INTRODUCTION , After removal of early gastric carcinomata,

INTRODUCTION Helicobacter  is spiral  flagellum, gram-negative, microaerophilic organism in the gastroduedenal mucosal layer, It is a common bacterial infection and a tremendous risk  for developing gastric cancer in56% – 93% of the people in the universe. Also it is associated with GIT diseases, as peptic ulcer , gastric crcinoma and MALT ( lymphoid tissue lymphoma).( Lee HS. Histopathologic Diagnosis of H. pylori Infection. Testing for H. pylori is highly recommended in patients with ; Active GIT ulcer disease , After removal of early gastric carcinomata, Dyspepsia investigated by endoscopy , MALT lymphoma,  thrombocytopenic purpura (ITP),Unexplained microcytic hypochromic anemia, Family history of gastric malignancy , familial GIT polypii and MALT. Transmission is via feco-oral or mouth to mouth. 90-95% of patients diagnosed by gastric ulcers are associated with H. pylori infections. Modern statistical analytic investigations  revealed that extra gastric diseases are also associated with H. pylori infections, such as unexplained iron deficiency, ITP, unexplained megaloblastic anemia . ( Vítor JM, Vale FF.) Urea breath test : is considered the gold  method of diagnostic value in both pre- and post-eradicated cases. It is non-invasive, simple, highly accurate and expensive ,  has a sensitivity of 98% and specificity of 99% , also is  the most reliable method of diagnosing HP infection in pre- and post-eradicated cases ( Osaki T, Mabe K, Hanawa T, Kamiya S.)Stool antigen test The stool antigen test provides accurate and sensitive diagnosis in pre and post eradicated cases of H. pylori infections. A duration of one to two months post eradication evaluation has excellent result but an evaluation before a whole month post-treatment gives false  misleading results. (Lario S,  Junquera F, Martinez-Bauer E, et al. Diagnostic accuracy of three monoclonal stool tests in a large series of untreated Helicobacter pylori infected patients..) IgG serology  Serum antigen marker G antibodies is a very simple testing for diagnosis of H. pylori infection. Positive results denotes that the patient has developed the infection but remains positive after ttt. However, it does not give false negative results in patients taking Proton pump inhibitors or antibiotics  so it is an excellent negative test as an exclusion of infection. (Marchildon PA, Sugiyama T, Fukada Y, Peacock JS, Asaka M, Shimoyama T, et al. Evaluation of the effects of strain-specific antigen variation )Rapid urease test (RUT)RUT is a characteristic urease reaction applied upon a fresh biopsy. It is simple and rapid, with very good sensitivity and adequacy , even in posteradicated cases. The sensitivity accounts for 95-98% and specificity varies from 95-100%. However it also gives false positive results in non-helicobacter urease producing organisms and in patients with achlorhydria. (Calvet X,Montserrat A, Lario S, Ramírez-Lázaro MJ, et al. Accuracy of diagnostic tests for Helicobacter pylor.)HistologyHistology using geimsa stained biopsy remains the gold standard for diagnosis with a sensitivity and specificity more than 95%. Immunostaining helps to increase the sensitivity to 100% and specitivity to 98 to 99%. (Buharideen S, Waduge R, Ratnatunga C. Evaluation of histology as a Helicobacter pylori detection methods.)Culture and sensitivityThe role of culture and sensitivity has a gargantuan and leading role in increasing H. pylori eradication as it not only diagnoses H. pylori infection but also guides clinicians on using the appropriate treatment regimen according to the sensitivities of drugs in specific regions where antibiotic resistance is high and that is the AIM OF THIS PILOT THAT WE WILL APPLY TO PATIENTS IN AGOUZA HOSPITAL.AVAILABLE DRUG THERAPIES used in eradication. (Kim SG, , Kim CG, et al. Guidelines for the diagnosis and treatment of Helicobacter pylori infection  )Standard therapyStandard triple therapy (PPI+ amoxicillin+ clarithromycin) for 7 days is the worldwide followed first line treatment regimen. However, IT fails in up to 30% of cases due to increased resistance to clarithromycin. (Yoon H, Kim N, Lee BH, Hwangt al. Moxifloxacin? Containing Triple Therapy as Second?Line Treatment for Helicobacter pylori Infection: Effect of Treatment Duration and Antibiotic Resistance on the Eradication Rate.) REGIMENS THERAPIES ACCORDING TO THE RECENT GUIDELINES  (Malfertheiner , Atherton J, Axon AT, Bazzoli F, et al. Management of Helicobacter pylori infection.)1st line regimen therapies include;  in high resistant areas to clarithromycin   we can use Bismuth quadruple therapy referred to as PBMT PPI + Bismuth + Metronidazole + Tetracycline or Concomitant quadruple therapy referred to as PAMC PPI + Amoxicillin + Metronidazole + Clarithromycin The challenge of Helicobacter pylori resistance to antibiotics: the comeback of bismuth-based quadruple therapy.).  In areas of low resistance to clarithromycin, The following are the preferred clarithromycin triple therapy regimens: Clarithromycin triple therapy (referred to as PAC PPI + Amoxicillin + Clarithromycin or PMC PPI +Metronidazole + Clarithromycin for 14 days The following are alternatives in case of failure of at least 2 previous first-line regimens: (Zagari RM, Romano, Annibale B, et al. Guidelines for the management of Helicobacter pylori infection)1.PAM (PPI + Amoxicillin + Metronidazole) for 2 weeks days  PPI:  omeprazole 20 mg twice , Amoxicillin 1000 mg twice, Metronidazole 500 mg twice2. Sequential therapy :PPI:  omeprazole 20 mg twice daily for five to seven days, then Amoxicillin 1000 twice daily for five to seven days, Followed by ppi +metronidazole +clarithromycin for five to seven days (Jung SM, Cheung DY, Kim JI, Kim I, Seong H. Comparing the Efficacy of Concomitant Therapy with Sequential Therapy as the First-Line Therapy of Helicobacter pylori Eradication)3.Hybrid therapy : PPI:  omeprazole 20 mg twice daily  tfor seven days ,then Amoxicillin 1000 mg twice daily for seven days Followed by ppi+metronidazole+amoxcicillin+clarithromycin for seven days4. Levofloxacin triple therapy for two weeks :  omeprazole 20 mg twice dailyI, Amoxicillin 1000 mg twice daily, andLevofloxacin 500 mg once daily (Yoon H, Kim N, Lee BH, Hwang TJ, Lee DH, Park YS, et levofloxacin? Containing Triple Therapy as Second?Line Treatment for Helicobacter pylori Infection: Effect of Treatment Duration and Antibiotic Resistance on the Eradication Rate )5. Levofloxacin sequential therapy : omeprazole 40 mg twice daily for one week ,then  Amoxicillin 1000 mg twice for a week, Followed by a week of omeprazole 40 mg twice daily plus Amoxicillin 1000 mg twice daily plus Levofloxacin 500 mg once daily plus Metronidazole 500 mg twice daily6.LOAD therapy (Levofloxacin + Omeprazole +alinia( nitazoxanide) + Doxycycline) therapy for ten days. (Basu ,rishnaswamy N, Flynn M. A randomized study comparing levofloxacin, omeprazole, nitazoxanide, and doxycycline versus triple therapy for the eradication of Helicobacter pylori. The American journal of gastroenterology)II. Materials And Methods All patients undergoing endoscopy for whatever reason in the agoza hospital, will be the test subjects of the pilot . All the biopsy samples from gastric and duedunal lesions will be gathered  without application of formalin followed by biopsy processing using  hematoxylin with eosin staining, In addition, Geimsa staining will be added for evaluation of  the presence of helicobacter Pylori . Biopsies confirmed positive to helicobacter pylori infection will be selected for culture and sensitivityIII. Aim of the pilot: to overcome the problem of Antibiotic resistance and eradication failure , by applying the culture and sensitivity testing ,before any medical approach will allow to use the most appropriate eradication regimen from the start .The high rate of clarithromycin resistance  made us prevent  its  empirical  use  in standard triple anti-H pylori  regimens. resistance  rates  of  metronidazole  and clarithromycin are significantly elevating allover wide world followed by levofloxacin. Therefore, the culture-guided therapy for H. pylori is currently mandatory specifically in well-known antibiotic resistant countries. IV. INCLUSION CRITERIA: these conditions will determine the candidate patients1. Patients with long term dyspepsia especially those who developed alarming signs as cachexia2. All patients undergoing endoscopy are not diagnosed or known to be infected with helicobacter pylori3. Patients wheather received  PPI or antibiotic therapy or both and the patients whom didn’t take any therapy will be included4. Patients providing full consent5. Biopsies will be mainly taken from the antrum of the stomach and the 1st part of duodenum6. Full medical examination along lab investigations as CBC ,liver and renal function tests7. Age of the patients will range from late twenties up to early fifties, pediatrics and geriatrics will be excluded.REFRENCES1. Vítor JM, Vale FF. Alternative therapies for Helicobacter pylori: Immunology & Medical Microbiology. 2. Choi YJ: Diagnosis of H. pylori Infection 3. Helicobacter, Group CC. Gastric cancer and Helicobacter pylori 20154. Kim SG, Jung HK et al. Guidelines for the diagnosis and treatment of Helicobacter pylori infection  20175. Tonkic , Mégraud F. Epidemiology and diagnosis of Helicobacter pylori infection 20086. Hun Van Der Merwe S. World gastroenterology organisation global guideline of gastrointestinal and liver disease. 20097. Zhang Yang Y, et al. Seroepidemiology of Helicobacter pylori infection. World journal of gastroenterology8. Kato M,  Recent knowledge of the relationship between Helicobacter pylori and gastric cancer and recent progress of gastroendoscopic diagnosis and treatment for gastric cancer. Japanese journal of clinical oncology. 9. Lee S-Y. Current progress toward eradicating Helicobacter pylori , differences in the 2013 revised guidelines between China, Japan, and South Korea. World journal of gastroenterology. 201410.Cancer Research UK: Information resource center 2004. 11 .Suzuki , Wakai K, et al. Smoking increases the treatment failure for Helicobacter pylori eradication. The American journal of medicine. 2006 12. Malfertheiner P,Atherton J, Axon AT, Bazzoli F, et al. Management of Helicobacter pylori infection—the Maastricht IV/Florence consensus 201213. Ekström AM, Held Nyrén O. Helicobacter pylori in gastric cancer established by CagA immune-Gastroenterology. 200114. Zagari RM, Romano B, et al. Guidelines for the management of Helicobacter pylori infection in Italy: the III Working Group Consensus Report 201515. Cid TP, Fernández MC, Jones NL. Pathogenesis of Helicobacter pylori infection. Helicobacter. 201316. Machado JC, Yamaoka Y. Pathogenesis of Helicobacter Pylori infection Helicobacter.200517.  Costa AC. Pathogenesis of Helicobacter pylori infection. Helicobacter 2009 18. Backert S, Clyne M. Pathogenesis of Helicobacter pylori infection. Helicobacter. 201119. Zou QH, Li RQ. Helicobacter pylori in the oral cavity and gastric mucosa: a meta?analysis. Journal of Oral Pathology & Medicine. 201120. Mentis A. Epidemiology and Diagnosis of Helicobacter pylori infection. Helicobacter. 201521. Lario A Ju F, Martinez-Bauer E, accuracy of three monoclonal stool tests in a large series of untreated Helicobacter pylori infected patients. Clinical biochemistry.201622. Calvet ,Lázaro MJ, Quesada M, et al. Accuracy of diagnostic tests for Helicobacter pylor. Clinical Infectious Diseases. 200923. Vaira D, Gci C. Diagnosis of Helicobacter pylori infection. Alimentary pharmacology. 200224. Ferwana M, Abdulmajeed , Firwana B, Hasan R, et al. Accuracy of urea breath test in Helicobacter pylori infection: Meta-analysis. World journal of gastroenterology 200925. Osaki T , Urease-positive bacteria in the stomach induce a false-positive reaction in a urea breath test for diagnosis of Helicobacter pylori infection. Journal of medical microbiology. 200826. Braden B. Diagnosis of Helicobacter pylori infection. 201227. Buharidee . Journal of Diagnostic Pathology. 201628. Lee HS. Histopathologic Diagnosis of H. pylori Infection and Associated Gastric Diseases. 201629.Black DD, Casteel HB et al. Comparison of immunohistochemistry and silver stain for the diagnosis of pediatric Helicobacter pylori infection in urease-negative gastric biopsy.200130. Uchida T al. Immunohistochemical diagnosis of the cagA?gene genotype of Helicobacter pylori with anti CagA?specific antibody. Cancer science. 200731. Allahverdiyev AM, et al. Isolation and diagnosis of Helicobacter pylori by a new method: microcapillary culture. World J Gastroenterology. 201532 Sato Y, Hayakawa M, et al. Detection of Helicobacter pylori (H. pylori) DNA in digestive systems by real- time PCR, Legal Medicine.200933. Kabir S. Detection of Helicobacter pylori DNA in feces and saliva by polymerase chain reaction: 200434. Glocker E, Kist M. Rapid detection of point mutations in the gyra gene of Helicobacter pylori conferring resistance to ciprofloxacin. Journal of clinical microbiology. 200435. Oleastro M, et al. Real-time PCR assay for rapid and accurate detection of point mutations conferring resistance to clarithromycin in Helicobacter pylori. 200336. Oleastro M,S, et al. Helicobacter pylori virulence genotypes in Portuguese adults with gastroduodenal pathology. European Journal of Clinical Microbiolog 2003

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