Does Helicobacter pylori eradication or proton pump inhibitor use benefit gastroesophageal reflux disease?

We read with great interest the recently published article by Moschos et al [1]. They aimed to show the beneficial effect of Helicobacter pylori (Hp) eradication in gastroesophageal reflux disease (GERD) patients. They indicated in this study that Hp eradication may positively influence GERD symptoms. We commend Moschos et al for this study, but we think there are some controversial situations that need to be clarified.

They indicated that they found improvement in manometric pattern at 17% of patients and acid reduction in 3-h pH results at 82.8% of patients. But there are controversies of this procedure. Firstly, weak acid and non-acid reflux were not mentioned in this study. Ambulatory pH monitoring shows only acid reflux, and multichannel intraluminal 24-h pH-impedance (MII-pH) monitoring is needed to determine weak and non-acid reflux [2]. Thus, we think that to determine the exact beneficial results of Hp eradication, MII-pH monitoring may be done. Secondly, it has been shown that the intragastric and esophageal pH levels are affected postprandial according to the meal composition and mealtime. High-fat meals have been shown to elicit heartburn and increased acid exposure [3]; however, in this study, the patients’ meal composition and type were not mentioned.

And thirdly, it is controversial whether the beneficial effect stems from proton pump inhibitor (PPI) use or from Hp eradication treatment. It is shown that PPI therapy aims to reduce the acidity of reflux episodes and conversely increases the exposure of the esophagus to non-acid and weakly acidic reflux [4]. Consistent with this study, Rinsma et al [5] showed improvement in distal baseline impedance and decrease in acid reflux in MII-pH monitoring, but they found an increase in non-acid reflux episodes in patients receiving PPIs after 6 months of therapy. In this study, the patients had taken rabeprazole for 10 days to eradicate Hp, followed by high-dose PPIs (4 times a day) for 30 days. Although there seems to be a 6-week without treatment period, it is a high acid suppressive dose that may affect acid secretion. Thus, we think that the beneficial effect observed during pH monitoring may be due to the long-term effect of PPI treatment. Based on the abovementioned data, we suggest that these controversies must be taken into account in future studies.