Current progress toward eradicating Helicobacter pylori in East Asian countries: differences in the 2013 revised guidelines between China, Japan, and South Korea

Abstract

New 2013 guidelines on Helicobacter pylori (H. pylori) infection have been published in China, Japan, and South Korea. Like the previous ones, these new guidelines differ between the three countries with regard to the indications for H. pylori eradication, diagnostic methods, and treatment regimens. The most profound change among all of the guidelines is that the Japanese national health insurance system now covers the expenses for all infected subjects up to second-line treatment. This makes the Japanese indications for eradication much wider than those in China and South Korea. With regard to the diagnosis, a serum H. pylori antibody test is not recommended in China, whereas it is considered to be the most reliable method in Japan. A decrease relative to the initial antibody titer of more than 50% after 6-12 mo is considered to be the most accurate method for determining successful eradication in Japan. In contrast, only the urea breath test is recommended after eradication in China, while either noninvasive or invasive methods (except the bacterial culture) are recommended in South Korea. Due to the increased rate of antibiotics resistance, first-line treatment is omitted in China and South Korea in cases of clarithromycin resistance. Notably, the Japanese regimen consists of a lower dose of antibiotics for a shorter duration (7 d) than in the other countries. There is neither 14 d nor bismuth-based regimen in the first-line and second-line treatment in Japan. Such differences among countries might be due to differences in the approvals granted by the governments and national health insurance system in each country. Further studies are required to achieve the best results in the diagnosis and treatment of H. pylori infection based on cost-effectiveness in East Asian countries.

Keywords: Diagnosis; Eradication; Guideline; Helicobacter pylori; Treatment.

Figure 1

Changes in serum pepsinogen levels according to the progress of gastric carcinogenesis. The pepsinogen II level is increased in the acute stage of Helicobacter pylori (H. pylori) infection. A pepsinogen II level exceeding 30 ng/dL indicates that the subject has a high risk of diffuse-type gastric cancer. The pepsinogen I level then decreases as the infection progresses to the chronic stage. These features altogether results in the pepsinogen I/II ratio decreasing with the progress of gastric carcinogenesis. A pepsinogen I level below 70 ng/dL and a pepsinogen I/II ratio below 3.0 indicate that the subject has a high risk of intestinal-type gastric cancer. Since the pepsinogen II level is decreased after H. pylori eradication to a variable degree, a combination test for serum H. pylori antibody and the pepsinogen I/II ratio is not recommended for gastric cancer screening after eradication.

Figure 2

Metachronous gastric cancer that developed after 6 years of Helicobacter pylori eradication. A 61 year-old South Korean man visited because of epigastric discomfort in March 2007. A: Initial endoscopic finding. Several raised erosions with central ulceration (arrow) were evident. Since H. pylori infection was found by gastric biopsy, eradication was achieved using amoxicillin (1 g), clarithromycin (500 mg), and a a standard dose of proton pump inhibitor twice daily for 7 d; B: Endoscopic finding after 2 years. In June 2009, a gastric adenoma near the pylorus (arrow) was diagnosed by endoscopic biopsy. Complete endoscopic resection was performed; C: Immunohistochemical staining of the resected specimen. Ki-67 staining was positive in the adenoma (Ki-67 stain, x 400); D: Endoscopic finding after 6 years. In January 2013, a slightly depressed lesion was evident on the lesser curvature side of the mid-antrum (arrow); E: Endoscopic submucosal dissection. The lesion was resected since the endoscopic biopsy revealed an adenocarcinoma; F: Pathological finding of the resected specimen. Early gastric cancer type IIc of Lauren’s intestinal-type, moderately-differentiated, tubular adenocarcinoma was diagnosed. The tumor size was 8.0 mm x 6.0 mm x 1.0 mm, and the depth of invasion was limited to the lamina propria (pT1a). Resection margins were free from carcinoma.