An important marker of the virulence of Helicobacter pylori strains is cagA encoding the cytotoxin-associated gene protein (cagA) . Almost all Helicobacter pylori isolates from patients with peptic ulcers, atrophic gastritis and gastric cancer are cagA+ . As there is an inverse relation between carcinoma in the cardia and lower oesophagus and colonization with cagA+ strains  it has been proposed that Helicobacter pylori colonization with especially cagA+ strains may protect against the development of GORD and its complications.
These suggestions have been underlined by the results of a cross-sectional study in 736 consecutive patients examining the relation between cagA+ and cagA— Helicobacter pylori strains in patients with reflux oesophagitis and Barrett's oesophagus . The authors found a significant lower prevalence of Helicobacter pylori (34,9%) in reflux patients than in controls with a prevalence of 59% cagA+ strains in the control group vs. 35% in the reflux group.
In conclusion cagA+ strains may on the one side be most harmful by increasing the risk of ulceration and distal cancer but on the other side be most beneficial by protecting against reflux oesophagitis and its sequelae. Further studies proved this concept .
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