Гастроэнтерология: язвенная болезнь, гепатиты, рефлюкс-эзофагит

                    Russian Gastroenterology Association
              Russian Group - Helicobacter pylori investigation

       Recommendations to conduct diagnosis and treatment of infection
    Helicobacter pylori in adults sufferred with gastric and peptic ulcer
                                  disease.

Accepted    at the scientific conference "Gastric ulcer and carcinoma of
the stomach. New sights on Helocobacter pylori", Moscow 21st April 1997.
Discussed   at the round table
Attendees   academician FI Komarov, academician VV Serov, academician VT
Ivashkin, academician AV Kalinin, corresponding member IA Morozov,
professor LI Aruin, professor PY Grigoriev, professor AR Zlatkina,
professor SI Rapoport, professor GV Tsodikov, professor ON Minushkin,
professor LP Miagkova, professor AA Sheptulin, professor VI Pogromov, MD VA
Isakov, MD TL Lapina

The development of the given recommendations were necessitated by the
following circumstances:
1.The Helicobacter pylori infecrion is one of the most spreadwide human
  infections nowadays.
2.The Helicobacter pylori bacterium is
          1. a cause for developing chronic gastritis associated by
             helicobacter
          2. the main factor for gastric and peptic ulcer pathogenesis
          3. the main factor for developing stomach limphoma of low degree
             malignancy (maltoma)
          4. carcinoma of the stomach.
3.Extermination (eradication) of Helicobacter pylori in stomach mucousa in
  infected patients will lead to:
          5. vanishing inflammatory infiltrate in stomach mucousa;
          6. considerable reducing frequency of gastric and peptic ulcer
             recurrences;
          7. histologic remissing maltoma of the stomach;
          8. probably, considerably reducing risk for developing of
             carcinoma of the stomach.
4.The Helicobacter pylori eradication in mucous membrane of the stomach in
  infected patients - the most difficult problem in the clinical
  gastroenterology associated with handling comlicated organisational
  tasks.
5.Nonadequate and/or incorrect treatment of the Helicobacter pylori
  infection brings to appearing amongst population a large number of
  bacterium strains resistant to effect of well-known antibiotics.

The Helicobacter pylori infection diagnosis

Primary diagnosis
The Helicobacter pylori infection diagnosis should be conducted by methods
revealing directly the bacterium or the products of its activity in the
patient's organism. The following methods satisfy above requirements:
1.Bacteriologic:       inoculation of biopsy specimen of stomach mucousa to
  the differential-diagnostic test medium.
2.Morphologic:         "gold standard" in Helicobacter pylori diagnosis:
  bacterium straining in the gistologic specimen of stomach musousa by
  Gimsa, toluidine blue, Vartin-Starri, Genta:
     9. citologic - bacterium straining in smears of biopsy specimen of
        stomach mucouse by Gimsa, Gram.
3.Respiratory:         identification of isotopes 14C or 13C in the air
  breathed out by the patient; isotopes are identified as a result of
  marked urea segregation in the patient's stomach under the influence of
  the Helicobacter pylori bacterium urease.
4.Urease:        identification of urease activity in biopsy spesimen of
  stomach mucousa by means of placing it in liqiud or gel medium consisting
  substrat, buffer and indicator.
While keeping to all requirements to conducting methods and due
sterilisation of endoscopic equipment, the Helicobacter pylori infection
primary diagnosis is sufficient to start anti-Helicobacter therapy after
discovering the bacterium by one of described above method.


Eradication diagnosis
Eradication means total extermination of the bacterium Helicobacter pylori
(both vegetative and coccus forms) in the stomach and duodenum.
1.Eradication diagnosis should be conducted in 4-5 weeks after quitting
  anti-Helicobacter therapy course, or after quitting treatment of
  concomitant disease by any antibiotics or antisecretory medicines.
2.Eradication diagnosis is carried out by at least two methods describes
  above. Using method of direct identification of the bacterium in biopsy
  specimen of the stomach mucousa (bacteriologic, morphologic, urease) it
  is important to investigate 2 biopsy specimen taken from the body of the
  stomach and 1 biopsy specimen taken from antral section.
3.Citologic method should not be used for eradicating.

Screening and other methods allowing to reduce the cost of the Helicobacter
pylori infection diagnosis
For screening they usually use methods based on identificationof specific
anti-Helicobacter antibodies class A and G in plasma serum or in capillary
blood of investigated patients.
1.Immunoenzyme analysis
2.Express-tests based on immunoprecipitation or immunocitochemie using
  patients' capillary blood as a test and colour potentiating reaction
  products.
Express-tests could be used for making cheaper the process of primary
diagnosis of the Helicobacter infection, as positive test result allows
toexclude expensive equipmentand using methods of direct diagnosis. Express-
tests can't be used for identifying eradication after treatment.

The Helicobacter pylori infection therapy

Indications to the Helicobacter pylori infection therapy
As Russian and foreign scientific and clinical experience showed, gastric
and peptic ulcer diseases associated by Helicobacter pylori is an
indication to anti-Helicobacter therapy both in the period of acute
condition and in the period of remission.
Therapy principles
The basic pronciple of therapy is using combined (3-component) therapy:
10. enable to eradicate the Helicobacter pylori bacterium min in 80% cases
  during the investigations conducted under control;
11. which has no noticable side effects thtat cause to stop using the
  medicines in more than 5% of cases;
12. effective if the course duration is 7-14 weeks.

Schemes of treatment
13. One-week 3-component therapy using H+-K+-AT Phase blockers standard
  dose2 times daily (foe example, omeprasol 20 mg 2 times daily, or
  pantaprasol 40 mg 2 times daily, or lansoprasol 30 mg 2 times daily)
  along with:
    14. metronodasol 400 mg 3 times daily (or tinidasol 500 mg 2 times
        daily) + claritromicin 250 mg 2 times daily
           OR
    15. amoxicillin 1000 mg 2 times daily + claritromicin 500 mg 2 times
        daily
           OR
    16. amoxicillin 500 mg 3 times daily + metronidasol 400 mg 3 times daily
17. One-week 3-component therapy with bismuth:
      bismush (colloid substrate bismuth, or gallat bismuth or subsalicilate
      bismuth) 120 mg 4 times daily along with
      tetraciclin 500 mg 4 times daily + metronodasol 250 mg 4 times daily
      or tinidasol 500 mg 2 times daily
18. One-week "quadro"-therapy which makes enable to eradicate Helicobacter
  pylori strains resistant to the action of well-known antibiotics.
      H+-K+-AT Phase blockers standard dose 2 times daily (for example,
      omeprasol 20 mg 2 times daily, or pantoprasol 40 mg 2 times daily, or
      lansoprasol 30 mg 2 times daily) along with
      bismuth (colloid substrate bismuth, or gallat bismuth or subsalicilate
      bismuth) 120 mg 4 times daily along with
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