Eradicate Helicobacter pylori and effectively prevent gastric cancer!

It is only for medical professionals to read and listen to expert interpretation, which is the most efficient way to absorb a guide.

Figure 1 "Screening and eradicating Helicobacter pylori to prevent gastric cancer: Taipei Global Consensus" is the main author of "Screening and eradicating Helicobacter pylori to prevent gastric cancer: Taipei Global Consensus" at the end of 2020.
Gut Magazine [1] (hereinafter referred to as " "Taipei Global Consensus"), the formulation of this consensus brought together core experts in the field of international digestion, including Professor Peter, the first author of the Maastricht Consensus II-V, Professor Kentaro, the first author of the Kyoto Global Consensus on Helicobacter pylori gastritis, and Professor David, the editor-in-chief of Helicobacter.
, Professor Emad, editor-in-chief of Gut magazine, Professor Lu Hong from mainland my country, and Professor Shen Zuyao from Hong Kong.

Big coffee gathered, a gathering of heroes.

It can be said that this consensus is the first consensus on the eradication of H.
pylori and the prevention of gastric cancer jointly drawn up by outstanding experts around the world.

In the recently successfully held 2021 Peking Union Medical College International Digestive Disease Forum and the 28th Peking Union Medical College Hospital Digestive Diseases and Digestive Endoscopy Symposium, Professor Lu Nonghua from the Department of Gastroenterology, the First Affiliated Hospital of Nanchang University gave a wonderful interpretation of this consensus.

The famous "intestinal" gastric cancer occurrence pattern theory According to the World Health Organization (WHO), among the global malignant tumors, the incidence and death of gastric cancer ranked the top 5 in 2018, and the country with the highest incidence of gastric cancer in the world is located in East Asia , my country, South Korea, Japan and Mongolia are among them.

In 1975, Professor Correa first proposed the "intestinal type" gastric cancer occurrence model (Figure 2).

Figure 2 The "intestinal" gastric cancer pattern proposed in 1975.
After Hp was discovered by the world in 1992, Professor Correa perfected the pattern of gastric cancer.He believes that in this series of reactions, the first and most critical link is that Hp infection induces the development of normal gastric mucosa to chronic superficial gastritis.
The high-salt diet promotes this link and further enriches it.
The theory of "intestinal type" gastric cancer occurrence pattern.

Figure 3 A more complete pattern of "intestinal" gastric cancer.
Professor Correa believes that Hp infection leads to chronic atrophic gastritis, and the atrophy of the gastric mucosa will lead to a state of low gastric acid and high pH in the stomach.
This state is very conducive to the excess of non-Hp bacteria.
Growth, thereby promoting the production of carcinogenic nitroso compounds, further aggravating the degree of atrophy of the gastric mucosa, forming a vicious circle.

Fresh vegetables and fruits with antioxidant effects can inhibit and block the production of carcinogenic nitroso compounds, thereby inhibiting the deterioration of chronic atrophic gastritis to a certain extent.

This hypothesis has been widely recognized internationally, and to this day, it is still our core theory for gastric cancer prevention.

It has been concluded that Hp eradication can reduce the risk of gastric cancer, and consensus guidance is urgently needed-Taipei Global Consensus was launched.
In 2014, a British scholar published the first meta-analysis comparing the impact of Hp eradication and non-eradication on the incidence of gastric cancer.
The results It was found that the risk of gastric cancer in the eradication group was reduced by 34% [2].
This study provided an important basis for the development of the Maastricht V consensus.

Six years later, the scholar updated his Meta-analysis again, and after including more studies and samples, and extending the follow-up time, he concluded that eradication of Hp can reduce the risk of gastric cancer by 46%.

That is to say, in the increased 6-year follow-up, the risk of gastric cancer in the Hp eradication group was reduced by 12% compared with the non-eradication group [1].

Figure 4 Meta analysis of the impact of Hp eradication and non-eradication on the incidence of gastric cancer.
Follow-up time increased by 6 years, and the incidence of gastric cancer in the Hp eradication group further decreased by 12%.
This also provides more favorable evidence for eradicating Hp and preventing gastric cancer.

In 2020, this research has also become one of the important basis for the formulation of the Taipei Global Consensus.

The preventive effect of eradication of Hp on gastric cancer has become an undisputed fact.

Our neighboring country, Japan, has already implemented a plan to eradicate Hp and prevent gastric cancer.

How can these research results be fully promoted to benefit mankind? This requires the guidance of corresponding consensus.
It is in this context that the Taipei Global Consensus came into being.

Figure 5 The promotion of H.
pylori eradication plan urgently needs a consensus to guide Professor Lv Nonghua’s interpretation of the main point of the Taipei Global Consensus 1 Hp infection-related gastric cancer disease burden (1-5) 1.
Although the global age-standardized gastric cancer incidence and mortality rate is declining, due to the elderly population On the increase, the number of new cases of gastric cancer is still high.

Consent rate: 96%; Level of evidence: Why does the increase in the middle-aged and elderly population increase the number of new cases of gastric cancer? We know that the occurrence of intestinal gastric cancer has gone through a long evolutionary process, and it takes approximately 30-50 years to develop intestinal gastric cancer from normal gastric mucosa.

Figure 6 The evolution process of intestinal gastric cancer takes 30-50 years.
According to the investigation, the incidence of gastric cancer presents obvious age stratification characteristics.

Compared with people before the age of 50, the incidence of gastric cancer in middle-aged and elderly people (from 50 to 80 years) has increased by nearly 10 times.

Figure 7 The incidence of gastric cancer in my country shows obvious age stratification.
With the improvement of people's living conditions and the improvement of medical standards, the average life expectancy in my country has been extended from 35 years in 1949 to 77.
3 years in 2019, and the curve has Continue the upward trend.

It can be seen that as the average life expectancy in our country continues to extend, the number of new patients with gastric cancer is difficult to decrease, and it will still maintain a high value.

Figure 8 Due to the increase in average life expectancy, the number of new patients with gastric cancer may continue to increase.
2-1.
Although the Hp infection rate in most Western countries is declining, the infection rate remains high among people with a high incidence of gastric cancer.

2-2.
In some populations, the child Hp infection rate has dropped below 10%, but it is still high in many parts of the world.

At present, the Hp infection rate in mainland China remains at 40% to 60%.

In Beijing, Shanghai, Guangzhou and Wuhan, the infection rate of children with H.
pylori is between 20% and 30%.

3.
Global >85% of gastric cancers are attributed to Hp infection, indicating that if Hp infection is eliminated from the population, most gastric cancers can be prevented. Agree rate: 88%; Evidence level: Medium 4.
Eradication of Hp can reduce the risk of gastric cancer in infected patients.

Agree rate: 92%; Level of evidence: In 2017, an article titled Gastric cancer as preventable disease was published on Gut, which proposed that 90% of non-cardia gastric cancers are caused by Hp Infection, and the other 3%~10% of non-cardia gastric cancer is caused by genetics, Epstein-Barr virus infection, autoimmune gastritis, hypertrophic gastritis and other reasons [3].

Figure 9 90% of the occurrence of non-cardia gastric cancer is caused by Hp infection.
5.
Hp eradication is recommended after resection of early gastric cancer, because it can reduce the risk of metachronous gastric cancer.

Agree rate: 96%; Level of evidence: high The results of 3 studies from Japan/Korea unanimously agree that the eradication of Hp can reduce the risk of gastric cancer by 51% after endoscopic submucosal dissection (ESD) in early gastric cancer (see The following figure).

Figure 10 Hp eradication after resection of early gastric cancer still has the value of preventing gastric cancer (the risk of gastric cancer is reduced by 51%) 2.
Hp screening and eradication programs in the population (6-12) 6.
It is recommended to screen in the high-risk or high-risk population of gastric cancer Check and eradicate Hp to prevent gastric cancer.

Agree rate: 84%; level of evidence: low In the Taipei consensus, if the incidence of gastric cancer in a certain area is higher than 20/100,000/year, it is defined as a high-incidence area, while the overall incidence of gastric cancer in mainland China is 30/100,000/year Therefore, my country's mainland as a whole is a high-risk area for gastric cancer, and it is recommended to screen and eradicate Hp in the population.

However, there are still significant differences between regions.
For example, Zhuanghe in Liaoning, Linqu in Shandong, Changle in Fujian, and Wuwei in Gansu have higher incidence rates, which are particularly high-risk areas for gastric cancer.

Figure 11 The Taipei Global Consensus defines the high-risk area, medium-incidence area, and low-incidence area of ​​gastric cancer.
In addition, it should be noted that the high-risk population of gastric cancer does not only refer to the residents in the high-incidence area of ​​gastric cancer, but also includes people from the high-incidence area of ​​gastric cancer (but currently People who are not active in high-risk areas), as well as people with family history of gastric cancer, Hp infection, age >40-50, male sex, high-salt diet, and smoking.

Figure 12 Taipei Global Consensus on the Definition of High-risk Groups of Gastric Cancer If high-risk groups can eradicate H.
pylori, they will benefit more than non-high-risk groups. 7.
It is recommended to screen and eradicate H.
pylori before the occurrence of atrophic gastritis and intestinal metaplasia.

Agree rate: 84%; level of evidence: low.
We know that eradication of Hp can prevent or delay the occurrence and development of gastric atrophy and intestinal metaplasia.

However, for the mucosa of different pathological stages, the degree of impact of Hp eradication on the risk of gastric cancer varies greatly.

If Hp eradication is performed after gastric mucosal atrophy and intestinal metaplasia occur, it is difficult to reverse the path of dysplasia.

Figure 13 The impact of Hp eradication on the development of gastric cancer at different stages in the development of intestinal gastric cancer.
8.
The implementation of screening and treatment strategies to prevent gastric cancer is the most cost-effective in young people in areas with high incidence of gastric cancer.

Agree rate: 84%; Level of evidence: low 9.
Young people benefit the most from Hp eradication because it can cure Hp-related gastritis, reduce the risk of gastric cancer, and reduce transmission to children.

Agree rate: 92%; Level of evidence: low Domestic and international consensus has slightly different recommendations on the age at which the population begins screening/eradication of H.
pylori.

The Kyoto Global Consensus on Hp Gastritis recommends screening/eradication of H.
pylori from the age of 12.
It is believed that at this age, the gastric mucosa has not yet undergone atrophy/intestinal metaplasia, and the effect of preventing gastric cancer is better; the Taipei Global Consensus of my country recommends it at 20 Screening/eradicating Hp in the -40-year-old population can prevent gastric cancer and other Hp-related diseases.
It is believed that eradicating Hp at this age can effectively prevent transmission to the next generation.

Figure 14 "Hp Gastritis Kyoto Global Consensus" recommends that residents start screening/eradication of H.
pylori at the age of 12; the age of H.
pylori screening/eradication recommended by the Taipei Global Consensus of my country is 20-40 years old.
11.
It is recommended for people with Hp infection (non-invasive Screening) those with a higher risk of gastric cancer should undergo further endoscopy.

Consent rate: 100%; Evidence level: low.
Since mainland China is a high-incidence area for gastric cancer, if only non-invasive (gastroscopy) examinations are used to determine whether Hp is infected or not, it is very likely that gastric cancer or precancerous changes will be missed.

Therefore, it is recommended to perform further endoscopy for those with a higher risk of gastric cancer among Hp-infected patients.

12.
Population-level Hp screening and eradication should be integrated or included in national health priorities to optimize resources. Agree rate: 92%; Evidence level: Low-level Hp eradication to prevent gastric cancer is one of the long-term strategies for Healthy China.

As early as 2019, Academician Li Zhaoshen organized and published my country’s first "Expert Consensus on Helicobacter Pylori Eradication and Gastric Cancer Prevention and Control in China".
This consensus clarifies that eradication of Hp is a first-level measure to prevent gastric cancer, and its release is at the forefront of the world.
, Has played an important role in promoting the prevention and treatment of Hp infection and gastric cancer in my country.

Treatment of H.
pylori infection in the three large-scale eradication projects (13-18) 13.
The global H.
pylori resistance to clarithromycin and levofloxacin is on the rise.

14.
When choosing the best plan in the community, Hp resistance, efficacy, adverse reactions and costs in different regions should be considered.

Agree rate: 100%; Level of evidence: low 15.
Recommendations are based on antibiotic management principles, and local reliable and effective programs should be selected.

Agree rate: 92%; Level of evidence: Medium 16.
It is recommended to monitor local Hp resistance to determine the best plan for large-scale empirical eradication of Hp in this population.

Agree rate: 96%; Level of evidence: The Chinese Taipei Global Consensus also proposes that if a drug susceptibility test is feasible, it is recommended to do a drug susceptibility test.

If it is not feasible, then recommend to the local proven effective plan.

Among them, the 14d bismuth quadruple regimen recommended by mainland my country, the 14d containing furan quinone regimen, and the 14d containing amoxicillin regimen have all been recommended and approved by the Taipei consensus.

Figure 15 Selection of H.
pylori eradication programs recommended by the Taipei Global Consensus in my country.
17.
The reinfection rate after large-scale Hp eradication is very low.

Agree rate: 96%; Level of evidence: Professor Lu Nonghua mentioned that many patients are worried about reinfection after eradication, but in fact, the Helicobacter pylori group of the Chinese Medical Association Digestive Diseases Branch has done a national multi-center study.
The results It shows that in my country's mainland, the reinfection rate of Hp has dropped significantly, and the current annual infection rate is less than 2%. Figure 16 The re-infection rate after Hp eradication in my country has decreased significantly (5%-7%/year in the early years, and 1%-1.
75% in the current year) Four potential adverse consequences after Hp eradication (19-23) 19.
With all antibiotic treatments Similarly, Hp eradication therapy may lead to increased antimicrobial resistance, but its use for gastric cancer prevention should not be ruled out.

Agree rate: 92%; Level of evidence: low 20.
Eradication of Hp treatment will cause short-term disturbances in the fecal microecological diversity, and most of it will be restored later.

Agree rate: 88%; Level of evidence: low 21-1.
Eradication of Hp will not increase the risk of new GERD.

Agree rate 92%: Evidence level: high 21-2.
Eradication of Hp will not increase the risk of recurrence of GERD.

Agree rate: 96%; Level of evidence: Moderate 22.
Eradication of Hp may be associated with a small increase in weight, but it will not increase the risk of metabolic syndrome.

Agree rate: 80%; Level of evidence: low 23.
Eradication of Hp will not increase the risk of asthma, inflammatory bowel disease and other immune-related diseases.

Consent rate: 80%; Level of evidence: Endoscopic monitoring of gastric cancer after eradication of low five Hp (24-26) 24.
After Hp eradication, patients with advanced gastric atrophy or intestinal metaplasia should undergo endoscopic monitoring.

25.
For patients with advanced gastric atrophy or intestinal metaplasia, endoscopy should be performed every 2 to 3 years; endoscopy should be performed every 12 months after gastric neoplasia.

Consent rate: 52%; Level of evidence: low.
Since different periods of follow-up have different effects in reducing the risk of gastric cancer, the Taipei Global Consensus clearly states that if the gastric mucosa has entered the stage of atrophy or intestinal metaplasia, the intensity of follow-up should be strengthened to prevent it.
The occurrence of dysplasia or intestinal gastric cancer.

Figure 17 Hp eradication in patients with advanced gastric atrophy or intestinal metaplasia has reduced benefits for gastric cancer prevention.
Therefore, it is recommended to strengthen endoscopic monitoring to detect potential cancer in time.
26.
Genetic and epigenetic markers show promise in the risk division of gastric cancer after Hp eradication , But it needs further verification in prospective studies.

Agree rate: 92%; Level of evidence: low Summary: Intestinal gastric cancer is a preventable disease.

Eliminating gastric cancer is not only possible, but feasible.

Hp eradication can prevent gastric cancer, and different groups of people have different benefits: if Hp eradication occurs before gastric mucosal atrophy/intestinal metaplasia, it can reduce the risk of gastric cancer by 100%; for people with a family history of gastric cancer, Hp eradication can increase the risk of gastric cancer Reduced by 73%; medium to long-term follow-up after Hp eradication can reduce the risk of gastric cancer by 53%; Hp eradication after endoscopic resection (ESD) for early gastric cancer can reduce the risk of gastric cancer by 51%; for healthy individuals, Hp eradication can increase the risk of gastric cancer 46% reduction.

In general, based on long-term follow-up predictions, Hp eradication can eliminate two-thirds of gastric cancer.

Achieving the goal of eliminating gastric cancer involves multiple elements: including eradication of Hp, correction of bad living habits, supplementation of antioxidants, etc.
, that is, primary prevention of gastric cancer.
Screening and follow-up of patients with atrophy and intestinal metaplasia, and detection of gastric mucosal epithelium that has occurred.
Endoscopic resection (ESD) for internal neoplasia is the secondary prevention of gastric cancer.

    Figure 18 To prevent gastric cancer, primary and secondary prevention are indispensable for the attention of government departments, active actions by medical staff, and the public to raise awareness of gastric cancer prevention; effective combination of primary and secondary prevention of gastric cancer to eliminate gastric cancer The goal will be achieved.

 Expert profile Professor Lv Nonghua, Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Professor, Doctoral Supervisor, Member of the Standing Committee of the Chinese Medical Association Gastroenterology Branch, Chairman of the Jiangxi Provincial Medical Association Gastroenterology Committee, Director of Jiangxi Gastroenterology Clinical Medicine Research Center Reference materials: [1] JM Liou, P Malfertheiner, YC Lee, et al.
Screening and eradication of Helicobacter pylori for gastric cancer prevention: the Taipei global consensus.
Gut,2020;322-368.
doi:10.
1136/gutjnl-2020-322368.
[2]Malfertheiner P,Megraud F,O'Morain CA,et al.
Management of Helicobacter pylori infection-the Maastricht V/Florence Consensus Report.
Gut.
2017;66:6-30.
[3]Rugge M,Genta RM,Di Mario F, et al.
Gastric cancer as preventable disease.
Clin Gastroenterol Hepatol 2017 Dec;15(12):1833-1843.