根除老年人消化性溃疡合并幽门螺旋杆菌感染的治疗策略

Strategies for eradication of Helicobacter pylori and peptic ulcer in elderly patients

目的对质子泵抑制剂（PPI）或铋剂三联疗法作为初治方案以及序贯疗法或四联疗法作为补救方案根除老年人消化性溃疡（PUA）合并幽门螺旋杆菌（Hp）感染的疗效进行比较。方法2009年7月至2010年7月间261例胃镜下尿素酶法诊断的PUA合并Hp感染患者，随机采用PPI三联疗法、铋剂三联1周疗法进行根除，观察治疗过程中不良反应发生率。PUA患者经上述抗Hp治疗后继续4周抗溃疡治疗，停药1月后复查胃镜并比较两种方法对Hp根除率及溃疡愈合率的疗效差异。对于首次三联疗法根除Hp失败者，随机应用10日序贯疗法和PPI、铋剂四联1周疗法再次行Hp根除。观察疗程中不良反应发生率，停药1个月后采用”C呼气试验观察Hp根除率。统计分析采用符合方案（PP）群组分析和意向治疗（ITT）群组分析。结果相比于铋剂三联疗法，PPI三联疗法Hp根除率（ITT：77．7％vs62．6％；PP：79．5％v564．1％；P〈0．05）及溃疡愈合率（ITT：78．5％vs64．9％；PP：80．3％vs66．4％；P〈0．05）高，不良反应发生率无明显差异（1TT：10．8％vs16．8％：PP：11．0％vs17．2％；P〉0．05）。对于首次三联疗法失败者以10日序贯疗法补救，Hp根除率较高（ITT：84．6％vJ61．5％；PP：86．8％v563．2％；P〈0．05），且不良反应发生率较四联疗法低（ITT：12．8％VS35．9％；PP：13．2％VS36．8％；P〈0．05）。结论PPI三联1周疗法进行Hp感染根除可作为PUA患者首选，有较高的溃疡愈合率和Hp根除率；首次根除失败者可优先改用10日序贯疗法进行补救。

Objective To evaluate the therapeutic effect of PPI or bismuth triple therapy for eradication of Helicobacter pylori（Hp） and 10-day sequential therapy or quadruple therapy for remedy eradication of peptic ulcer in the aged （PUA）. Methods A total of 261 elderly patients with Hp caused peptic ulcer diagnosed by rapid urease method under gastroscope from July 2009 to July 2010 were randomized to receive one week of PPI or bismuth triple therapy for Hp first eradication. The adverse reactions were observed. Four weeks of anti-ulcer therapy by PPI and mucosa protectant were carried out after the Hp first eradication. The curative effect on Hp eradication and ulcer healing were compared at one month afterwards. All the patients who failed in the first Hp eradication randomly received 10-day sequential therapy or PPI and bismuth quadruple therapy for Hp remedy eradication. The adverse reactions were observed and Hp infection status was assessed by 13C-urea rapid breath test at one month after the medications stopped. Per protocol（PP） cohort analysis and intention-to-treat（ITT） cohort analysis were used. Results Compared with bismuth triple therapy, PPI triple therapy had higher Hp eradication rate[ITT： 77.7% vs 62.6%; PP： 79.5% vs 64.1%; P 〈 0,05] and higher ulcer healing rate[ITT： 78.5% vs 64.9%; PP： 80.3% vs 66.4%; P 〈 0.05]. There was no obvious difference in adverse reaction between the two strategies[ITT： 10.8% vs 16.8%; PP： 11.0% vs 17.2%; P 〉 0.05]. For Hp remedy eradication, 10-day sequential therapy had better Hp eradication effect[ITT： 84.6% vs 61.5%; PP： 86.8% vs 63.2%; P 〈 0.05] and lower adverse reaction rate[ITF： 12.8% vs 35.9%; PP： 13.2% vs 36.8%; P 〈 0.05]. Conclusions PPI triple therapy is the main choice on PUA patients for its better Hp eradication and ulcer healing effects. Ten-day sequential therapy is recommended to patients who failed Hp first eradication by triple therapy.