Helicobacter pylori test-and-treat strategy in the management of dyspepsia in primary care: an overview

Helicobacter Pylori "Test-and-Treat" Strategy for Management of Dyspepsia: A Comprehensive Review

OBJECTIVES:

Deciding on whether the Helicobacter pylori test-and-treat strategy is an appropriate diagnostic–therapeutic approach for patients with dyspepsia invites a series of questions. The aim present article addresses the test-and-treat strategy and attempts to provide practical conclusions for the clinician who diagnoses and treats patients with dyspepsia.

METHODS:

Bibliographical searches were performed in MEDLINE using the keywords Helicobacter pylori, test-and-treat, and dyspepsia. We focused mainly on data from randomized controlled trials (RCTs), systematic reviews, meta-analyses, cost-effectiveness analyses, and decision analyses.

RESULTS:

Several prospective studies and decision analyses support the use of the test-and-treat strategy, although we must be cautious when extrapolating the results from one geographical area to another. Many factors determine whether this strategy is appropriate in each particular area. The test-and-treat strategy will cure most cases of underlying peptic ulcer disease, prevent most potential cases of gastroduodenal disease, and yield symptomatic benefit in a minority of patients with functional dyspepsia. Future studies should be able to stratify dyspeptic patients according to their likelihood of improving after treatment of infection by H. pylori.

CONCLUSIONS:

The test-and-treat strategy will cure most cases of underlying peptic ulcer disease and prevent most potential cases of gastroduodenal disease. In addition, a minority of infected patients with functional dyspepsia will gain symptomatic benefit. Several prospective studies and decision analyses support the use of the test-and-treat strategy. The test-and-treat strategy is being reinforced by the accumulating data that support the increasingly accepted idea that “the only good H. pylori is a dead H. pylori”.

Helicobacter pylori "test-and-treat" strategy is not suitable for the management of patients with uninvestigated dyspepsia in Shanghai

OBJECTIVE

The safety of Helicobacter pylori "test-and-treat" and "test-and-endoscopy" strategies for the management of young patients with uninvestigated dyspepsia has not been evaluated in Shanghai.

MATERIAL AND METHODS

A total of 14,101 consecutive patients with dyspepsia receiving endoscopy in our hospital from October 2002 to December 2003 were retrospectively studied. The detection rates of esophageal or gastroduodenal malignancies and alarm symptoms were investigated, and H. pylori status was assessed.

RESULTS

A total of 202 (1.4%) gastrointestinal (GI) malignancies were found, including 162 cases (1.15%) of gastric cancer, 4 of gastric lymphoma, 35 (0.25%) of esophageal cancer and 1 case of duodenal cancer. Among those patients with GI malignancies, 99 (49.0%) were infected with H. pylori and 108 (53.5%) presented with alarm symptoms. Eighteen patients (0.46%, 18/3952) under 45 years of age were diagnosed as having gastric cancer. Of these patients, 5 (27.8%) presented with alarm symptoms and 13 (72.2%) were infected with H. pylori. If the H. pylori "test-and-treat" strategy were used in dyspeptic patients under the age of 45 years without alarm symptoms in the Shanghai region, then 13 cases (72.2%) of gastric cancer would be missed. If the H. pylori "test-and-endoscopy" strategy were applied, then 3 cases (16.7%) of gastric cancer would be missed.

CONCLUSIONS

H. pylori "test-and-treat" and "test-and-endoscopy" strategies are both not suitable for the management of patients with uninvestigated dyspepsia in Shanghai. For most Shanghai dyspeptic patients, prompt endoscopy should be recommended as the first-line initial management option.