【重磅】世界胃肠病学组织全球指南：幽门螺杆菌World Gastroenterology Organisation Global Guidelines：Helicobacter pylori
世界胃肠病学组织全球指南：幽门螺杆菌
杨万里简介中国幽门螺杆菌分子医学中心（CCHpMM）
钟子劭、徐包慧 I 译
郜恒骏 I 审校
1. Summary
1. 摘要
Helicobacter pylori continues to be a major health problem worldwide, causing considerable morbidity and mortality due to peptic ulcer dia and gastric cancer.
幽门螺杆菌仍然是世界范围内的一个主要健康问题，由于消化性溃疡病和胃癌导致了相当高的
发病率和死亡率。
The burden of dia falls disproportionately on less well-resourced populations. As with
most infectious dias, the greatest impact on reducing this burden comes from
improvements in socioeconomic status, which interrupt transmission. This has been obrved
in many regions of the world, but the prevalence of infection remains high in many regions in
which improvements in living standards are slow to occur.
疾病的负担不成比例地落在资源不足的人群身上。与大多数传染病一样，对减少这种负担的最
大影响来自于社会经济地位的改善，以阻断传播。在世界许多地区已经观察到了这一点，但在
许多生活水平改善缓慢的地区，感染率仍然很高。
Meanwhile, the optimal clinical management and treatment pathways remain unttled and
are evolving with changing antimicrobial resistance patterns. Despite decades of rearch and clinical practice, major challenges remain. The quest for the most effective, safe, and simple therapy is still a major issue for clinicians. An effective vaccine also still appears to be elusive.
同时，最佳的临床管理和治疗路径仍未确定，并随着抗生素耐药性模式的变化而不断发展。尽
管经过几十年的研究和临床实践，重大挑战依然存在。寻求最有效、最安全、最简单的疗法仍
然是临床医生面临的主要问题。一种有效的疫苗似乎也仍然遥不可及。
Clinical guidelines not infrequently proffer discordant advice. It is very difficult for guidelines to achieve relevance across a variety of populations with varying spectrums of dia, antimicrobial resistance rates, and vastly different resources. As local factors are central to determining the impact and management strategies for H. pylori infection, it is important for pathways to be bad on the best available local knowledge, rather than solely extrapolated
from guidelines formulated in other regions, which may be less applicable. To this end, this
revision of the WGO H. pylori guideline us a “cascades” approach that eks to summarize
the principles of management and offer advice for pragmatic, relevant, and achievable
diagnostic and treatment pathways bad on established key treatment principles and using
local knowledge and available resources to guide regional practice.
临床指南经常提供不一致的建议。指南很难在具有不同疾病谱、抗生素耐药率和巨大的资源差
异的各种人群中实现一致性。由于地区因素是决定幽门螺杆菌感染的影响和管理策略的核心，
因此，重要的是，治疗方案应基于现有的最佳当地认识，而不是仅仅从其他地区制定的指南中
推断出来，因为这些指南可能不太适用。为此，本次修订的WGO幽门螺杆菌指南采用了 '级联
'方法，旨在总结管理原则，并根据既定的关键治疗原则，利用当地知识和现有资源指导地区实
践，为务实、相关和可实现的诊断和治疗路径提供建议。
2. Introduction
2. 介绍
Helicobacter pylori has been recognized as a major pathogen of humankind for nearly four decades. However, despite the impact of treatment of infected individuals and the reduced transmission of infection in communities in which socioeconomic living standards have improved, it continues to be the most common human bacterial pathogen, infecting perhaps
关于改革的名言
half of the world’s population [1]. As a result, it is still a major cau of morbidity and mortality worldwide.
近四十年来，幽门螺杆菌被认为是人类的主要病原体。然而，尽管对感染者的治疗产生了影响，而且在社会经济生活水平提高的社区，幽门螺杆菌的传播也有所减少，但它仍然是最常见的人类细菌病原体，可能感染了世界上一半的人口[1]。因此，它仍然是全世界发病和死亡的一个主要原因。
H. pylori infection invariably caus active chronic gastritis. In most people, this may be clinically silent throughout life, but in a substantial minority it caus gastroduodenal dias, most importantly peptic ulcer dia, noncardia gastric cancer, and gastric mucosa-associated lymphoid tissue (MALT) lymphoma. It also increas the risk of gastroduodenal ulceration and bleeding in patients who are taking nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and is responsible for symptoms in a subt of patients with functional dyspepsia.
幽门螺杆菌感染总是会引起慢性活动性胃炎。在大多数人中，这可能在临床上终生无症状，但在相当少的人中，它引起胃十二指肠疾病，包括最重要的消化性溃疡病、非贲门胃癌和胃粘膜相关淋巴组织（MALT）淋巴瘤。它还增加了正在服用非甾体抗炎药（NSAIDs）如阿司匹林的病人的胃十二指肠溃疡和出血的风险，并且是造成一部分功能性消化不良病人症状的原因。H. pylori has been studied inte
nsively. A literature arch reveals more than 45,000 publications. A great deal has been learned about the epidemiology of infection, biology, genetics, pathophysiology, dia expression, diagnosis, and treatment. However, major gaps in our knowledge remain. The preci mode of transmission of infection remains unclear, despite many epidemiological studies that identify risk factors for infection. The determinants of dia expression are still incompletely understood, including many aspects of the host–pathogen interaction. The pathophysiology of this interaction is complex and has been reviewed in detail elwhere [2,3]. The optimal clinical management pathways in different ttings are still a matter of debate, and refinements in diagnostic modalities continue to be sought. The quest for the most effective, safe, and simple treatment is still a major issue for clinicians, and the problem of antimicrobial resistance to therapy is a significant challenge. The best method for surveillance of adver histological changes in the gastric mucosa has not been determined, and the quest for an effective vaccine is ongoing.幽门螺杆菌已经得到了深入的研究。搜索显示有超过45,000份研究相关文献。在幽门螺杆菌感染的流行病学、生物学、遗传学、病理生理学、疾病表达、诊断和治疗方面已经有了很大的了解。然而，我们的知识仍有很大差距。尽管许多流行病学研究确定了感染的风险因素，但感染的确切传播方式仍不清楚。疾病表达的决定因素仍未完全了解，包括宿主-病原体相互作用的许多方面。这种相互作用的病理生理学是复杂的，已在其他地方进行了详细回顾[2,3]。在不同的环境下，最佳的临床管理方法仍然是一个争论不休的问题，且还在继续
寻求诊断方式的改进。追求最有效、最安全、最简单的治疗方法仍然是临床医生的主要问题，而抗生素耐药对治疗的问题也是一个重大挑战。监测胃粘膜不良组织学变化的最佳方法尚未确定，对有效疫苗的探索也在进行。
There have been many reviews and clinical guidelines on H. pylori [4–12]. As the field is changing rapidly, there is a need for periodic updating and revision of the position papers. In addition, it is very difficult for guidelines to achieve relevance across a wide variety of populations with varying spectrums of dia and often with vastly different resources with which to deal with it. Guidelines not infrequently proffer discordant advice. As local factors are central to determining the impact and management strategies for H. pylori infection, this is not surprising. It is important for clinical advice to be bad on the best available local data, rather than extrapolated from guidelines formulated in other regions, which may be less applicable. However, in many areas in which the impact of H. pylori infection is greatest, there is a lack of high-quality data to determine the local best practice. Addressing this gap in knowledge is a significant challenge. In the meantime, decisions need to be bad on the best available local evidence, extrapolation from higher-quality data from elwhere, and expert opinion.
目前已经有很多关于幽门螺杆菌的评论和临床指南[4-12]。由于该领域变化迅速，有必要定期更新和
修订这些立场文件。此外，指南很难在具有不同疾病谱的各种人群中实现相关性，而且通常具有处理疾病的巨大不同资源。指南经常提供不一致的建议。由于地区因素是决定幽门螺杆菌感染的影响和管理策略的核心，这并不令人惊讶。重要的是，临床建议应以当地的最佳数据为基础，而不是从其他地区制定的指南中推断出来，因为这些指南可能不太适用。然而，在幽门螺杆菌感染影响最大的许多地区，缺乏高质量的数据来确定当地的最佳做法。解决这一知识差距是一个重大挑战。同时，幽门螺杆菌治疗管理策略需要根据现有的最佳当地证据、其他地方的高质量数据的推断和专家意见来做出决定。
The purpo of this update to the WGO guideline is to summarize and review the evidence from a number of new guidelines that outline best practice and to suggest how the principles may be applied around the world using the “cascades” approach. This approach recognizes variations in the regional prevalence and impact of infection and the vast
differences in health resources available to address the problem, which require pragmatic, tailored local approaches. The burden of dia wrought by H. pylori falls disproportionately on less well-resourced regions, which are insufficiently reprented in epidemiological surveys and are often not the focus of clinical guidelines.
这次更新WGO指南的目的是总结和回顾一些新指南的证据，这些指南概述了最佳做法，并建议如何利用 '级联 '方法在世界各地应用这些原则。这种方法认识到各地区感染的流行程度和影响的差异，以及可用于解决该问题的卫生资源的巨大差异，这就要求采取务实的、适合当地的方法。幽门螺杆菌造成的疾病负担不成比例地落在资源不足的地区，而这些地区在流行病学调查中的代表性不足，往往不是临床指南的重点。
串烧dj”
Key statement
夸女人漂亮的句子幽默It is a major challenge for guidelines to achieve relevance across a wide variety of populations with varying spectrums of dia and with vastly different resources with which to deal with it.
关键陈述
对于指南来说，如何在不同的人群中实现相关性是一个重大的挑战，这些人群有着不同的疾病谱，而且处理疾病的资源也大不相同。
3. Natural history, transmission and epidemiology—global aspects
3. 自然历史、传播和流行病学-全球方面
3.1 Natural history of infection
3.1 感染的自然史内阁制
H. pylori infection usually persists for life, unless it is treated with antibiotics or autoeradication occurs when long-standing infection caus widespread gastric mucosal atrophy and metaplasia with achlorhydria. Transient infection may occur in some infants. Reinfection after treatment in adults is uncommon in both higher-prevalence and lower-prevalence regions. Reinfection may be confud with recrudescence, when infection is suppresd transiently, below the threshold of detection by tests, but has not been eradicated by antibiotics. There are variations in the virulence of different H. pylori strains globally. The interplay between host and environmental factors may result in differences in the expression of dia.
幽门螺杆菌感染通常会持续终身，除非用抗生素治疗，或者当长期感染导致广泛的胃粘膜萎缩和肠化并伴有胃酸缺乏症时发生自身消除。一些婴儿可能发生短暂的感染。无论在高发地区还是低发地区成人治疗后的再感染都不常见。再感染可能与复发相混淆，复发是指感染被暂时抑制，低于检测的阈值，但没有被抗生素所根除。在全球范围内，不同的幽门螺杆菌菌株的毒力存在差异。宿主和环境因素之间的相互作用可能导致疾病表现的差异。
3.2 Transmission of infection
王奶奶
3.2 感染的传播
Although there are well-described risk factors for infection, and plausible hypothes, the preci mode of transmission has not been definitively established. Most infection appears to occur in early childhood, with a minority of cas developing in adults. There is strong evidence from epidemiology and genetic studies of person-to-person transmission, particularly within families. Mothers appear to be particularly important in transmission to their young children. Ingestion of the organism ems most plausible via the gastro–oral or oral–oral route. Fecal–oral transmission appears less likely, at least in developed countries. Whether transmission occurs via water, food, houhold pets, or flies is still a matter of speculation.
虽然有很好的感染风险因素和合理的假说，但确切的传播方式还没有明确的确定。大多数感染似乎发生在儿童早期，少数病例发生在成人。流行病学和遗传学研究有强有力的证据表明幽门螺杆菌存在人与人之间的传播，特别是在家庭内部。母亲似乎在传染给其年幼子女方面特别重要。通过胃-口或口-口途径传播该生物体似乎是最合理的。粪口传播似乎不太可能，至少在发达国家是这样。幽门螺杆菌是否通过水、食物、家庭宠物或苍蝇传播，仍然是一个猜测的问题。
3.3 Epidemiology
3.3 流行病学
Although half of the world’s population are thought to be infected with H. pylori, there is widespread variation in the prevalence of infection, between and within countries (Fig. 1). In addition, the prevalence may vary within a single city and also between subgroups within a population (Fig. 2) [13]. For example, there may be wide variations in the prevalence between more affluent urban populations and rural populations.
尽管世界上有一半的人口被认为感染了幽门螺杆菌，但在国家之间和国家内部，感染率存在着广泛的差异（图1）。此外，在一个城市内，以及在一个人口的亚群之间，感染率也会有所不同（图2）[13]。例如，较富裕的城市人口和农村人口之间的患病率可能有很大差异。
The quality of prevalence data varies. Many studies are not true prevalence studies, but rather audits of clinical subts. Other studies may not reprent a valid cross-ction of the population. Moreover, there is significant variability in the quality of reports. In some regions, diagnostic methods may be less reliable, while some countries are poorly reprented as they lack any reliable data at all. For all the reasons, a single figure cannot be taken to summarize and reprent the prevalenc
e of infection in an entire country and must be applied with caution. For example, a prevalence study from one city in one region of a populous, multiethnic country with wide variation in socioeconomic standards is unlikely to reprent the true prevalence across the entire country and cannot reflect high-risk and low-risk subts. However, countries and regions can usually be characterized as high-prevalence, mid-prevalence, and low-prevalence locations [1].
长治市政府官网
患病率数据的质量各不相同。许多研究不是真正的流行病研究，而是对临床子集的审核。其他研究可能不代表有效的人口横断面。此外，报告的质量也有很大差异。在一些地区，诊断方法可能不太可靠，而一些国家由于根本没有任何可靠的数据，所以代表性很差。由于所有这些原因，不能用一个数字来概括和代表整个国家的感染率，必须谨慎。例如，在一个人口众多、社会经济水平差异很大的多民族国家的一个地区的一个城市的流行率研究，不太可能代表整个国家的真实流行率，也不能反映高风险和低风险的子集。然而，国家和地区通常可以被描述为高发区、中发区和低发区[1]。
The major determinant of the prevalence of infection is socioeconomic status in childhood. Socioeconomic factors reflect levels of hygiene, sanitation, density of living, and educational level.
感染率的主要决定因素是儿童时期的社会经济因素。社会经济因素反映了卫生、环境卫生、居住密度和教育水平的水平。
A strong inver relationship has been consistently reported. Thus, as expected, the prevalence of infection is generally higher in developing countries, and infection is almost ubiquitous in some of the most resource-poor subts of the populations. Migrants from such regions are recognized as being a high-risk group in more developed, low-prevalence countries.
一直以来，都有强负关系的报道。因此，正如预期的那样，发展中国家的感染率普遍较高，而且在一些人口资源最匮乏的人群中，感染几乎普遍存在。来自这些地区的移民被认为是较发达的低发病率国家的高风险群体。
”
Key statement
The major determinant of the prevalence of infection is socioeconomic status in childhood.关键陈述
感染率的主要决定因素是儿童时期的社会经济地位。
The prevalence of H. pylori infection increas with age. This is mostly due to the cohort effect, in which the risk of acquiring infection was greater during the childhood of tho born longer ago in comparison with more recently, rather than reflecting ongoing adult acquisition. Ethnicity has been d
escribed as a risk factor, but is most likely cloly correlated with socioeconomic status or practices that may increa the risk of transmission, rather than having a genetic basis.
幽门螺杆菌感染的流行率随着年龄的增长而增加。这主要是由于队列效应，即那些出生时间较久的人在童年时期获得感染的风险比最近出生的人要大，而不是反映正在进行的成人感染。种族被认为是一个风险因素，但很可能与社会经济地位或可能增加传播风险的做法密切相关，而不是具有遗传基础。
万燕vcdA striking obrvation has been the change in the prevalence of infection over time in some countries. Reports of rapidly falling infection rates, most marked in children and younger adults, are common from developed countries, and from countries that have undergone rapid economic development that has led to raid socioeconomic standards. In the countries, the prevalence of infection is now low.
一个引人注目的现象是一些国家的感染率随时间的推移而变化。发达国家和经历了快速经济发展导致社会经济标准提高的国家普遍报告幽门螺杆菌感染率迅速下降，在儿童和年轻成人中最为明显。在这些国家，现在的感染率很低。
A gradual fall in the prevalence of peptic ulcer dia and noncardia gastric cancer is predicted by this obrvation, since in general the prevalence of peptic ulcer dia and gastric cancer reflects t
he prevalence of H. pylori in a population. Indeed, the prevalence of ulcer dia and gastric cancer have been falling for decades in developed countries. The fall in dia expression lags behind the fall in infection rates for many years. The declining prevalence of infection and dia occurred long before H. pylori was recognized and treatments were developed.
根据这一观察，消化性溃疡病和非贲门胃癌的发病率会逐渐下降，因为一般来说，消化性溃疡病和胃癌的发病率反映了幽门螺杆菌在人群中的流行情况。事实上，几十年来，发达国家的溃疡病和胃癌的发病率一直在下降。通常疾病表达的下降滞后于感染率的下降很多年。感染率和疾病的下降早在幽门螺杆菌被认识和治疗方法被开发之前就发生了。
As with most endemic infectious dias, a decline in prevalence has more to do with improvements in population hygiene and sanitation than with individual, ca-by-ca treatment, since in most countries, only a minority of infected individuals will ever receive therapy. Notable exceptions are well-resourced high-prevalence countries such as Japan, where screening and treatment is now done systematically in early adulthood. The prevalence of infection appears to be stable in countries in which standards have not improved or have deteriorated, and it is unlikely to fall substantially until improvements do occur. Peptic ulcer dia is still rampant in many of the countries. The burden of gastric cancer also falls disproportionately on the populations.
与大多数地方性传染病一样，流行率的下降更多的是与人口卫生和环境卫生的改善有关，而不是与个别的、单个病例治疗有关，因为在大多数国家，只有少数感染者会接受治疗。值得注意的例外是资源丰富的高发病率国家，如日本，已在年轻人中开展系统性的筛查和治疗。在那些标准没有改善甚至更加恶化的国家，感染率似乎是稳定的，而且在出现改善之前，感染率不太可能大幅下降。在其中许多国家，消化性溃疡病仍然很猖獗。胃癌的负担也不成比例地落在这些人口身上。
”
Key statement
As with most endemic infectious dias, a decline in prevalence has more to do with improvements in population hygiene and sanitation than with individual, ca-by-ca treatment, since in most countries, only a minority of infected individuals will ever receive therapy.
关键陈述
与大多数地方性传染病一样，流行率的下降更多的是与人口卫生和环境卫生的改善有关，而不是与个别的、单个病例治疗有关，因为在大多数国家，只有少数感染者会接受治疗。
4. The impact of H. pylori infection and the effect of eradication
4. 幽门螺杆菌感染的影响和根除的效果
4.1 H. pylori and peptic ulcer dia
4.1 幽门螺杆菌和消化性溃疡病
The recognition that H. pylori was the cau of most duodenal ulcers and about two-thirds of gastric ulcers was a minal, Nobel Prize–winning medical breakthrough [14]. In many developed countries with a decreasing prevalence of infection and cure of ulcer patients, the proportion of all peptic ulcers due to H. pylori is falling. In less developed countries, where the prevalence of infection remains high and fewer ulcer sufferers receive curative treatment, peptic ulcer dia (PUD) continues to be a very common and important condition. H. pylori infection has been estimated to confer an individual lifetime risk of peptic ulcer dia of
15–20%. Untreated, PUD is a chronic relapsing and remitting dia that caus major mortality and morbidity due to pain, bleeding, and perforation. It also results in economic
