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Should you test for H pylori in patients with nonulcer dyspepsia?
POSSIBLY. Helicobacter pylori increases the risk of developing peptic ulcer disease (strength of recommendation [SOR]: B, cohort study), but there is no evidence that treating H pylori reduces that risk.
Treating H pylori in patients with nonulcer dyspepsia reduces symptoms, but doesn’t improve quality of life in the short term (SOR: B, systematic review of randomized controlled trials [RCTs] with inconsistent results), but may alleviate symptoms in the long term (SOR: B, RCT with methodological flaws).
Eradicating H pylori is relatively inexpensive (SOR: A, systematic review of economic analyses).
Evidence summary
Nonulcer dyspepsia is defined by upper abdominal symptoms (nausea, bloating, and abdominal pain) in the absence of an ulcer.1 A prospective study evaluating the natural history of 209 Taiwanese patients with nonulcer dyspepsia found a 45% prevalence of H pylori. The patients presented with dyspeptic symptoms and had no history of peptic ulcer disease or treatment for H pylori. Investigators performed an initial endoscopy to establish a diagnosis of nonulcer dyspepsia and followed the patients for 24 months. Patients with H pylori infection were more likely to develop peptic ulcer disease (odds ratio [OR]=3.59; 95% confidence interval [CI], 1.07-12.05; P=.039).2
In addition, a prospective cohort study of Japanese patients with nonulcer dyspepsia found that 4.7% of patients infected with H pylori developed gastric cancer after 10 years.3
Eradicating H pylori doesn’t prevent peptic ulcer disease
A prospective, placebo-controlled trial found that therapy to eradicate H pylori didn’t reduce peptic ulcer disease in patients with functional dyspepsia. Investigators recruited 161 patients with H pylori infection who had had functional dyspepsia symptoms for 3 months and no peptic ulcer disease at baseline. They gave lansoprazole, metronidazole, and tetracycline for 1 week to the treatment group and placebo antibiotics and lansoprazole to the placebo group. Fewer of the treated patients developed peptic ulcers by 12 months, but the difference wasn’t significant (2.5% treatment vs 7.5% placebo; P=.167).4
Eradication improves symptoms, but not quality of life
A Cochrane systematic review of 17 RCTs (total N=3566) compared drugs known to eradicate H pylori with placebo or drugs known to be ineffective against H pylori for patients with nonulcer dyspepsia. Investigators evaluated individual and global dyspeptic symptom scores and quality-of-life measures. At 3 to 12 months of follow-up, treated patients reported improved symptom scores (number needed to treat=14; 95% CI, 10-25). Three studies that evaluated quality-of-life indicators found no significant benefit with H pylori eradication.5
Evidence for outcomes beyond 12 months is limited. An RCT evaluated 100 patients with nonulcer dyspepsia who received bismuth subcitrate for 4 weeks or metronidazole and tetracycline for 7 days or placebo. At 5 years, investigators performed urea breath testing on 64 patients and found that 67% were negative for H pylori. More H pylori-negative patients reported complete symptom resolution than patients who were still infected (34% vs 8.3%; chi-square <0.001). However, investigators grouped patients at 5-year follow-up according to their H pylori status at that time and not by their original treatment group.6
H pylori eradication is low cost
A 2000 systematic review with economic analysis found that eradicating H pylori would cost less than $50 per patient per year compared with antisecretory therapy alone.7
Recommendations
The European Helicobacter Study Group states that treatment of H pylori in nonulcer dyspepsia is appropriate.8 The American College of Gastroenterology agrees that offering treatment for H pylori in nonulcer dyspepsia is acceptable.9
The American Gastroenterological Association recommends a “test and treat” strategy for H pylori in dyspeptic patients.1
1. Talley NJ, Vail NB, Moayyedi P. American Gastroenterological Association technical review on the evaluation of dyspepsia. Gastroenterology. 2005;129:1756-1780.
2. Hsu PI, Lai KH, Lo GH, et al. Risk factors for ulcer development in patients with non-ulcer dyspepsia: a prospective two-year follow-up study of 209 patients. Gut. 2002;51:15-20.
3. Uemura N, Okamoto S, Yamamoto S, et al. Helicobacter pylori infection and the development of gastric cancer. N Engl J Med. 2001;345:784-789.
4. Hsu PI, Lai KH, Tseng HH, et al. Eradication of Helicobacter pylori prevents ulcer development in patents with ulcer-like functional dyspepsia. Aliment Pharmacol Ther. 2001;15:195-201.
5. Moayyedi P, Soo S, Deeks J, et al. Eradication of Helicobacter pylori for non-ulcer dyspepsia. Cochrane Database Syst Rev. 2006;(2):CD002096.-
6. McNamara D, Buckley M, Gilvarry J, et al. Does Helicobacter pylori eradication affect symptoms in nonulcer dyspepsia: a 5-year follow-up study. Helicobacter. 2002;7:317-321.
7. Moayyedi P, Soo S, Deeks J, et al. Systematic review and economic evaluation of Helicobacter pylori eradication treatment for non-ulcer dyspepsia. Dyspepsia Review Group. BMJ. 2000;321:659-664.
8. Malfertheiner P, Megraud F, O’Morain C, et al. Current concepts in the management of Helicobacter pylori infection: the Maastricht III Consensus Report. Gut. 2007;56:772-781.
9. Chey WD, Wong BC. Practice Parameters Committee of the American College of Gastroenterology. American College of Gastroenterology guideline on the management of Helicobacter pylori infection. Am J Gastroenterol. 2007;102:1808-1825.
POSSIBLY. Helicobacter pylori increases the risk of developing peptic ulcer disease (strength of recommendation [SOR]: B, cohort study), but there is no evidence that treating H pylori reduces that risk.
Treating H pylori in patients with nonulcer dyspepsia reduces symptoms, but doesn’t improve quality of life in the short term (SOR: B, systematic review of randomized controlled trials [RCTs] with inconsistent results), but may alleviate symptoms in the long term (SOR: B, RCT with methodological flaws).
Eradicating H pylori is relatively inexpensive (SOR: A, systematic review of economic analyses).
Evidence summary
Nonulcer dyspepsia is defined by upper abdominal symptoms (nausea, bloating, and abdominal pain) in the absence of an ulcer.1 A prospective study evaluating the natural history of 209 Taiwanese patients with nonulcer dyspepsia found a 45% prevalence of H pylori. The patients presented with dyspeptic symptoms and had no history of peptic ulcer disease or treatment for H pylori. Investigators performed an initial endoscopy to establish a diagnosis of nonulcer dyspepsia and followed the patients for 24 months. Patients with H pylori infection were more likely to develop peptic ulcer disease (odds ratio [OR]=3.59; 95% confidence interval [CI], 1.07-12.05; P=.039).2
In addition, a prospective cohort study of Japanese patients with nonulcer dyspepsia found that 4.7% of patients infected with H pylori developed gastric cancer after 10 years.3
Eradicating H pylori doesn’t prevent peptic ulcer disease
A prospective, placebo-controlled trial found that therapy to eradicate H pylori didn’t reduce peptic ulcer disease in patients with functional dyspepsia. Investigators recruited 161 patients with H pylori infection who had had functional dyspepsia symptoms for 3 months and no peptic ulcer disease at baseline. They gave lansoprazole, metronidazole, and tetracycline for 1 week to the treatment group and placebo antibiotics and lansoprazole to the placebo group. Fewer of the treated patients developed peptic ulcers by 12 months, but the difference wasn’t significant (2.5% treatment vs 7.5% placebo; P=.167).4
Eradication improves symptoms, but not quality of life
A Cochrane systematic review of 17 RCTs (total N=3566) compared drugs known to eradicate H pylori with placebo or drugs known to be ineffective against H pylori for patients with nonulcer dyspepsia. Investigators evaluated individual and global dyspeptic symptom scores and quality-of-life measures. At 3 to 12 months of follow-up, treated patients reported improved symptom scores (number needed to treat=14; 95% CI, 10-25). Three studies that evaluated quality-of-life indicators found no significant benefit with H pylori eradication.5
Evidence for outcomes beyond 12 months is limited. An RCT evaluated 100 patients with nonulcer dyspepsia who received bismuth subcitrate for 4 weeks or metronidazole and tetracycline for 7 days or placebo. At 5 years, investigators performed urea breath testing on 64 patients and found that 67% were negative for H pylori. More H pylori-negative patients reported complete symptom resolution than patients who were still infected (34% vs 8.3%; chi-square <0.001). However, investigators grouped patients at 5-year follow-up according to their H pylori status at that time and not by their original treatment group.6
H pylori eradication is low cost
A 2000 systematic review with economic analysis found that eradicating H pylori would cost less than $50 per patient per year compared with antisecretory therapy alone.7
Recommendations
The European Helicobacter Study Group states that treatment of H pylori in nonulcer dyspepsia is appropriate.8 The American College of Gastroenterology agrees that offering treatment for H pylori in nonulcer dyspepsia is acceptable.9
The American Gastroenterological Association recommends a “test and treat” strategy for H pylori in dyspeptic patients.1
POSSIBLY. Helicobacter pylori increases the risk of developing peptic ulcer disease (strength of recommendation [SOR]: B, cohort study), but there is no evidence that treating H pylori reduces that risk.
Treating H pylori in patients with nonulcer dyspepsia reduces symptoms, but doesn’t improve quality of life in the short term (SOR: B, systematic review of randomized controlled trials [RCTs] with inconsistent results), but may alleviate symptoms in the long term (SOR: B, RCT with methodological flaws).
Eradicating H pylori is relatively inexpensive (SOR: A, systematic review of economic analyses).
Evidence summary
Nonulcer dyspepsia is defined by upper abdominal symptoms (nausea, bloating, and abdominal pain) in the absence of an ulcer.1 A prospective study evaluating the natural history of 209 Taiwanese patients with nonulcer dyspepsia found a 45% prevalence of H pylori. The patients presented with dyspeptic symptoms and had no history of peptic ulcer disease or treatment for H pylori. Investigators performed an initial endoscopy to establish a diagnosis of nonulcer dyspepsia and followed the patients for 24 months. Patients with H pylori infection were more likely to develop peptic ulcer disease (odds ratio [OR]=3.59; 95% confidence interval [CI], 1.07-12.05; P=.039).2
In addition, a prospective cohort study of Japanese patients with nonulcer dyspepsia found that 4.7% of patients infected with H pylori developed gastric cancer after 10 years.3
Eradicating H pylori doesn’t prevent peptic ulcer disease
A prospective, placebo-controlled trial found that therapy to eradicate H pylori didn’t reduce peptic ulcer disease in patients with functional dyspepsia. Investigators recruited 161 patients with H pylori infection who had had functional dyspepsia symptoms for 3 months and no peptic ulcer disease at baseline. They gave lansoprazole, metronidazole, and tetracycline for 1 week to the treatment group and placebo antibiotics and lansoprazole to the placebo group. Fewer of the treated patients developed peptic ulcers by 12 months, but the difference wasn’t significant (2.5% treatment vs 7.5% placebo; P=.167).4
Eradication improves symptoms, but not quality of life
A Cochrane systematic review of 17 RCTs (total N=3566) compared drugs known to eradicate H pylori with placebo or drugs known to be ineffective against H pylori for patients with nonulcer dyspepsia. Investigators evaluated individual and global dyspeptic symptom scores and quality-of-life measures. At 3 to 12 months of follow-up, treated patients reported improved symptom scores (number needed to treat=14; 95% CI, 10-25). Three studies that evaluated quality-of-life indicators found no significant benefit with H pylori eradication.5
Evidence for outcomes beyond 12 months is limited. An RCT evaluated 100 patients with nonulcer dyspepsia who received bismuth subcitrate for 4 weeks or metronidazole and tetracycline for 7 days or placebo. At 5 years, investigators performed urea breath testing on 64 patients and found that 67% were negative for H pylori. More H pylori-negative patients reported complete symptom resolution than patients who were still infected (34% vs 8.3%; chi-square <0.001). However, investigators grouped patients at 5-year follow-up according to their H pylori status at that time and not by their original treatment group.6
H pylori eradication is low cost
A 2000 systematic review with economic analysis found that eradicating H pylori would cost less than $50 per patient per year compared with antisecretory therapy alone.7
Recommendations
The European Helicobacter Study Group states that treatment of H pylori in nonulcer dyspepsia is appropriate.8 The American College of Gastroenterology agrees that offering treatment for H pylori in nonulcer dyspepsia is acceptable.9
The American Gastroenterological Association recommends a “test and treat” strategy for H pylori in dyspeptic patients.1
1. Talley NJ, Vail NB, Moayyedi P. American Gastroenterological Association technical review on the evaluation of dyspepsia. Gastroenterology. 2005;129:1756-1780.
2. Hsu PI, Lai KH, Lo GH, et al. Risk factors for ulcer development in patients with non-ulcer dyspepsia: a prospective two-year follow-up study of 209 patients. Gut. 2002;51:15-20.
3. Uemura N, Okamoto S, Yamamoto S, et al. Helicobacter pylori infection and the development of gastric cancer. N Engl J Med. 2001;345:784-789.
4. Hsu PI, Lai KH, Tseng HH, et al. Eradication of Helicobacter pylori prevents ulcer development in patents with ulcer-like functional dyspepsia. Aliment Pharmacol Ther. 2001;15:195-201.
5. Moayyedi P, Soo S, Deeks J, et al. Eradication of Helicobacter pylori for non-ulcer dyspepsia. Cochrane Database Syst Rev. 2006;(2):CD002096.-
6. McNamara D, Buckley M, Gilvarry J, et al. Does Helicobacter pylori eradication affect symptoms in nonulcer dyspepsia: a 5-year follow-up study. Helicobacter. 2002;7:317-321.
7. Moayyedi P, Soo S, Deeks J, et al. Systematic review and economic evaluation of Helicobacter pylori eradication treatment for non-ulcer dyspepsia. Dyspepsia Review Group. BMJ. 2000;321:659-664.
8. Malfertheiner P, Megraud F, O’Morain C, et al. Current concepts in the management of Helicobacter pylori infection: the Maastricht III Consensus Report. Gut. 2007;56:772-781.
9. Chey WD, Wong BC. Practice Parameters Committee of the American College of Gastroenterology. American College of Gastroenterology guideline on the management of Helicobacter pylori infection. Am J Gastroenterol. 2007;102:1808-1825.
1. Talley NJ, Vail NB, Moayyedi P. American Gastroenterological Association technical review on the evaluation of dyspepsia. Gastroenterology. 2005;129:1756-1780.
2. Hsu PI, Lai KH, Lo GH, et al. Risk factors for ulcer development in patients with non-ulcer dyspepsia: a prospective two-year follow-up study of 209 patients. Gut. 2002;51:15-20.
3. Uemura N, Okamoto S, Yamamoto S, et al. Helicobacter pylori infection and the development of gastric cancer. N Engl J Med. 2001;345:784-789.
4. Hsu PI, Lai KH, Tseng HH, et al. Eradication of Helicobacter pylori prevents ulcer development in patents with ulcer-like functional dyspepsia. Aliment Pharmacol Ther. 2001;15:195-201.
5. Moayyedi P, Soo S, Deeks J, et al. Eradication of Helicobacter pylori for non-ulcer dyspepsia. Cochrane Database Syst Rev. 2006;(2):CD002096.-
6. McNamara D, Buckley M, Gilvarry J, et al. Does Helicobacter pylori eradication affect symptoms in nonulcer dyspepsia: a 5-year follow-up study. Helicobacter. 2002;7:317-321.
7. Moayyedi P, Soo S, Deeks J, et al. Systematic review and economic evaluation of Helicobacter pylori eradication treatment for non-ulcer dyspepsia. Dyspepsia Review Group. BMJ. 2000;321:659-664.
8. Malfertheiner P, Megraud F, O’Morain C, et al. Current concepts in the management of Helicobacter pylori infection: the Maastricht III Consensus Report. Gut. 2007;56:772-781.
9. Chey WD, Wong BC. Practice Parameters Committee of the American College of Gastroenterology. American College of Gastroenterology guideline on the management of Helicobacter pylori infection. Am J Gastroenterol. 2007;102:1808-1825.
Evidence-based answers from the Family Physicians Inquiries Network