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Management of patients with uninvestigated dyspepsia

Department of Medicine Queen Elizabeth II Health Sciences Centre Dalhousie University Halifax, NS; Department of Family Medicine University of Alberta Edmonton, Alta.; Division of Gastroenterology McMaster University Hamilton, Ont. for the Canadian Dyspepsia Working Group

A recently published randomized controlled trial of the eradication of Helicobacter pylori in patients without ulcers who presented with functional dyspepsia¹ was reviewed in a CMAJ Clinical Update.² We believe the Clinical Update oversimplifies the management of dyspepsia in that it incorrectly leads the reader to believe that these results are applicable to the management of primary care patients with uninvestigated dyspepsia, when in fact this is not the case.

It is essential to distinguish between uninvestigated and investigated dyspepsia. By definition, functional dyspepsia is a diagnosis of exclusion after investigation has ruled out organic disease such as peptic ulcer, gastroesophageal reflux and, less frequently, gastric cancer.³ For this, upper gastrointestinal endoscopy is the investigation of choice. Over half of patients with dyspepsia will have a normal endoscopy and they are said to have nonulcer dyspepsia.

There is indeed a lot of controversy about whether eradication of H. pylori infection in patients with functional dyspepsia leads to sustained improvement in symptoms. Although the study reviewed in the Clinical Update suggests that there is no benefit from eradication of H. pylori in patients with functional dyspepsia, a recent meta-analysis of 12 randomized controlled trials shows a modest risk reduction in dyspeptic symptoms resulting from eradication of H. pylori (risk reduction 9%, 95% confidence interval 4%–14%).⁴

Perhaps the clinically more relevant question is what is the value of a noninvasive H. pylori test-and-treat strategy in patients with uninvestigated dyspepsia in the primary care setting. A recently completed randomized controlled trial of 294 patients showed that 50% of patients randomized to active treatment for eradication of H. pylori had improvement in symptoms at 12 months compared with 36% in the group of patients randomized to a placebo.⁵ Patients in this study did not undergo endoscopy, so it is not known how much of the improvement is attributable to patients with an ulcer diathesis.

Infection with H. pylori is also a risk factor for the development of gastric cancer. We might reasonably expect that eradication of H. pylori may provide the additional benefit of preventing some cases of gastric cancer, although there are not yet any data from randomized controlled trials to support this view.

In summary, we believe there are data to support a noninvasive H. pylori test-and-treat strategy in patients with univestigated dyspepsia who are less than 50 years old, who do not have alarm symptoms, who are not taking nonsteroidal anti-inflammatory drugs and who do not have symptoms suggesting reflux disease. This was clearly outlined in our recently published CMAJ supplement.⁶

References

1. Talley NJ, Vakil N, Ballard ED II, Fennerty MB. Absence of benefit of eradicating Helicobacter pylori in patients with nonulcer dyspepsia. N Engl J Med 1999;341(15):1106-11.[Abstract/Free Full Text]
2. Hoey J. The dyspepsia dilemma. CMAJ 2000; 163(2):203.[Free Full Text]
3. Talley NJ, Stranghellini V, Heading RC, Kick KL, Malagelada JR, Tytgat GNJ. Functional gastroduodenal disorders. Gut 1999;45(2 Suppl):137-42.
4. Moayyedi P, Soo S, Deeks J, Forman D, Mason J, Innes M, et al, on behalf of the Dyspepsia Group. Systematic review and economic evaluation of Helicobacter pylori eradication treatment for non-ulcer dyspepsia. BMJ 2000;321:659-64.[Abstract/Free Full Text]
5. Chiba N, Veldhuyzen van Zanten SJO, Sinclair P, Ferguson RA, Escobedo SR. Beneficial effect of H. pylori eradication therapy on long term symptom relief in primary care patients with uninvestigated dyspepsia. The CADET Hp Study Group [abstract]. Gastroenterology 2000;118(4 Suppl):A2350.
6. Veldhuyzen van Zanten SJO, Flook N, Chiba N, Armstrong D, Barkun A, Bradette M, et al, for the Canadian Dyspepsia Working Group. An evidence-based approach to the management of uninvestigated dyspepsia in the era of Helicobacter pylori. CMAJ 2000;162(12 Suppl):S1-S23.

This Article Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Zanten, S. Articles by Chiba, N. Search for Related Content PubMed PubMed Citation Articles by Zanten, S. Articles by Chiba, N. Related Collections Gastroesophageal reflux Other evidence-based medicine Helicobacter pylori

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