Helicobacter pylori continues to be a major health problem worldwide, causing considerable morbidity and mortality due to peptic ulcer disease and gastric cancer.

The burden of disease falls disproportionately on less well-resourced populations. As with most infectious diseases, the greatest impact on reducing this burden comes from improvements in socioeconomic status, which interrupt transmission. This has been observed 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.

Meanwhile, the optimal clinical management and treatment pathways remain unsettled and are evolving with changing antimicrobial resistance patterns. Despite decades of research 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.

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 disease, 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 based 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 uses a “cascades” approach that seeks to summarize the principles of management and offer advice for pragmatic, relevant, and achievable diagnostic and treatment pathways based on established key treatment principles and using local knowledge and available resources to guide regional practice.

Keywords: H. pylori, stomach, peptic ulcer, gastric cancer, dyspepsia, antibiotics

Background

Gastroparesis is a condition characterized by epigastric symptoms and delayed gastric emptying (GE) rate in the absence of any mechanical obstruction. The condition is challenging in clinical practice by the lack of guidance concerning diagnosis and management of gastroparesis.

Methods

A Delphi consensus was undertaken by 40 experts from 19 European countries who conducted a literature summary and voting process on 89 statements. Quality of evidence was evaluated using grading of recommendations assessment, development, and evaluation criteria. Consensus (defined as >=80% agreement) was reached for 25 statements.

Results

The European consensus defined gastroparesis as the presence of symptoms associated with delayed GE in the absence of mechanical obstruction. Nausea and vomiting were identified as cardinal symptoms, with often coexisting postprandial distress syndrome symptoms of dyspepsia. The true epidemiology of gastroparesis is not known in detail, but diabetes, gastric surgery, certain neurological and connective tissue diseases, and the use of certain drugs recognized as risk factors. While the panel agreed that severely impaired gastric motor function is present in these patients, there was no consensus on underlying pathophysiology. The panel agreed that an upper endoscopy and a GE test are required for diagnosis. Only dietary therapy, dopamine-2 antagonists and 5-HT4 receptor agonists were considered appropriate therapies, in addition to nutritional support in case of severe weight loss. No consensus was reached on the use of proton pump inhibitors, other classes of antiemetics or prokinetics, neuromodulators, complimentary, psychological, or more invasive therapies. Finally, there was consensus that gastroparesis adversely impacts on quality of life and healthcare costs and that the long-term prognosis of gastroparesis depends on the cause.

Conclusions and Inferences

A multinational group of European experts summarized the current state of consensus on definition, symptom characteristics, pathophysiology, diagnosis, and management of gastroparesis.

Keywords: consensus, endoscopy, gastric emptying, gastroparesis, guideline, prokinetic