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Should you test for H. pylori to treat dyspepsia?

From the January ACP-ASIM Observer, copyright © 2002 by the American College of Physicians-American Society of Internal Medicine.

By Linda Gundersen

A patient comes into your office complaining of classic symptoms of dyspepsia. Proton pump inhibitors help for a while, but the patient is back a month later. What do you do?

One obvious strategy is to look for an ulcer, but there are other options. You could test the patient for Helicobacter pylori infection and, if the results are positive, prescribe antibiotics. Questions abound, however, about the effectiveness of H. pylori eradication as a treatment for dyspepsia.

Research suggests the test-and-treat approach yields some benefits, but some experts claim that any gain will be minimal. At the heart of the issue is the decision whether to pursue testing for H. pylori before an ulcer has been ruled out.

Consensus panels have been less than clear on the issue. Guidelines from both the National Institutes of Health and the American College of Gastroenterology say that physicians should test patients with dyspepsia for H. pylori on a case-by-case basis. In other words, they leave the decision on whether to test and treat for H. pylori up to individual physicians.

Nonulcer dyspepsia

Any discussion of how to treat dyspepsia must start by distinguishing between two conditions: uninvestigated dyspepsia and nonulcer dyspepsia. The distinction is important because H. pylori affects each type differently.

Your patient with uninvestigated dyspepsia may actually be harboring an ulcer. Because a wealth of research has shown that H. pylori is one cause of ulcers, conventional wisdom holds that eradicating H. pylori may eliminate the ulcer. If the ulcer was the cause of the dyspepsia, the thinking goes, you may cure the dyspepsia.

If your patient with dyspepsia does not have an ulcer, however, the science is a bit murkier. Studies on the eradication of H. pylori to treat nonulcer dyspepsia offer conflicting results, with some researchers finding little benefit and others suggesting a small but significant benefit.

Most studies agree, however, that even when a benefit is derived from eradicating H. pylori in patients without an ulcer, the success rate roughly equals that of placebo. William D. Chey, FACP, a gastroenterologist and associate professor at the University of Michigan's department of internal medicine, noted that most of the benefits from the test-and-treat approach appear in patients with dyspepsia who actually have ulcers. Patients with nonulcer dyspepsia, in other words, are no more likely to improve after cure of H. pylori than those treated with a short course of proton pump inhibitors or placebo.

As a result, testing and treating patients with uninvestigated dyspepsia for H. pylori—the patients that most generalists see—is loaded with uncertainty. The patient could have an ulcer, in which case eradicating H. pylori is likely to help. If the cause of the dyspepsia is not an ulcer, however, eliminating H. pylori may not be useful, and it could just delay obtaining a diagnosis and starting appropriate treatment.

The merits of treating

Despite the uncertainty, a number of experts say that the test-and-treat approach has certain merits. David Y. Graham, FACP, chief of the digestive disease division at Baylor College of Medicine in Houston, said the test-and-treat strategy is more cost-effective than another popular treatment for dyspepsia: proton pump inhibitors.

He explained that proton pump inhibitors are a short-term solution that ends up costing more in the long run. "If you take a PPI, you'll get better," he said. "As soon as you stop, the symptoms come back." He explained that it's better to discover the underlying cause.

Dr. Graham also argued that testing and treating is justified because H. pylori can lead to serious problems. Of patients who have H. pylori, he said, "One in six people will get a peptic ulcer, and in America 1% to 3% will get gastric cancer." Overall, he explained, about 20% of people with H. pylori will have some significant health problem.

While Dr. Graham said he suggests advising patients of the added benefits of H. pylori eradication, he cautioned doctors to tell patients that there is only about a one in 10 chance that the infection is causing their symptoms.

Loren A. Laine, MD, author of a meta-analysis on the topic in the March 6, 2001, issue of Annals of Internal Medicine, said he advocates testing and treating only in uninvestigated dyspepsia, not in patients in whom an ulcer has been eliminated. If endoscopy shows there is no ulcer, he emphasized, treating patients for H. pylori will produce no better response than if you give a placebo. If the patient has uninvestigated dyspepsia, however, Dr. Laine said he approves of testing and treating before looking for ulcer through endoscopy.

That position, however, raises another question: If you know that treating H. pylori will be most effective in patients with ulcers, why not look for ulcers before deciding to treat? Most professionals agree that endoscopy is the best way to determine the presence of an ulcer, but as Dr. Laine pointed out, most internists cannot perform endoscopy on their patients and often don't give them a referral for the procedure.

With dyspepsia patients who don't fall into that category, however, internists can easily test and treat for H. pylori, and treating H. pylori with antibiotics costs considerably less than endoscopy for ulcers. "Even if we 'cure' dyspepsia in the minority of patients presenting with the condition who have ulcers," Dr. Laine explained, "we have avoided endoscopy in a number of patients. That saves money on treating the overall group, with a small benefit or no change in the group's dyspeptic symptoms."

(Supporters of the test-and-treat approach emphasized that patients with "alarm" symptoms—evidence of bleeding, weight loss or persistent vomiting—as well as patients in their late 40s and 50s, should typically be referred for early endoscopy.)

Questionable results?

The test-and-treat approach, however, has its critics. Ronald L. Koretz, FACP, chief of the gastroenterology division at the San Fernando Valley Program in Sylmar/ Sepulveda, Calif., said he opposes the strategy because the benefits do not outweigh the risks.

"If we're not going to get much of a benefit," he asked, "why bother? If H. pylori was the cause of dyspepsia, these studies would surely have shown it." Dr. Koretz said he believes that doctors may rely too heavily on H. pylori eradication as a quick fix. "Doctors think in terms of 'What can I do right now?' not, 'What can I do so that 10 years from now the situation will be better?' " He suggested that antacid intervention was an appropriate treatment for dyspepsia. Even if that strategy fails, he added, he would not consider H. pylori testing and treatment an option.

David A. Peura, FACP, professor of medicine and associate chief of the division of gastroenterology and hepatology at University of Virginia Health System, added that even when you have clearly established your patient has an ulcer, the benefits of test and treat are questionable.

"Following H. pylori eradication, most people eventually go back on medicine because their symptoms return," Dr. Peura explained. "With duodenal ulcers, about one in five will have a return of either the ulcer or the symptoms after eradication of H. pylori."

Doubters also stress another caveat: early evidence suggesting a link between H. pylori eradication and acid reflux. New research indicates that eradicating H. pylori may increase a patient's chances of developing acid reflux.

To make matters even more confusing, eradicating H. pylori in a patient who already has reflux will not worsen the condition, preliminary studies say. Experts emphasize that this is relatively new research, and that additional studies are needed before conclusions can be drawn.

Test before treating

While experts may debate whether to test for ulcers before testing for H. pylori, most agree on one point: Physicians should not treat patients for H. pylori without first doing some form of diagnostic testing, whether noninvasive or endoscopic.

"Some doctors are saying 'You have dyspepsia, here are some antibiotics,' " Dr. Graham explained. He added that treating without first testing for H. pylori, however, should not be an option.

In part, experts say you should test for H. pylori before treating because the prevalence of the infection is relatively low in the United States.

And Dr. Chey gave several other reasons he said warranted testing before treating: Noninvasive diagnostic testing is relatively inexpensive; patients may not want to be exposed to side effects associated with three or four drugs if infection is unlikely; and most people who have H. pylori remain asymptomatic throughout their lives.

Another serious consideration is antibiotic resistance. "We have to be responsible in the way that we target antibiotic use," Dr. Chey explained. Dr. Koretz, the gastroenterologist from San Fernando, also cited antibiotic resistance as a compelling reason not to test and treat at all. He argued that resistance to powerful antibiotics is potentially a much more serious problem than H. pylori infection.

Proponents of test and treat, however, say they do not believe that antibiotic resistance should be physicians' primary consideration in these cases. Dr. Graham, for example, argued that physicians' main concern should be eradicating H. pylori and the subsequent possibility—albeit a small one—that H. pylori could lead to gastric cancer.

Pressure from patients

The evidence supporting the test-and-treat approach may not be crystal clear, but testing and treating does offer physicians at least one tantalizing advantage: another weapon to fight dyspepsia, a problem that can be difficult to treat.

Dr. Chey acknowledged that patients suffering from dyspepsia might occasionally become demanding, especially when symptoms persist. If they know there is a chance of eliminating the dyspepsia by eradicating H. pylori, he said, they may request the test-and-treat option. He also acknowledged that some patients may be concerned about the slight possibility of H. pylori leading to an ulcer or gastric cancer.

In these circumstances, he said, testing and treating patients for H. pylori is acceptable, though there is little current evidence to suggest that treatment prevents ulcers or gastric cancer.

In making the decision about whether to test and treat H. pylori in patients with uninvestigated dyspepsia, Dr. Chey offered some final advice: "It really depends on whether you're a person who practices evidence-based medicine or a purely pragmatic clinician. If you have a group of patients who are very difficult to manage, maybe it's not such a bad thing to get a 20% to 30% treatment response by eliminating H. pylori."

Linda Gundersen is a freelance health care and pharmaceutical writer in Perkasie, Pa.

The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP-ASIM.

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