H. Selwyn ODES, Lisa R. ODES and Alexander FICH.

Departments of Gastroenterology and Internal Medicine B, Soroka Medical Center and Ben Gurion University of the Negev, Beer Sheva, Israel

Address for reprint requests: Prof. H. S. Odes, Department of Gastroenterology, Soroka Medical Center, P O Box 151, Beer Sheva, 84101, Israel.

The public health implications of Helicobacter pylori (HP) infection are considerable in view of the universality of the infection (1) and its attributable risk in the causation of atrophic gastritis and peptic ulcer (2), gastric hyperplastic polyps (3) and gastric cancer (4). Gastric and duodenal ulcers associated with HP infection are eminently curable. The important considerations in selecting therapy are efficacy of eradication, prevention of resistance, minimization of adverse effects, patient compliance and cost. The most effective regimens include an antisecretory drug (preferably a proton pump inhibitor, PPI) plus two antibiotics (amoxycillin and either chlarithromycin or metronidazole); a bismuth preparation (perhaps with ranitidine) may be used in place of a PPI (5). Triple-drug regimens are more likely to eradicate HP and less likely to generate resistant strains among surviving organisms (6,7). This "classical treatment" is fairly expensive, particularly when clarithromycin is used. The success rate is about 80% on an "intention to treat" basis at the first try.
Based on the above, several short-term low-cost treatments have been tested for efficacy. Examples are the 2-day PPI + bismuth + two antibiotics regimen (8), the 3 day PPI + two antibiotic regimen (9) and the one-day high-dose quadruple therapy with amoxycillin, clarithromycin, lansoprazole and bismuth subcitrate (10). These brief regimens all require further evaluation. Increasing antibiotic resistance impairs our ability to cure HP infection and this is always a risk with short-term therapy of bacterial infections. In Europe the resistance rate to metronidazole is about 30%, and to clarithromycin 0 - >20%, depending on the country studied (11).
Polaprezinc, a mucosal protective agent, was used in combination with a 7-day triple regimen of lansoprazole, amoxycillin and clarithromycin and a high success rate was reported (12). This therapy requires further validation. Certain topical treatments have been attempted against HP. While the natural foods honey, capsaicin and garlic (13) inhibit HP in vitro, a recent study should no effect on HP in the human stomach when garlic or jalapeno peppers were ingested, while bismuth was very effective (14). Organic compounds with covalently bound bismuth show stronger and more consistent anti-HP activity in vitro than inorganic bismuth salts (15) and further study in humans is indicated. A 6-week course of ranitidine, then omeprazole with pronase 36000 units/day for 2 days, followed by 1-h topical therapy with a solution of bismuth, metronidazole, amoxycillin and pronase gave poor results (16). Based on experience with cholestyramine, it was recently suggested that finely divided ion-exchange resins would be useful for topical treatment of the gastric mucosa, for example in targeting drugs to eradicate HP infection (17). This method has yet to be tried in man. In a study from Russia, eradication of Helicobacter pylori was achieved in 6 out of 14 patients receiving Lactobacillus acidophilus milk as the sole therapy (18). Another study has shown that 4 weeks daily high dose vitamin C treatment in HP infected patients with chronic gastritis resulted in a significant rise in gastric juice total vitamin C concentration and there was eradication of HP in 30% of those treated (19).
 The Eastern European literature contains anecdotal evidence that ingestion of spa water cures peptic ulcer disease. In this issue of the Archives, Popovic et al. postulated an effect of spa water on HP. They treated ten HP-confirmed patients with water from the Sijarinska Spa in Yugoslavia; the dose was 200 ml before meals four times daily for 2 weeks. However, the results were discouraging since HP was not eradicated in any of the patients.
How could spa water be expected to affect HP? Presumably it would cause an alteration in the internal milieu in the gastric juice and in the unstirred water layer adjacent to the gastric epithelium, thereby altering the environment of HP and its ability to metabolize urea and to reproduce. The unstirred layer contains mucus and HCO3- and has a neutral pH, compared with the very acid pH of the gastric juice (20,21). The spa water in this study had a pH of 6.9 at 30.9 OC and high electrolyte concentrations. Mineral waters vary in their contents and, presumably, their properties in man. A commonly ingested mineral water in our country (EdenTM Natural Mineral Water with pH 7.8 at room temperature) has a different composition (mg/L): Na+ 32, K+ 3.5, Mg2+ 18, HCO3- 198, Ca2+ 26, SO42- 6, and NO3- 15. However we have never tested its therapeutic effects. Could the ingestion of spa water be harmful? The drinking of spa water may expose patients to Legionnaires' disease (22), pseudomonas infection (23) and toxic amounts of radon (24). HP has been detected in unchlorinated drinking water (25,26). The metabolic effects of frequent ingestion of spa water are unknown.
The problem of how to attain rapid and effective HP eradication in all patients is not yet resolved. The use of spa water raised by Popovic et al. is interesting and worthy of further study. It should be noted that many pharmacological agents were discovered when "folklore medicine" was explored scientifically; digitalis is but one example. However, the spa water must first be tested to make sure it does not harbor HP. Secondly, an attempt must be made to show an in vitro bactericidal effect on HP. Only then can a clinical trial be undertaken, with placebo (distilled water). For the present, the treatment of HP will continue to be a PPI and two antibiotics.

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