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PRISE EN CHARGE DE L’INFECTION A

HELICOBACTER PYLORI : LES

RECOMMANDATIONS INTERNATIONALES

SONT-ELLES APPLICABLES EN AFRIQUE ?

Dr Ruffin NTOUNDA,

CHU Saint-Pierre, Bruxelles

Belgian Hp and microbiota Study Group (BHpMSG)

Journées Scientifiques de la SCGE

Yaoundé, Octobre 2019

! sérendipité !

Barry J. Marshall et

J. Robin Warren, Prix

Nobel 2005 de médecine

La découverte de H. pylori par Marshall et Warren

en 1982 a bouleversé cette conception et a fait de

l'ulcère gastroduodénal une maladie

essentiellement infectieuse...

1/ Est- ce qu'il faut eradiquer Helicobacter pylori ?

2/ Les recommandations internationales sont-elles applicables

en Afrique ?

Pathogenesis of Helicobacter pylori Infection

- Host immune gene polymorphisms and gastric acid secretion largely determine the bacterium's ability to

colonize a specific gastric niche.

- Bacterial virulence factors such as the cytotoxin-associated gene pathogenicity island-encoded protein

CagA and the vacuolating cytotoxin VacA aid in this colonization of the gastric mucosa and subsequently

seem to modulate the host's immune system

Johannes G. Kusters, Arnoud H. M. van Vliet, and Ernst J. Kuipers Clin Microbiol Rev. 2006 Jul; 19(3): 449–490

PREVENTION OF GASTRIC CANCER AND OTHER COMPLICATIONS (WORKSHOP 3)

With 4 Guidelines on H pylori, What Should Clinicians Do Differently?

Since 2015, 4 major Helicobacter pylori consensus documents have been published

❑ American College of Gastroenterology Clinical Guideline

❑ Toronto Consensus

❑Houston consensus

❑ Maastricht V/Florence Consensus Report (which was updated

from an initial report published in 2012)

David A. Johnson, Medscape Gastroenterology, Aug 29, 2018

The Maastricht Florence Consensus

1996- Maastricht I- Gut 1997

2000- Maastricht II- APT 2002

2005- Maastricht III-Florence- Gut 2007

2010- Maastricht IV-Florence- Gut 2012

2015 – Maastricht V- Florence- Gut 2016

INDICATIONS

THERAPEUTIQUES

Helicobacter Pylori InfectionWhen to Eradicate, How to Diagnose and Treat

Wolfgang Fischbach and Peter Malfertheiner, Dtsch Arztebl Int 2018; 115(25): 429-36

Dépistage ciblé

Recommandation 7:

Tester et rechercher Hp chez les immigrants de première

génération (prévalence élevée d’infection )

(82% sont d'accord / tout à fait d’accord, Grade 1B).

Recommandation 8:

Les latino-américains et Les afro-américains peuvent être

testés en raison du taux élevé de l’infection à Hp dans ces

groupes

(91% d’accord / tout à fait d’accord, Grade 2C).

HOUSTON CONSENSUS CONFERENCE ON TESTING FOR

HELICOBACTER PYLORI INFECTION IN THE UNITED STATES

HASHEM B. EL-SERAG, JOHN Y. KAO, FASIHA , AL.

Clinical Gastroenterology and Hepatology 2018;16:992–1002

Recommandation 11:

Tester les membres de la famille vivant dans le même foyer

que des patients dont l’infection est activement prouvée

(experts versus sondage: 91% contre 78% sont d’accord / tout à fait d'accord, avis d’expert 1B)

Recommandation 12:

Tester Hp chez des patients avec ATCD familiaux d’ulcère

peptique

(experts versus sondage: 91% contre (73%) d'accord / tout à fait d'accord, avis d’expert 1B) .





Recommandation 14:

Tester H pylori chez les patients traités par des médicaments

dont l'absorption peut être affectée par l’infection (par exemple

L-DOPA, thyroxine)

(experts versus enquête 63% vs 68% d’accord / tout à fait d’accord, niveau d’experts 2C)





Colm O’Morain

Summary of the main studies performed from 1993à 2002 evaluating the impact of H. pylori eradication on the

regression of low grade gastric MALT lymphoma

Author Year N. Patients % remission

Wotherspoon,al 1993 6 83

Bayerdörffer, al 1995 33 69

Roggero, al. 1996 25 60

Fischbach, al. 1995 15 93

Montalban, al. 1996 9 88

Pinotti, al. 1997 45 68

Neubauer, al. 1997 50 80

Nobre-Leitao, al. 1997 17 100

Steinbach, al. 1998 28 50

Thiede, al. 1999 84 81

Fischbach, al. 2000 36 89

Accumulated data 1993-2002 604 72,8%

En 2010: 32 séries publiés, 1271 cas

Gastric Malt Lymphoma Stage IE-IIE

Hp positive Hp neg or

t (11;18 ) or undertermined Hp pos with t (11;18 )

Antibiotic resistant or

No lymphoma response

t repeat EGD 2-3 months

after eradication therap ry

Antibiotic resistant

Hp eradication therapy with

Standard antibiotics and PPI regimen

Hp test at 2-3 months and

2nd ligne antibiotic regimen if Hp detected Repeat

EGD and biopsies at 3-6 months

After Hp eradication

Gastric Malt Lymphoma Stage IE-IIE

Neg. for lymphoma Pos. for residual Pos. lymphoma , symptomatic

Lymphoma, asymptomatic or with other treat.

indications - overt

progression

- deep invasion

- nodal invasion

- t (11;18) translocation

After Hp eradication

EGD and biopsy

Every 6 months for 2 years

Then every 12-18 months

Radiotherapy

Chlorambucil or other alkylants

and or rituximab when

radiotherapy is not feasible or not

indicated

EGD and biopsy

Every3- 6 months

Gastric Malt Lymphoma, stade IV

Asymptomatic lymphoma Smptomatic lymphoma or

with other treatment indications:

- overt progression

- bulky disease

- Impending organ damage

- patient preference

Hp eradication therapy with standard antibiotics and PPI regimen

if the infection is present

Wait and see with EGD and

biopsies and EUS/ 6 months

Additional imaging if clinically

indicated bone marrow biopsy if

clinical indicated

Chemotherapy and/or Rituximab

Consider enrollment in clinical trial

Tests Diagnostiques

Diagnostic tests for the detection of H,pylori infection: Non invasive

Test Se(%) Sp(%) Advantages Disadvantages

Serology 76-84 79-90 Widely available, inexpensive Positive result may reflect previous rather than current infection, not useful after treatment

UBT >95 >95 High negative and positive predictive values, useful before and after treatment

False-negative results possible in the presence of PPI or with recent use of antibiotics of bismuth preparations, consederable resources and personnel required to perform test

Stool antigen

test

96 97 High negative and positive predictive valuesUseful before and after treatment

Process of stool collection may be distasteful to patient, false-negative results possible in the presence of PPI or with recent use of antibiotics or bismuth preparations

Diagnostic tests for the detection of H,pylori infection: Invasive

Test Se(%) Sp(%) Advantages Disadvantages

Histology 95 99 Excellent sens, and Sp, especially with special and immune stains, provides additionnal information about gastric mucosa

Expensive ( endoscopy and histopathology costs), interobserver variability, accuracy affected by PPIs and antibiotics use, requires trained personnel

RapidUrease

test

90 93 Rapid results, accurate in patients not using PPIs or antibiotics, no added histopathology cost

Requires endoscopy, less accurate after treatment or in patients using PPIs

Culture 58,1 100 Sp 100%, allows antibiotics sensitivity testing

Variable sensitivity: requires trained staff and properly equipped facilities, expensive

PCR ?

Colm O’Morain

Artificial intelligence diagnosis of Helicobacter pylori infection

using blue laser imaging-bright and linked color imaging: a single-center prospective study

Hirotaka Nakashimaa , al,Annals of Gastroenterology (2018) 31, 1-7

Feature maps of the AI corresponding to the endoscopic images. Endoscopic images of a H. pylori-positive subject (test group). An image in WLI of EGD (A) showsyellowish mucosa in the lesser curvature (lower part of the picture). An image in BLI-bright (B) shows small whitish spots scattered over the mucosal surface (regionbetween the central part and the lower right part of the picture). An image in LCI (C) shows a pale-white color change in the same area. Feature maps of convolutionallayers during the AI test are also shown for WLI (D), BLI-bright (E) and LCI (F). In each IEE image, the AI responded to the lesser curvature of the stomach, which was theregion of mucosal atrophy with intestinal metaplasia, indicated by a light green or a light blue colorAI, artificial intelligence; WLI, white light imaging; BLI, blue laser imaging; LCI, linked color imaging; H. pylori, Helicobacter pylori

Image enhanced endoscopy. (A) Narrow band imaging (NBI) of the gastric mucosa. Round homogeneous sized pits with regularly arranged

collecting venules are shown (left). This pattern (regular arrangement of collecting venules) named ‘RAC’ pattern in the corpus mucosa

highly indicates a Helicobacter pylori negative state. In the H. pylori-infected mucosa with inflammation, pit patterns are elongated, varied in

sizes and shapes with spaces between them. Collecting venules are obscured owing to inflammation (centre). When intestinal metaplasia

develops, the pit pattern is further elongated with light blue lines (light blue crest sign) decorating the pits margins (right). The images were

provided by Dr Kazuyoshi Yagi. (B) Blue laser imaging (BLI) of the gastric mucosa. BLI is a new modality of image enhancement. The BLI-

bright mode can easily obtain lower magnification images, similar to the NBI images in (A) (left). With BLI-magnification mode, further

mucosal details including periglandular capillary networks (red coloured circles surrounding the pits) are seen (centre). BLI endoscopy is

useful for identifying the area of intestinal metaplasia where greenish coloured elongated pit patterns predominate (right).

The images were provided by Dr Hiroyuki Osawa, Jichi Medical University.

Magnifying NBI (left) and BLI (right) features of Hp infection negative (Hp−, upper) and positive (Hp+, lower) gastric mucosa. Hp− gastric

mucosa is characterized as small, round pits, accompanied with regular honeycomb-like SECNs, being regularly interspersed with collecting

venules (light blue arrow). On the other hand, Hp+ gastric mucosa is characterized as enlarged or elongated pits with unclear SECNs or dense

fine irregular vessels. NBI, narrow-band imaging; BLI, blue laser imaging; Hp, Helicobacter pylori; SECNs, subepithelial capillary networks.

Typical images for gastric pathology using MLI. a, b Same patient, (c, d) different patients. a Overview image of CG with larger areas of

mucosal atrophy with a yellow appearance in white light. b Mucosal atrophy at the lesser curvature using LCI atrophy appears white and

deeper vascular structures can be visualized. c Patchy distribution of IM in the antrum appearing as white areas in BLI mode. d

Magnification of angulus revealing light blue crest sign (arrows) as a sign of IM.

A) White light imaging with a small-caliber endoscope shows a small red area measuring 3 mm in diameter on the posterior wall

near the gastric angle, which is not suspicious for gastric cancer. (B) Linked color imaging enhances the red lesion and the

surrounding red portion. (C) Bright blue laser imaging reveals a discolored lesion measuring 10 mm around a central red area. (D)

Blue laser imaging produces a high color contrast between the malignant lesion and the surrounding mucosa. Several irregular

vessels are seen in the discolored lesion even with small-caliber endoscopy, suggesting early gastric cancer.

Esophagogastroduodenoscopy (EGD) is of growing importance

in the diagnosis of Helicobacter pylori (H. pylori) gastritis,

Image-enhanced endoscopy (IEE) with magnifying function is

useful for improving the diagnosis of H. pylori infection. H•

The AI demonstrated an excellent ability to diagnose H. pylori

infection using the novel IEEs

AI technology with IEE is likely to become a useful image

diagnostic tool for H. pylori infection

Hirotaka Nakashimaa , al,Annals of Gastroenterology (2018) 31, 1-7

Gisbert JP, EHMSG , Magdeburg 2016

Quadritherapie Bismuthée 10j Concomitant au moins 10j

Concomitant 14j Q. Bismuthée 10j

Trithérapie optimisée en fonction

De la sensibilité à la Clari et Aux

quinolones

JD de Korwin. JFHOD 2016

1e Ligne

2e Ligne

3e Ligne

Echec Echec

Echec Echec

Culture ou PCR

- Clari-S : IPP-Amoxi-Clari 14 jours (Amoxi 1gx3)

- Clari-R et Quinolones-S : IPP-Amoxi-Levo 14j

- Clari-R et Quinolones-R : IPP-Amoxi-Metro 14j

Traitement empirique de l'infection à Hp en France après Maastricht V

ou

Updated German Guidelines 2016

Low risk of Clari-R High risk of Clari-R

1st Line STT (14 days better than 7 days) or

Bismuth quadruple therapy

Bismuth quadruple therapy or

Concomitant quadruple

Risk factors for clarithromycin

resistance

- Geographical background

- Prior macrolide exposure

- Femal gender

Fischbach W et al. Z Gastroenterol 2016;54:327-63

Carlo A Fallone, al. Gastroenterology 2016;151:51–69The Toronto Consensus

Evidence-based Treatment Regimens for H. pylori Infection in North America, Listed in Recommended Order

Sheila E. Crowe, N Engl J Med 2019;380:1158-65

SCHEMAS

THERAPEUTIQUES et

RESULTATS

Triple therapy when Hp infection is known to be susceptible to clarithromycin

•PPI x2

•Amoxi (1g) x2

•Clari (500mg) x2

(or Tini or Metro (500mg) x2)

For 10 days, preferably 14 days

Traitement Hp en 2019: Triple therapie standardLow Clari-R

Pays Type trait Tx d'éradication Auteurs, Année

Japon Controlé: Metro vs Clari Metro: 98%

Clari: 60%

Mabe K, 2018

Rwanda Controlé:

Metro vs Clari vs Cipro

Metro:64%

Clari: 87%

Cipro: 81%

Kabakambira JD, 2018

Turquie Meta Analyse: Durée 7j vs 14j 57% vs 60% Sezgin O, 2019

Chine Controlé: Triple vs Bismuth

triple

Triple 7j: 79%

14j;89=%

Bismuth 7j: 82%

Leow AH, 2018

Inde Controlé: standard vs “ Daily

Single-dose triple

86% vs 90%

(meilleure

compliance)

Shahbazi S, 2018

O'Connor et al. Helicobacter 2019

Sequential therapy

• PPI + Amoxi (1g) x2 for 5 days

followed by

• PPI +Clari (500mg) + Tini (500mg) or

Metro (500mg) x2 for a further 5 days

( Total 10 days)

Concomitant therapy

• PPI +

• Amoxicillin (1g) +

• Clarithromycin (500mg) +

• Tinidazole or Metro (500mg)

Twice daily for 10-14 days

Sequential - Concomitant therapyor Hybrid

PPI +Amoxicillin (1g) x2 for 7 days

Followed by

PPI, Amoxi (1g), Clari(500mg) and Tini

or Metro (500mg) for a further 7 days

( Total 14 days)

Traitement Hp en 2019Quadruple: concomitant, Sequentiel, Hybrid


Meta-analyse, Conc. vs

triple

23 études controlées

N=6632

Conc 5-10 j > Triple 7-1à j

Mais Conc = Triple 14j

Chen MJ, 2018

Hybrid bénéfice du sequentiel +

conco; mais compliance

mauvaise

Taiman Etude controlée

N=352

Reverse -Hybrid 96%

Q. Bismuth= idem

HSU PL, 2018

Espagne Cross selected selectional Conco 98%

Bismuth 94%

Macias Garcia,2019

Rescue 3è ligne

Conco 14j

Résistant

- Clari-R:79%

- Levo-R: 95%

- Metro-R: 67%

Non resistant: 81%

Huang HT, 2018

Bismuth quadruple therapy

•PPI x2

•Bismuth x4 (subsalicylate or subcitrate)

•Tetracycline hydrochloride (500mg) x4

with meals and at bedtime (bismuth and TTC)

•Tinidazole or Metro (500mg) x3 with meal

(for 10 days, or preferaly 14 days)

Alternatives:• Pylera + PPI x2 for 10-14 days

Nonghua Lu ,EHMSG , Magdeburg 2016

The fourth chinese consensus report on the management of H.pylori infection

Liu Wen Zhong, al. J Digestive Disease 2013;14:211-221

Essais thérapeutiques avec Pylera(Bismuth, metro, TTC)

Traitement Hp en 2019: Bismuth


Europ

Hp-Eurog

N=1141

1è ligne

88% McNicholl AG, 2019

Italie N=500 Seq= 91%

Pylera= 92%

Fiorini, 2018

Chine controlé Avec Bismuth=85%

Sans Bismuth= 64%

Long X, 2018


Real-Word studies of Bismuth-based quadruple regimens

Study Zagari Agudo-Fernandez

Country Italy Spain

Number 376 185

1st line (%) 91,4 78,2

2nd line(%) 87,5 85,3

3rd line (%) 91,7 61,3

Adverse Events(%) 32,4 3,8

Abondoned(%) 6,1 4,9


Fluoroquinolone therapy when Hp infection is known to be susceptible to fluoroquinolones

•PPI x2

•Amoxi (1g) x2

•Fluoroquinolone (Levo 500mg) x1

(or x2)

For 10-14 days

Traitement Hp en 2019: Levofloxacine


Iran Controlé Seq 10j: 78%

Conco 14j: 83%

Hajiani E, 2018

Mexico Controlé Levo triple:63%

Stand triple:58%

Ladron-e-Guevara,2018

Pakistan Controlé

N=300

Levo 14j: 92%

Stand: 87%

Latif S, 2018

Italie Levo

+/- lactoferine

avec lactoferine:96%

Sans lactoferine: 75%

Ciccaglione, 2019


Rifabutin triple therapy

• PPI x2 +

• Rifabutin (150mg) x2 +

• Amoxicillin (1g) x2

( Total 14 days)

J. P. Gisbert,X. CalvetAliment Pharmacol Ther 2012; 35: 209–221

Review article: rifabutin in the treatment of

refractory Helicobacter pylori infection

One randomized trial showed that regimens with

rifabutin were effective rescue therapies in

patients with treatment failure who had H. pylori

infection that was resistant to both

metronidazole and clarithromycin

Perri F, Festa V, Clemente R, et al. Am J Gastroenterol 2001; 96: 58-62.

Traitement Hp en 2019: Probiotics


Espagne Standard vs Concomitant

+ Lacobacillus vs Placebo

N=209

Placebo= 95%

Probiotics=97%

McNicholl AG.2018

By

Chinese

Group

MetaAnalyse

40 etudes

8924 patients

- ↑ Eradication

- ↓ Effet II

Dore MP.2019


Kawashima K, al. Dig Liver Dis. 2016

Vonoprazan

The First-in-Class Potassium-

Competitive Acid Blocker,

(Vonoprazan Fumarate)

Eradication rate of Vonoprazan VPZ triple therapy (1wk)

Murakami K et al. Gut 2016; 65: 1439-46

VAC or LAC triple

Traitement Hp en 2019: Vonoprazan

- N= 1355, 1stline

Standard 86%

Voroprazan Triple 97% erad

- MetaAnalyse, 5 studies, 1599 patients

Clari-S: Vonoprazan triple = Standard triple: 95% vs 93%

Clari-R: Vonoprazan triple ≠ Standard triple: 82% vs 40%

Mori N, al.Biomed Rep. 2018

Li M, al. Helicobacter. 2018

Helicobacter Pylori: New Therapies

❑ Bromopyruvate ( anticancereux)

❑ Goshuyuto ( Herbicide): Japon

❑ Lactoferrine bovine 10 mg/ml

❑ Dual therapy > concomitant ( Taiwan)

- IPP+ Amoxi high dose

Yang X, al.Medicine (Baltimore) 2019

Sue S, al. J Gastroenterol Hepatol 2019

DISCUSSION

Evolution of primary resistance of H.pylori to Clarithromycin,

Metronidazole and Fluoroquinolones in Brussels, Belgium

Macrolides (10.5% to 18%),

Nitro-imidazoles (28% to 40%)

Fluoroquinolones (12.4% to 22.8%)

VERONIQUE Y MIENDJE DEYI; M'Kinansoi S Lare, Alain

Burette; Ruffin NTOUNDA; Samy Cadranel; Okyay ELKILIC,

PATRICK BONTEMS; Marie HALLIN,

Diagn Microbiol Infect Dis. 2019 Jul 30:114875

https://www.ncbi.nlm.nih.gov/pubmed/31474463

Hp resisance to antibiotics in the studies published during the last year worldwide

Author N Region AMO% CLA% Met% Quin% TTc% Rif% Fur%

Liu 1117 China 3,4 22,1 78,2 19,2 1,9 1,5 -

Forini 1424 Italy 0,06 35,9 40,2 29,3 - - 0,06

Bashir 270 Algeria 5,2 29,7 46,7 17,2-17,9 2,6 - -

Lopo 2194 Portugal 0,1 42 25 9-18 0,2 - -

Gonzalez-

Hormazabal

191 Chile - 31,2 - 14,1 - - -

Mosites 800 USA - 28,8 42,8 45-58,7 - - -

Saniee 218 Iran 27,1 34,4 79,4 27,9 38,5 - 23,9

Khien 2318 Vietnam 15 34,1 69,4 - 17,9 - -

Kageyama 208 Japan 13 48 49 - - - -

Zhang 144 China - 70 - 6 - - -

Pinkowska 170 Poland - 46 56 39,2 - - -

Lee 74 S-Korea 6,7 31 41,8 - - -


Pan- European Registry on H. pylori management (Hp- EuReg):

interim analysis of 16 600 first- line treatments

A. G. McNicholl et al. Helicobacter 2018

Pan- European Registry on H. pylori management

(Hp- EuReg): interim analysis of 16 600 first- line treatments

❑ La gestion de l'infection à Hp par les gastro-

entérologues européens est hétérogène, sous-

optimale et souvent en contradiction avec les

recommandations actuelles.

❑ Seuls les quadruple-therapies d'une durée d'au

moins 10 jours peuvent atteindre un taux

d'éradication supérieur à 90 %.

A. G. McNicholl et al. Helicobacter 2018

A recent observational study showed that only 35% of patients

who had been treated for H. pylori infection underwent follow-up

testing to confirm eradication and that many patients who had

treatment failure were retreated with the same regimen

Rubin J, Lai A, Al.Gastroenterology 2018; 154: S503-S504.

Epidémiologie de l’infection à Helicobacter Pylori à Yaoundé :

de la particularité à l’énigme Africaine

Firmin Ankouane Andoulo, Dominique Noah Noah,&, Michèle Tagni-Sartre3,

Elie Claude Ndjitoyap Ndam, Katleen Ngu Blackett

Pan African Medical Journal. 2013 16:115

171 sujets symptomatiques.

Test rapide à l'uréase kit commercial Pronto Dry®

La prévalence Hp 72,5% (124/171)

H.pylori était de 63,0% pour l'ulcère duodénal,

50% pour l'ulcère gastrique et

100% pour le cancer gastrique.

Conclusion: la prévalence de l'infection à H.pylori au Cameroun est très élevée et

significativement liée à l'âge de moins de 40 ans.

Molecular detection of Hp and its antimicrobial resistance in Brazzaville, Congo

Antibiotics Resistance (%)

Clarithromycin 1,7

Tetracycline 2,5

Quinolone 50

•Hp prevalence : 89 %

•Ontsira Ngoyi EN, al. Helicobacter. 2015 Aug;20(4):316-20

Antibiotique Tx Resistance (%)

Amoxicilline 0

Tetracycline 0

Clarithromycine 8,9

Levofloxacine 75

Metronidazole 100

• 58 patients (Dl Abd), Age moyen=39 ans homme=60 %

• Biopsies stockées à -18° (Kivu), puis congelées à -70 °(BXL)

• 23 souches ( 1 souche morte, 5 souches contaminées)

Natmako S, Nteranya O, Mwengte J, Van Gossum M, Miendje Y, 2016.

Profil de resistance aux antibiotiques de l’Hp dans la région du Sud-Kivu : Resultats préliminaires d’une étude

monocentrique

Resistance Primaire en Algerie

Clarithromycine Metronidazole

Boucekkine Mouffok Djennane-Hadibi 2003 2013 2015

12,5% 12% 33%

LARH 2008

37%

Boucekkine T,al. 2003Mouffok F, al.Saidal santé Fev 2013

Djennane-Hadibi F,al. Microbiol drug Resistance 2015

•Reza Ghotaslou, al, World J Methodol,2015 Sep 26;5(3):164-174

Prevalence of Antibiotic Resistance in Helicobacter pylori:A Systematic Review and Meta-analysis in World Health

Organization Regions

Alessia Savoldi, Elena Carrara, David Y. Graham, Michela Conti, and Evelina Tacconelli. Gastroenterology 2018;155:1372–1382

Efficacy of Helicobacter pylori eradication regimens in Rwanda: a randomized controlled trial

JD Kabakambira, al.BMC Gastroenterol. 2018; 18: 134.

Efficacy of Helicobacter pylori eradication regimens in Rwanda: a randomized controlled trial

JD Kabakambira, al,BMC Gastroenterol. 2018; 18: 134.

- Coûts, efficacité et profil d'innocuité documentés dans cette

étude; => utiliser clarithromycine et des thérapies combinées à

base de ciprofloxacine pour l'éradication de H. pylori au Rwanda.

- Métronidazole à base de la trithérapie est inférieure et mauvais

choix parmi les quatre schémas thérapeutiques étudiés.

Classification de OLGA et OLGIM: impacts de facteurs ethniques, démographiques et

environnementaux

Afr. sub-saharienne: Hp elevé, moins d'ulcus et cancer

< type de souche, facteurs immunitaires, génétiques, diététiques

G1: Patient europeens (680) G2= centre africain (250)

- Pas de différence significative sur la sévérité des gastrites

- Role de l'Hp et l'âge dans la sévérité, mais pas de facteurs

geographiques

- Lésions endoscopiques significatives: 27% G1 et G2

Van Gossum M, al. JFHOD 2020

Images obtained with a normal-caliber endoscope: (A) white light imaging and (B) linked color imaging cannot clearly reveal the site of the

early gastric cancer (white arrows) because of the tangential view. (C) Blue laser imaging with middle magnification shows a brown

malignant lesion surrounded by green mucosa (white arrows). (D) Blue laser imaging using high magnification shows irregular

microvascular and irregular microstructural patterns on the mucosal surface

Pimentel-Nunes Pedro et al. MAPS II … Endoscopy 2019; 51: 365–388

•Facteurs à retenir lors du choixd’un traitement éradicateur Hp

•WGO Global Guideline Hp in developing countries, 2010

Niveau de ressources à disposition et options diagnostiques

•WGO Global Guideline Hp in developing countries, 2010

•Prevalence of antibiotic resistance in Hp: A recent literature review

Reza Ghotaslou, al, World J Methodol,2015 Sep 26;5(3):164-174

Contrôle d’éradication

❑Au plus tôt 4 semaines après la fin du traitement.

❑ Lorsque l'endoscopie n'est pas nécessaire, seul le BTU ou le test à

l'antigène fécal est acceptable.

❑ Le bismuth et les ATB doivent être arrêtés pendant 28 j et les IPP

pendant 14 j avant le BTU

❑ Le HpSAg fécal ne devrait pas être effectué moins de 4 sem ( de

préférence 8 à 12 sem) après le traitement.

Conclusion I

- Helicobacter pylori est carcinogene de classe 4, son éradication ne

laisse aucun doute dans les inications bien précises

- Les recommandations internationales offrent actuellement plusieurs

possibilités de prise en charge qui peuvent s'appliquer partout dans

le monde

- La zone Afrique, particulièrement la zone sub-saharienne soufre

beaucoup du manque de moyens diagnostiques et therapeutiques,

mais les resultats des études publiées, certes peu nombreux,

montrent que ces recommandations sont bien adaptables

Conclusion II

- Afr. sub-saharienne: Hp elevé, moins d'ulcus et cancer < type

de souche, facteurs immunitaires, génétiques, diététiques

- L'endoscopie diagnostique fait de grands progrès. est ce que

l'intelligence artificielle est l'avenir ? Celà reste à demontrer et

difficile à généraliser

- Le consensus Brésilien par exemple recommande encore les

schemas à base de Clarithromycine malgré Clari-R> 15% car

Bismuth non disponible

- Levofloxacin, Sitafloxacin, Furazolidone, Rifabutine restent

interessants en “Rescue”

« Tant que les lions n'auront pas leurs propres

historiens, les histoires de chasse ne peuvent que

chanter la gloire du chasseur ».

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