Review article: the initial management of uninvestigated dyspepsia in younger patients-the value of symptom-guided strategies should be reconsidered

Proton pump inhibitors: effective first-line treatment for management of dyspepsia

The aim of this study was to evaluate the reasons for trial exclusion among dyspeptic patients and estimate the proportion that may have benefited from proton pump inhibitor (PPI) therapy. Stringent inclusion criteria for enrollment in two multicenter functional dyspepsia trials included dyspepsia (predominant persistent/recurrent upper abdominal discomfort [UAD] during the prior 3 months) of at least moderate intensity during > or =30% of days during the prior 2 to 3 weeks. Exclusion criteria were mild/infrequent UAD; heartburn and UAD of equal frequency; predominant heartburn with UAD; endoscopic evidence of erosive esophagitis or Barrett's or gastric and/or duodenal erosions (>5) or ulcers; irritable bowel syndrome (IBS); other gastrointestinal diagnoses; or other "non-categorized" disorders. Of 2,588 screened patients, 1,667 were excluded. Excluded patients by category had mild/infrequent UAD (12.5%, n=324), heartburn and UAD of equal frequency (1.1%, n=29), predominant heartburn with UAD (11.6%, n=300), endoscopic evidence of erosive esophagitis or Barrett's (6.2%, n=160), gastric and/or duodenal erosions (1.4%, n=36), gastric and/or duodenal ulcers (2.0%, n=53), IBS (7%, n=180), "other" gastrointestinal diagnoses (2.8%, n=73), or other "non-categorized" disorders (19.8%, n=512). Fifty-four percent of patients (902/1,667) had symptoms/diagnoses that would be expected to improve with PPI therapy. Individuals with IBS, "other," or "non-categorized" disorders were considered to have symptoms unlikely to respond to PPI treatment. Empiric PPI treatment would be expected to provide symptom relief to the majority of dyspepsia sufferer who present in clinical practice. PPIs represent the best currently available therapy for acid-related disorders and should be considered the first-line management approach in patients with uninvestigated dyspepsia.

Long-term follow-up of empirical treatment or prompt endoscopy for patients with persistent dyspeptic symptoms?

BACKGROUND

There are concerns about the safety and possible high costs of ongoing proton pump inhibitor therapy of empirical management strategies for patients with persistent dyspeptic symptoms.

AIM

To compare the long-term results of two treatment strategies: empirical treatment followed by the Helicobacter pylori test and treat strategy (treat and test group) and prompt upper gastrointestinal endoscopy followed by directed medical treatment (endoscopy group).

METHODS

In this study we describe the long-term follow-up data from a previously published randomized clinical trial. At least 6 years after randomization all participating general practitioners and patients were asked to give information about medication use, diagnostic testing, symptoms and quality of life by questionnaire.

RESULTS

Information about a total of 77 out of the 80 patients initially included (96%) was retrieved. Overall, 16 patients from the treat and test group (41%) underwent 18 diagnostic investigations. The 34 patients (100%) from the endoscopy group underwent 38 investigations (P < 0.01). The number of patients of the treat and test group and endoscopy group using acid inhibition therapy was 15 (38%) and 19 (56%), respectively (P = 0.14). There were also no differences in symptom prevalence and quality of life between the groups.

CONCLUSIONS

Treat and test management for patients with dyspeptic symptoms is safe and does not lead to additional diagnostic testing or use of medication when compared to prompt endoscopy.

Predominant symptom behavior in patients with persistent dyspepsia during treatment

BACKGROUND

Grouping of patients based on a predominant dyspeptic symptom is frequently employed in management strategies for dyspepsia. Such subdivision, however, suggests that dyspeptic symptom patterns are constant over time.

OBJECTIVE

To investigate the behavior of symptoms over time and to study the effects of diagnostic procedures and treatment on the pattern and severity of dyspeptic symptoms.

METHODS

Patients with persistent dyspeptic symptoms completed a validated questionnaire at regular time intervals as part of a clinical trial in primary care. Based on predominant symptoms, patients were classified into ulcer-like dyspepsia, reflux-like dyspepsia, dysmotility-like dyspepsia, and unspecific dyspepsia according to the Rome II criteria.

RESULTS

Questionnaires were returned at baseline, 1, 3, and 6 months by 185, 172, 169, and 170 patients, respectively. At baseline, 35% of patients reported predominantly reflux-like dyspepsia, 34% had ulcer-like dyspepsia, 16% had dysmotility-like dyspepsia, and in 15% symptoms were not specific. During the 6-month follow-up period, only 35% of patients kept the same predominant symptom. Symptom (in)stability was not dependent on diagnostic procedures or on therapy with proton pump inhibitors, H2-receptor antagonists, prokinetics, or antacids.

CONCLUSION

In the majority of dyspeptic patients, symptoms change continuously as time goes on. Symptom instability is not influenced by diagnostic procedures or therapy. Thus, there is little sense in symptom-based management of dyspepsia in primary care.

Does the 'test-and-treat' strategy work in primary health care for management of uninvestigated dyspepsia? A prospective two-year follow-up study of 1552 patients

BACKGROUND

Although the 'test-and-treat' strategy is suggested as first-line therapy for uninvestigated dyspepsia, no large-scale studies in a real-life setting are available.

METHODS

1552 dyspeptic patients aged between 25 and 60 with no alarm symptoms were recruited to the study. After screening with a 13C-urea breath test, they were randomized into three treatment arms: Helicobacter pylori-positive either to eradication therapy with OAM (omeprazole, amoxycillin and metronidazole) (Hp+/erad) or omeprazole 20 mg daily (Hp+/ome) for 10 days, whereas H. pylori-negative patients (Hp-/ome) were treated with 20 mg omeprazole for 10 days. Gastrointestinal symptoms were registered at baseline at 1 and 2 years on the Gastrointestinal Symptom Rating Scale (GSRS) and quality of life with the Psychological General Well-Being index (PGWB). Additional visits, referrals for and number of endoscopies and their findings were registered during the 2 years' follow-up.

RESULTS

Of the 1552 patients, 583 were H. pylori-positive (37.6%), and 288 of these were randomized for omeprazole and 295 to OAM. The Hp-/ome group had fewer general practitioner (GP) contacts (P<0.0001) than the H. pylori-positive groups. Eradication therapy significantly improved general well-being and reduced upper gastrointestinal symptoms: abdominal pain (P=0.0001), heartburn (P=0.0061), acid regurgitation (P=0.003), hunger pain (P=0.009), especially in Hp+/erad. Peptic ulcer was found in 6.2%, 1.0%, 0.2% in Hp+/ome, Hp-+/erad and Hp-/ome, respectively (P=0.0007). Only 3 patients (1.0%) developed peptic ulcers in Hp-+/erad, all eradication failures.

CONCLUSIONS

In uninvestigated dyspepsia, a negative test result for H. pylori reduces the number of GP contacts and endoscopy referrals compared to H. pylori-positive regardless of eradication therapy. Applied in real life, the test-and-treat strategy failed to reduce the number of endoscopies, but significantly reduced peptic ulcer disease and improved dyspeptic symptoms and quality of life.

Low yield of endoscopy in patients with persistent dyspepsia taking proton pump inhibitors

BACKGROUND

Options for the evaluation of dyspepsia include a Helicobacter pylori test-and-treat strategy, empiric acid suppression, and initial endoscopy. The aim of this study was to determine the yield of endoscopy in patients in whom empiric therapy is unsuccessful compared with patients who received no empiric therapy and to identify factors associated with endoscopic findings.

METHODS

A total of 100 patients with dyspepsia referred for endoscopy completed a questionnaire that included a query concerning response to therapy. EGD findings were compared in patients taking an H2-receptor antagonist, patients taking a proton pump inhibitor, and those not receiving empiric therapy.

RESULTS

There were fewer endoscopic findings in patients being treated with a proton pump inhibitor compared with those taking an H2-receptor antagonist or those not receiving therapy (p < 0.01). Fewer proton pump inhibitor recipients had esophagitis or ulcer compared with patients in the no therapy group. Lack of symptom relief (<20%) by acid suppression was highly associated with a normal endoscopy (17/17).

CONCLUSIONS

Patients with persistent dyspepsia being treated with a proton pump inhibitor have fewer endoscopic abnormalities compared with patients with dyspepsia taking an H2-receptor antagonist and those receiving no therapy. For patients with partial symptom relief, proton pump inhibitor therapy may mask endoscopic findings, particularly esophagitis. Interruption of proton pump inhibitors before endoscopy may increase diagnostic yield. Endoscopy is unlikely to yield a positive finding in patients who experience no symptom relief while taking a proton pump inhibitor or H2-receptor antagonist.

Dyspepsia and Helicobacter pylori infection: a prospective multicentre observational study

OBJECTIVES

Dyspepsia still represents an unsolved clinical enigma.

AIM

The aims of this study were to determine whether symptoms and Helicobacter pylori infection are predictors of organic disease in uninvestigated dyspepsia, and if H. pylori eradication improves symptoms in functional dyspepsia.

METHODS

An observational study was performed on outpatients with uninvestigated dyspepsia. Symptoms were scored and H. pylori status determined. Patients with functional dyspepsia and H. pylori infection were randomly given either a standard eradicating treatment or a 1-month course of empirical treatment. The latter was also given to functional dyspeptic patients without infection. Symptoms were re-assessed in functional dyspeptic patients at 2- and 6-month follow-up visits. Patients receiving eradicating treatment were re-tested for H. pylori at the 2 month visit.

RESULTS

A total of 860 patients were studied and 605 (70.3%) were affected by functional dyspepsia. H. pylori infection was diagnosed in 71.8% of patients with organic dyspepsia and in 65.0% with functional dyspepsia (p=0.053). Male sex, anaemia, smoking habit, age over 45 years, and severe epigastric pain, but not H. pylori infection, were independent predictors of organic disease. Symptoms significantly improved in most functional dyspeptic patients regardless of their H. pylori status and type of treatment.

CONCLUSION

H. pylori infection is not a strong predictor of organic disease in uninvestigated dyspepsia. H. pylori eradication is not essential to improve symptoms in functional dyspepsia.

Helicobacter pylori test-and-treat intervention compared to usual care in primary care patients with suspected peptic ulcer disease in the United States

OBJECTIVES

[corrected] The Helicobacter pylori (H. pylori) "test-and-treat" strategy in uninvestigated dyspepsia is an effective alternative to prompt endoscopy. Our aims were to determine whether the combination of an educational session and availability of office-based H. pylori testing (test-and-treat intervention [TTI]) increases use of the test-and-treat strategy by primary care practitioners and whether it improves patient outcomes.

METHODS

We conducted a 1-yr prospective trial of patients with suspected peptic ulcer disease in six primary care centers, three with TTI and three designated as usual care controls (UCC).

RESULTS

H. pylori testing was performed in 81% of 54 TTI patients and in 49% of 39 UCC patients (p = 0.004). TTI and UCC patients had similar gastroenterology referral rates (24% vs 33%, p = 0.33), endoscopy or upper GI radiography rates (30% vs 31%, p = 0.91), and primary care visits per patient (3.1 +/- 2.8 vs 3.1 +/- 2.6, p = 0.92). TTI patients were less likely than UCC patients to receive repeated antisecretory medication prescriptions (35% vs 66%, p = 0.003). Symptomatic status at 1 yr and satisfaction with medical care did not differ between groups. Median (and interquartile range) annualized disease-related expenditures per patient were $454 ($162-932) for TTI and $576 ($327-1,435) for UCC patients (p = 0.17).

CONCLUSIONS

The combination of an educational session and availability of office-based H. pylori testing may increase acceptance of the test-and-treat strategy by primary care providers. It remains to be determined whether increased use of the test-and-treat strategy yields significant improvements in clinical and economic outcomes compared to usual care.

Helicobacter pylori antimicrobial resistance in the United Kingdom: the effect of age, sex and socio-economic status

BACKGROUND

Helicobacter pylori antimicrobial resistance is the most common reason for eradication failure. Small studies have shown metronidazole resistance to be more prevalent in certain population groups.

AIM

To determine the resistance rates in a large cohort of patients from a single centre in the UK, and to evaluate resistance patterns over time, according to age, sex and socio-economic status.

METHODS

Consecutive patients with H. pylori-positive antral gastric biopsy samples were studied from 1994 to 1999. Susceptibility testing was performed to metronidazole, tetracycline, macrolide and amoxicillin by the modified disk diffusion

METHOD

The Jarman under-privileged area score was used as a measure of socio-economic status.

RESULTS

A total of 1064 patients were studied. Overall metronidazole resistance was 40.3%, decreasing with age (P < 0.0001, odds ratio for patients over 60 years 0.63, 95% CI: 0.48-0.80). Women were more likely to have metronidazole resistant strains (P=0.003, odds ratio 1.5, 95% CI: 1.15-1.91), but there was no association with Jarman score. Macrolide resistance was associated with metronidazole resistance (P=0.03, odds ratio 2.14, 95% CI: 1.07-4.28).

CONCLUSIONS

Metronidazole resistance in H. pylori is highly prevalent and more common in women and the young, but does not appear to be related to socio-economic status.

Outcomes of initial noninvasive Helicobacter pylori testing in U.S. primary care patients with uninvestigated dyspepsia

OBJECTIVE

Recent European trials demonstrate that testing and treatment for Helicobacter pylori (H. pylori) is an effective alternative to prompt endoscopy in uninvestigated dyspepsia. The eventual endoscopy rate after H. pylori testing, which is a key determinant of cost-effectiveness, is unknown in the United States. Our aim was to determine the endoscopy rate after H. pylori testing in primary care practice in the United States and to compare outcomes among seropositive and seronegative patients.

METHODS

We performed a retrospective review with mean 13 month follow-up of primary care patients with dyspeptic symptoms tested with office-based H. pylori serology.

RESULTS

Of 268 adults tested (37+/-11 yr, 58% women), 57 (21%) were seropositive and 49/57 (86%) received eradication therapy. Endoscopy or contrast radiography was performed on 19% of seropositive and 19% of seronegative patients (p = 0.97). Annualized median disease-related expenditures were similar among seropositive and seronegative patients ($228 [$93-$654] vs $366 [$107-$1268], p = 0.19). However, aggregate expenditures were substantially lower than the cost of endoscopy alone ($816 [$296-$970]). On follow-up, seropositive and seronegative patients had similar numbers of primary care visits (2.9+/-3.2 vs 3.5+/-3.6, p = 0.23), prolonged antisecretory medication use (25 vs 33%, p = 0.27), and specialist referrals (23 vs 24%, p = 0.83).

CONCLUSION

In a United States center, 81% of primary care patients tested for H. pylori did not undergo endoscopy, and patients incurred significantly lower median expenditures after noninvasive H. pylori testing than the cost of endoscopy alone. Seropositive and seronegative patients experienced comparable outcomes after H. pylori testing.

Review article: the continuing dilemma of dyspepsia

This article reviews the issue of dyspepsia from various perspectives. Firstly, the current relevance of dyspepsia as a major health problem on account of its high prevalence and substantial morbidity. Secondly, the various definitions of dyspepsia and the epidemiological and pathophysiological evidence that support them, as well as subclassifications. Thirdly, the issue of dyspepsia as a clinical challenge, in the absence of well established and uniform management guidelines. Thus, the title "The continuing dilemma of dyspepsia" describes realistically the current status of this important condition.