment recommended as first-line treatment (14-day concomitant quadruple therapy or bismuth quadruple therapy) was associated with a significant reduction in the activity of gastritis and the density of H. pylori. Follicular gastritis lesions regressed significantly for the only 14-day concurrent quadruple therapy which was the most used protocol in our study (49.4%). The size of our sample (170 patients) was relatively small, which could affect the power of the statistical tests. Longer follow-up could refine our results. All the work carried out on this theme, particularly in countries with a high incidence of gastric cancer,,, focused on large cohorts with long-term follow-up.
| Conclusion|| |
The eradication treatment for H. pylori improved the elements of the Sydney system of CG except intestinal metaplasia.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]