Helicobacter pylori eradication in the treatment of gastric hyperplastic polyps: beyond National Health Insurance

Article information

Korean J Intern Med. 2018;33(3):490-492
Publication date (electronic) : 2018 May 1
doi : https://doi.org/10.3904/kjim.2018.122
Division of Gastroenterology, Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea
Correspondence to Moon Kyung Joo, M.D. Division of Gastroenterology, Department of Internal Medicine, Korea University Guro Hospital, 148 Gurodong-ro, Guro-gu, Seoul 08308, Korea Tel: +82-2-2626-3007 Fax: +82-2-2626-1038 E-mail: latyrx@korea.ac.kr
Received 2018 April 2; Accepted 2018 April 15.

See Article on Page [Related article:] 506-511

Gastric hyperplastic polyps (HPPs) are among the most common types of polyps in the stomach, and are usually asymptomatic and incidentally found during screening esophagogastroduodenoscopy. However, if polyp size is significantly larger, focal adenocarcinoma may arise from surface of polyp in an average of 2.1% (range, 0% to 8%) [1-3]. In general, if the size of the gastric HPP is greater than 1.0 cm, endoscopic resection is recommended due to the possibility of bleeding and malignant potential of the polyp. Regular endoscopic follow-up may be considered in cases of smaller HPPs [4]. However, several case-control studies and a randomized controlled trial showed that eradication of Helicobacter pylori not only significantly reduced the size of the gastric HPP, but also improved the degree of histopathologic inflammation [5-7]. Furthermore, atrophic gastritis, which is a major risk factor for gastric adenocarcinoma and is mainly caused by chronic H. pylori infection, is commonly seen in patients with gastric HPPs [8]. Thus, the presence of gastric HPPs may be a potential marker for increased risk of precancerous atrophic gastritis and gastric adenocarcinoma. Therefore, eradication of H. pylori infection in patients with H. pylori-positive gastric HPP is considered an optimal treatment strategy for gastric HPPs.

Based on clinical data on gastric HPPs, the Japanese guideline for the management of H. pylori infection (revised 2009 edition) recommends eradication of H. pylori in patients with multiple gastric HPPs (evidence level II) [9]. Consistent with this, the British Society of Gastroenterology recommends H. pylori testing and treatment for the management of gastric HPP (high evidence, definite recommendation) [10]. However, the Korean National Health Insurance System did not approved the eradication of H. pylori infection for management of gastric HPPs until recently, and Korean gastroenterologists needed to present domestic data to persuade national insurance authorities. In a retrospective study, we previously reported that regression of gastric HPPs was significantly higher in the H. pylori eradication group than in the non-eradication group (42.5% vs. 22.2%, p < 0.05), and H. pylori eradication was the only significant predictor of regression of gastric HPPs [11]. Another Korean retrospective study enrolled a large number of healthy subjects from a Private Health Screening Cohort at the National Cancer Center, and also showed that successful eradication of H. pylori was significantly associated with the disappearance of gastric HPPs compared with persistent H. pylori infection (85.0% vs. 29.0%, p = 0.001) [12]. However, the studies were based on outpatient data from a tertiary referral hospital or on data from private screening patients, which may have a selection bias due to patients’ motivation for health care or medical cost.

In the current issue, Nam et al. [13] enrolled more than 10,000 participants from a National Cancer Screening Cohort, and 183 subjects with H. pylori-positive gastric HPPs were followed-up regularly. The authors showed that eradication of H. pylori infection dramatically induced the disappearance of gastric HPPs compared with non-eradication (83.7% vs. 34.1%, p = 0.001) [13]. Furthermore, successful eradication was a useful predictor for the disappearance of gastric HPPs (adjusted odds ratio, 5.56; 95% confidence interval, 2.63 to 11.11) [13]; and this was consistent with the results of their previous retrospective study, which was based on a private screening cohort [12]. We would like to acknowledge the authors’ efforts to establish H. pylori eradication as an effective treatment for gastric HPPs, and for providing strong justification for expanding the coverage of H. pylori eradication by the Korean National Health Insurance System. Some authors may believe that the data from this study should only be only considered as “low level evidence” due to the inherent limitations of studies involving retrospective review of medical records. However, it is not easy to perform a prospective randomized controlled trial for evaluating the effect of H. pylori eradication, because patients usually refuse non-eradication and the “wait and see” strategy. At present, the “test and treat” strategy for H. pylori appears to be a reasonable option for the management of multiple small gastric HPPs.

In terms of insurance issues, the Korean Ministry of Health and Welfare recently approved the non-reimbursed eradication of H. pylori in patients with gastric HPPs. In contrast, the National Health Insurance Authority approved the eradication of H. pylori without coverage in cases where the patient has endoscopic resection of gastric adenoma, a family history of gastric cancer (among first degree relatives) or atrophic gastritis, or if the physician explains the necessity for H. pylori eradication and the patient agrees [14]. However, more solid evidence based on domestic data (i.e., multicenter, prospective trial) would be necessary for expansion of National Health Insurance coverage of H. pylori eradication including patients with gastric HPPs, and outcomes from these studies may be a cornerstone for achieving this goal.


No potential conflict of interest relevant to this article was reported.


1. Daibo M, Itabashi M, Hirota T. Malignant transformation of gastric hyperplastic polyps. Am J Gastroenterol 1987;82:1016–1025.
2. Dirschmid K, Platz-Baudin C, Stolte M. Why is the hyperplastic polyp a marker for the precancerous condition of the gastric mucosa? Virchows Arch 2006;448:80–84.
3. Ginsberg GG, Al-Kawas FH, Fleischer DE, Reilly HF, Benjamin SB. Gastric polyps: relationship of size and histology to cancer risk. Am J Gastroenterol 1996;91:714–717.
4. Shaib YH, Rugge M, Graham DY, Genta RM. Management of gastric polyps: an endoscopy-based approach. Clin Gastroenterol Hepatol 2013;11:1374–1384.
5. Ji F, Wang ZW, Ning JW, Wang QY, Chen JY, Li YM. Effect of drug treatment on hyperplastic gastric polyps infected with Helicobacter pylori: a randomized, controlled trial. World J Gastroenterol 2006;12:1770–1773.
6. Ohkusa T, Miwa H, Hojo M, et al. Endoscopic, histological and serologic findings of gastric hyperplastic polyps after eradication of Helicobacter pylori: comparison between responder and non-responder cases. Digestion 2003;68:57–62.
7. Ohkusa T, Takashimizu I, Fujiki K, et al. Disappearance of hyperplastic polyps in the stomach after eradication of Helicobacter pylori. A randomized, clinical trial. Ann Intern Med 1998;129:712–715.
8. Veereman Wauters G, Ferrell L, Ostroff JW, Heyman MB. Hyperplastic gastric polyps associated with persistent Helicobacter pylori infection and active gastritis. Am J Gastroenterol 1990;85:1395–1397.
9. Asaka M, Kato M, Takahashi S, et al. Guidelines for the management of Helicobacter pylori infection in Japan: 2009 revised edition. Helicobacter 2010;15:1–20.
10. Goddard AF, Badreldin R, Pritchard DM, Walker MM, Warren B, ; British Society of Gastroenterology. The management of gastric polyps. Gut 2010;59:1270–1276.
11. Lim SA, Yun JW, Yoon D, et al. Regression of hyperplastic gastric polyp after Helicobacter pylori eradication. Korean J Gastrointest Endosc 2011;42:74–82.
12. Nam SY, Park BJ, Ryu KH, Nam JH. Effect of Helicobacter pylori infection and its eradication on the fate of gastric polyps. Eur J Gastroenterol Hepatol 2016;28:449–454.
13. Nam SY, Park BJ, Ryu KH, Nam JH. Effect of Helicobacter pylori eradication on the regression of gastric polyps in National Cancer Screening Program. Korean J Intern Med 2018;33:506–511.
14. Korean Ministry of Health and Welfare. Expansion of indication for Helicobacter pylori eradication [Internet]. Sejong (KR): Korean Ministry of Health and Welfare; 2017. [cited 2018 Apr 13]. Available from: http://www.mohw.go.kr/react/index.jsp.

Article information Continued