Helicobacter pylori and functional dyspepsia: a real causal link?

Prevalence of Helicobacter pylori infection and the effect of its eradication on symptoms of functional dyspepsia in Kashmir, India

BACKGROUND AND AIM

Epidemiology of Helicobacter pylori infection has regional variation. Effect of eradication of H. pylori on symptoms of functional dyspepsia is uncertain, and the data in Asian scenario are scanty. The study aimed to see H. pylori positivity rate in patients of functional dyspepsia and the effect of its eradication on symptoms.

METHODS

Randomized, double-blind, placebo-controlled study was the study design used. Patients of functional dyspepsia defined as per Rome 2 criteria were tested for H. pylori infection by rapid urease test and gastric biopsy. H. pylori-positive patients were randomly allocated to triple therapy (20 mg of omeprazole, 500 mg of clarithromycin, and 1000 mg of amoxicillin orally two times daily) and omeperazole plus identical placebo for 2 weeks. Symptoms were assessed with the weekly Likert scale.

RESULTS

H. pylori positivity rate in functional dyspepsia was 1160/2000 (58%). At 6 weeks, the eradication rate for H. pylori in triple therapy and placebo group was (181/259 [69.8%] and 13/260 [5.0%], P = 0.001), respectively. On intention-to-treat analysis, the symptom resolution at 1 month was (157/259 [60.7%] and 136/260 [52.3%], P = 0.38), respectively. At 12 months, H. pylori eradication and healing of gastritis in triple therapy and placebo group were (116/174 [66.7%] and 12/180 [6.7%], P = 0.001) and (132/174 [75.9%] and 11/180 [6.1%], P = 0.001), respectively. On intension to treat, the resolution of symptoms in triple therapy and placebo group was (95/217 [43.7%] and 72/195 [36.9%], P = 0.13).

CONCLUSION

There is high H. pylori positivity rate in patients of functional dyspepsia. The eradication of H. pylori does not resolve the symptoms despite healing of gastritis.

Serum pepsinogen can predict response to H2-receptor antagonist in patients with functional dyspepsia

BACKGROUND

Therapy for the relief of symptoms of functional dyspepsia is unpredictable.

AIM

To identify which patients may benefit from antisecretory therapy.

METHODS

Twenty-seven patients with functional dyspepsia were selected to receive H2-receptor antagonist (H2RA) treatment for 4 weeks. Serum pepsinogen A, pepsinogen C and gastrin were measured, and Helicobacter pylori status was determined. Symptoms were assessed at baseline and after H2RA treatment.

RESULTS

Fourteen patients were identified as H2RA responders and the remaining patients were non-responders. No differences were found between responders and non-responders with regard to serum pepsinogen A, pepsinogen C, gastrin and H. pylori status. However, the pepsinogen A/C ratio was significantly higher in responders than in non-responders. Ten of the 13 functional dyspepsia patients (77%) with a high value of the pepsinogen A/C ratio (> or = 4.5) achieved symptom resolution by H2RA, compared with only one of the eight patients (13%) with a low value of the pepsinogen A/C ratio (< or = 3.0).

CONCLUSIONS

The serum pepsinogen A/C ratio seems to identify those functional dyspepsia patients for whom acid control provides benefit. This ratio may be a practical tool for the management of functional dyspepsia patients.

Helicobacter pylori and dyspepsia: a population-based study of the organism and host

OBJECTIVE

The role of Helicobacter pylori (HP) infection in dyspepsia in the absence of peptic ulcer remains controversial. Specific attributes of the organism or the host response may be important. We aimed to determine whether HP infection overall, CagA status, serum gastrin, or serum pepsinogen levels are associated with dyspepsia in the community.

METHODS

A self-report bowel disease questionnaire was mailed to a random sample of Olmsted County, Minnesota residents, aged 20-50 yr. All respondents who reported symptoms of dyspepsia or irritable bowel syndrome (cases) and all respondents without significant GI symptoms (controls) were invited to participate (n = 260). They were each assessed by a physician and their medical records reviewed. Serum was obtained to measure HP and CagA antibodies, pepsinogen I and II levels, and basal serum gastrin using validated assays.

RESULTS

Of the 148 (57%) subjects who agreed to participate, 36 had dyspepsia (17 had ulcer-like dyspepsia), 35 had irritable bowel syndrome (IBS) without dyspepsia, and 77 were asymptomatic. The proportion who were seropositive for HP were 17% in dyspepsia (24% in ulcer-like dyspepsia), 20% in IBS, and 12% in asymptomatic controls. HP was not associated with dyspepsia, ulcer-like dyspepsia, or IBS after adjusting for age. Pepsinogen levels and serum gastrin were not associated with any of the conditions studied. However, CagA antibody positivity was associated with IBS (p < 0.05), and a borderline statistically significant association with dyspepsia was detected (p = 0.08).

CONCLUSIONS

In this community, HP infection overall does not seem to explain dyspepsia, although the role of CagA-positive HP strains deserve further study.

Nonulcer dyspepsia

Nonulcer dyspepsia, characterized by unexplained persistent or recurrent epigastric pain or discomfort, affects approximately 20% of the general population. Symptom-based diagnostic criteria, first developed by an international group of experts, have been refined in the past year in an effort to increase the applicability of the criteria (Rome II criteria). New disease-specific questionnaires that were developed to measure quality of life in patients with dyspepsia are now available and are expected to be widely used in clinical research studies. Studies on the pathophysiology and management of nonulcer dyspepsia were other major topics in the past year, including three large, well-conducted randomized controlled trials of Helicobacter pylori eradication and symptom resolution.

Lack of effect of treating Helicobacter pylori infection in patients with nonulcer dyspepsia. Omeprazole plus Clarithromycin and Amoxicillin Effect One Year after Treatment (OCAY) Study Group

BACKGROUND

It is uncertain whether treatment of Helicobacter pylori infection relieves symptoms in patients with nonulcer, or functional, dyspepsia.

METHODS

We conducted a double-blind, multicenter trial of patients with H. pylori infection and dyspeptic symptoms (moderate-to-very-severe pain and discomfort centered in the upper abdomen). Patients were excluded if they had a history of peptic ulcer disease or gastroesophageal reflux disease and had abnormal findings on upper endoscopy. Patients were randomly assigned to seven days of treatment with 20 mg of omeprazole twice daily, 1000 mg of amoxicillin twice daily, and 500 mg of clarithromycin twice daily or with omeprazole alone and then followed up for one year. Treatment success was defined as the absence of dyspeptic symptoms or the presence of minimal symptoms on any of the 7 days preceding the 12-month visit.

RESULTS

Twenty of the 348 patients were excluded after randomization because they were not infected with H. pylori, were not treated, or had no data available. For the remaining 328 patients (164 in each group), treatment was successful for 27.4 percent of those assigned to receive omeprazole and antibiotics and 20.7 percent of those assigned to receive omeprazole alone (P=0.17; absolute difference between groups, 6.7 percent; 95 percent confidence interval, -2.6 to 16.0). After 12 months, gastritis had healed in 75.0 percent of the patients in the group given omeprazole and antibiotics and in 3.0 percent of the patients in the omeprazole group (P<0.001); the respective rates of H. pylori eradication were 79 percent and 2 percent. In the group given omeprazole and antibiotics, the rate of treatment success among patients with persistent H. pylori infection was similar to that among patients in whom the infection was eradicated (26 percent vs. 31 percent). There were no significant differences between the groups in the quality of life after treatment.

CONCLUSIONS

In patients with nonulcer dyspepsia, the eradication of H. pylori infection is not likely to relieve symptoms.