Helicobacter pylori infektsiooni ravijuhend
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1 Helicobacter pylori infektsiooni ravijuhend Helicobacter pylori infektsiooni ravijuhend on koostatud lähtudes järgmistest üldtunnustatud ja publitseeritud seisukohtadest: 1. European Helicobacter Pylori Study Group: Current European Concepts on the Management of Helicobacter Pylori Infection. The Maastricht Consensus Report National Institute of Health (NIH) Guidelines 1994 for Helicobacter Pylori Eradication The Management Plan for Peptic Ulcer Disease: Reviewed and Approved by the World Congress of Gastroenterology 1990 Ravijuhend on heaks kiidetud Eesti Gastroenteroloogide Seltsi poolt 23. oktoobril 1998.a ja ta on soovitatava iseloomuga.
2 A. Helicobacter pylori infektsiooni ravi näidustused 1. Endoskoopiliselt tõestatud peptiline haavand (maohaavand või kaksteistsõrmikuhaavand), seejuures kaksteistsõrmikuhaavand ei vaja endoskoopilist kinnitust iga ägenemise korral. 2. Tüsistunud peptiline haavand (verejooks, üleõmbluse ja haavandi ekstsisiooniga ravitud perforatsioon). 3. Peptiline haavand pärast vagotoomiat või maoresektsiooni. 4. MALT lümfoom. Funktsionaalse düspepsia, mittesteroidseist põletikuvastastest ravimeist põhjustatud haavandi, gastroösofageaalse reflukshaiguse ja patsiendi sugulastel diagnoositud maovähi puhul Helicobacter pylori infektsiooni uurimise ja ravi vajalikkus pole piisavalt tõestatatud. Vaevusteta patsientidel ja mitteseedetraktihaiguste puhul Helicobacter pylori uurimine ja ravi ei ole otstarbekas. MALT lümfoom mucosa-associated lymphoid tissue lymphoma (inglise keeles).
3 B. Helicobacter pylori infektsiooni diagnoosimine 1. Histoloogiline meetod (vähemalt 1 proovitükk antrumist ja 1 korpusest gastroskoopia ajal). 2. Tsütoloogiline meetod. 3. Ureaasi kiirtest (proovitükis antrumist gastroskoopia ajal). 4. Seroloogiline meetod (Helicobacter pylori antikehade määramine kapillaarveres). 5. C13 (C14) hingamistest. 6. Bakterioloogiline meetod. Helicobacter pylori määramiseks ei pea samal haigel kasutama üheaegselt mitut diagnostilist meetodit. Kui gastroskoopia on kliiniliselt näidustatud haavandi diagnoosimiseks, siis proovitükkides võib kasutada kas ureaasi kiirtesti või histoloogilist meetodit või tsütoloogilist meetodit. Kui gastroskoopia kliiniliselt näidustatud ei ole (kaksteistsõrmikuhaavand eelnevalt endoskoopiliselt diagnoositud), siis on soovitatav kasutada seroloogilist meetodit või hingamistesti. Üldjuhul on soovitatav lähtuda põhimõttest Helicobacter pylori olemasolu uurida siis, kui on näidustatud selle infektsiooni ravi.
4 C. Helicobacter pylori infektsiooni ravi 1. Enne ravi alustamist määrata Helicobacter pylori infektsiooni olemasolu 2. Ravis kasutatakse üheaegselt antisekretoorseid ravimeid (prootonpumba inhibiitorid või ranitidiinvismuttsitraat) ja antimikroobseid ravimeid (amoksitsilliin, klaritromütsiin, metronidasool). 3. Eelistatud on 7-päevane ravi. 4. Soovitatavad ravimite kombinatsioonid ja päevased ravimi annused a) omeprasool 20 mg 2 korda ööpäevas, amoksitsilliin 1000 mg 2 korda ööpäevas, klaritromütsiin 500 mg 2 korda ööpäevas b) omeprasool 20 mg 2 korda ööpäevas, metronidasool 500 mg 2 korda ööpäevas, klaritromütsiin 250 mg 2 korda ööpäevas c) ranitidiinvismuttsitraat 400 mg 2 korda ööpäevas, metronidasool 500 mg 2 korda ööpäevas, klaritromütsiin 250 mg 2 korda ööpäevas. d) ranitidiinvismuttsitraat 400 mg 2 korda ööpäevas, amoksitsilliin 1000 mg 2 korda ööpäevas, klaritromütsiin 250 mg 2 korda ööpäevas 5. Helicobacter pylori infektsiooni ravi ebaõnnestumisel otsustab edasised uuringud ja ravi gastroenteroloog.
5 D. Helicobacter pylori infektsiooni ravi efektiivsuse kontroll 1. Tüsistumata kaksteistsõrmikuhaavand Helicobacter pylori infektsiooni ravi tulemust ei ole otstarbekas kontrollida, sest infektsiooni püsimisel tekib kliiniliselt uus ägenemine. 2. Tüsistumata maohaavand maohaavandi paranemist kontrollitakse alati endoskoopiliselt ja histoloogiliselt 2-3 kuud pärast ravi, histoloogilise uuringuga (või ureaasi kiirtestiga) tõestatakse ka helikobakterite olemasolu või puudumist. 3. Tüsistunud peptiline haavand Helicobacter pylori infektsiooni ravi järgne helikobakterite olemasolu kontroll on vajalik, eelistatuim meetod on hingamistest. Haavandi üleõmbluse ja haavandi ekstsisiooniga ravitud haigeid peab 2-3 kuu möödudes endoskoopiliselt kontrollima koos histoloogilise uuringuga helikobakterite olemasolule. Juhul, kui Helicobacter pylori kolonisatsioon jäi ravijärgselt püsima, vajab patsient uute tüsistuste vältimiseks antisekretoorset säilitusravi. Säilitusravi peab kindlasti rakendama eakatel patsientidel raskete kaasuvate haigustega ning antikoagulantide ja mittesteroidse põletikuvastaste ravimite kasutamisel olenemata Helicobacter pylori olemasolust. Helicobacter pylori infektsiooni kontroll tüsistumata maohaavandi ja tüsistunud peptilise haavandi haigeil toimub mitte enne kui infektsiooni ravist on möödunud vähemalt 6-8 nädalat. 4 nädalat enne kontrolli ei ole soovitav kasutada prootonpumba inhibiitoreid, histamiin 2 retseptorite antagoniste, antibiootikume ega vismutpreparaate, kuna võib saada valenegatiivse vastuse tingituna Helicobacter pylori supressioonist nende ravimite poolt. Seroloogilist meetodit ei ole ravitulemuste kontrolliks soovitatav kasutada.
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