Helicobacter pylori eradication does not cause reflux oesophagitis in functional dyspeptic patients: a randomized, investigator-blinded, placebo-controlled trial

Eradication of Helicobacter Pylori Infections and GERD: A systematic review and meta-analysis

BACKGROUND/AIMS

This study evaluates the association between the eradication of Helicobacter pylori (H. pylori) and gastroesophageal reflux disease (GERD).

MATERIALS AND METHODS

Relevant studies were identified by conducting literature search in PubMed, Cochrane, Embase, CNKI, VANFUN, and VIP databases. The prevalence rates of gastroesophageal reflux, heartburn, epigastric pain, and nausea were extracted from the identified research articles and were used in meta-analysis of relative risks (RR) to achieve an overall effect size of the relationship between H. pylori eradication and GERD.

RESULTS

A total of 19 randomized controlled trials were included in this meta-analysis. The prevalence of gastroesophageal reflux was significantly higher in patients with H. pylori eradication compared with patients without it (RR: 1.54, 95% CI: 1.06-2.24; p=0.02). A subgroup analysis did not identify any significant difference in GERD prevalence in studies conducted outside China (RR: 1.62, 95% CI: 0.98-2.68) or in China (RR: 1.30, 95% CI: 0.76-2.22). There were no significant differences in heartburn (RR: 1.03, 95% CI: 0.88-1.20), epigastric pain (RR: 0.98, 95% CI: 0.13-7.56), or nausea (RR: 0.44, 95% CI: 0.07-2.72) risk between patients with and without H. pylori eradication.

CONCLUSION

Eradication of H. pylori infection is found to be associated with GERD, although regional differences may exist in the prevalence. Well-designed studies especially those with stratification of patients' basic conditions are needed to seek refined evidence of the association between H. pylori eradication and the GERD.

Endoscopic Reflux Esophagitis and Reflux-Related Symptoms after Helicobacter pylori Eradication Therapy: Meta-Analysis

Backgrounds: The etiology of gastroesophageal reflux disease (GERD) including reflux esophagitis and non-erosive reflux disease is multifactorial and a recent meta-analysis showed no association between the development of GERD and Helicobacter pylori eradication in both Western and East-Asian populations. However, the problem remains that various inclusion criteria are used in these studies, which hinders meta-analysis. With a focus on reflux esophagitis with endoscopic mucosal injury, we meta-analysed to evaluate the association between eradication and reflux esophagitis and symptoms using a clearly defined set of inclusion criteria. Methods: We conducted a meta-analysis of studies published up until March 2020, which compared the incidence of reflux esophagitis and symptoms between patients undergoing H. pylori eradication therapy in a randomized placebo-controlled trial (Category A); between patients with successful and failed eradication (Category B); and between patients with successful vs. failed eradication, receipt of placebo, or no-treatment H. pylori-positives (Category C). Results: A total of 27 studies were included. Significant statistical effects were found for development of endoscopic reflux esophagitis [relative risk (RR): 1.46, 95% confidence interval (CI): 1.16-1.84, p = 0.01] or de novo reflux esophagitis (RR: 1.42, 95% CI: 1.01-2.00, p = 0.03) in the case group that received eradication in all studies, especially in Western populations. There was no significant difference in the incidence of symptoms after eradication between patient and control groups, regardless of category, location of population, or baseline disease. Conclusions: Eradication therapy for H pylori increases the risk of reflux esophagitis, irrespective of past history of esophagitis. In contrast, no effect was seen on reflux-related symptoms.

Potential roles of Helicobacter pylori treatment, body mass index and waist circumference in the causation of erosive esophagitis: a randomized clinical trial (HEROES-GERD)

BACKGROUND

In recent decades, the prevalence of gastroesophageal reflux disease (GERD) and obesity has been increasing while Helicobacter pylori infection has been decreasing.

OBJECTIVE

To evaluate if H. pylori treatment, excess body weight and other anthropometric measurements are associated with incident erosive esophagitis, as a secondary objective of a trial which tested the efficacy of treatment of H. pylori on the symptoms of functional dyspepsia.

SUBJECTS/METHODS

Upper gastrointestinal endoscopy and anthropometric assessments were performed, at baseline and after 12 months, in H. pylori positive patients with functional dyspepsia who had no baseline reflux symptoms or esophagitis. Patients were randomly assigned to receive omeprazole, amoxicillin, and clarithromycin (antibiotic group; n = 201) or omeprazole plus placebo (control group; n = 203). The primary outcome was the incidence of esophagitis 12 months after randomization, according to treatment groups, and the association of BMI and other anthropometric measurements.

RESULTS

Four hundred and four patients were included (mean age, 46.1 years; 78.7% women). The 12-month follow-up endoscopic esophagitis rates for the antibiotic and control groups were 10.9% (22/201) and 9.4% (19/203), respectively (p = 0.60). The number needed to harm was 67. Baseline anthropometric measurements were performed in 94% (380/404) of patients. The 12-month follow-up esophagitis rates for overweight and normal body weight patients were 13.6% (29/213) and 6.0% (10/167), respectively (p = 0.015); rates for patients with and without increased baseline waist circumference were 15.4% (24/156) and 6.7% (15/224), respectively (p = 0.006). Following logistic regression, only the combination of increased baseline body mass index and waist, but not H. pylori treatment, was independently associated with new-onset esophagitis (OR 2.88; 95% CI: 1.28-6.45).

CONCLUSIONS

Excess body weight and concomitant increased waist circumference, but not H. pylori treatment, predicts new-onset esophagitis.

Interactions between Helicobacter pylori and gastroesophageal reflux disease

Interactions between Helicobacter Pylori (HP) and gastroesophageal reflux disease (GERD) are a complex issue. Several pathophysiological factors influence the development and the course of GERD, HP infection might be only one of these. Many studies emphasize the co-existence of these diseases. HP infection could contribute to GERD through both a protective and an aggressive role. Gastric acid secretion is a key factor in the pathophysiology of reflux esophagitis. Depending on the type of gastritis related to HP, acid secretion may either increase or decrease. Gastritis in corpus leads to hypoacidity, while antrum gastritis leads to hyperacidity. In cases of antral gastritis and duodenal ulcers which have hyperacidity, the expectation is an improvement in pre-existing reflux esophagitis after eradication of HP. In adults, HP infection is often associated with atrophic gastritis in the corpus. Atrophic gastritis may protect against GERD. Pangastritis which leads to gastric atrophy is commonly associated with CagA strains of HP and it causes more severe gastric inflammation. In case of HP-positive corpus gastritis in the stomach, pangastritis, and atrophic gastritis, reflux esophagitis occurs frequently after eradication of HP. Nonetheless, as a predisposing disease of gastric cancer, HP should be treated. In conclusion, as the determinative factors affecting GERD involving in HP, detailed data on the location of gastric inflammation and CagA positivity should be obtained by the studies at future.

The effect of Helicobacter pylori eradication therapy on the development of gastroesophageal reflux disease

BACKGROUND

It is uncertain whether the Helicobacter pylori eradication therapy makes a role in the progression of gastroesophageal reflux disease (GERD).

METHODS

A meta-analysis was undertaken to investigate the effect of H pylori eradication therapy on the development of GERD.

RESULTS

Overall, 16 cohort studies were included. The authors demonstrated that H pylori eradication had no significant effect on the occurrence of GERD in these cohort studies (odds ratio = 0.87, 95% confidence interval = 0.66-1.14, I = 32.4%, P = 0.103).

CONCLUSIONS

In general, H pylori eradication has no significant effect on the development of GERD in the long term. However, eradication therapy should be taken once there is H pylori infection, because H pylori infection is acknowledged to be a major cause of acute and chronic gastritis and peptic ulcer diseases and has been established as a definite etiologic factor for gastric cancer.

Efficacy of Bacillus licheniformis combined with PPI triple therapy in eradication of Helicobacter pylori

AIM: To observe the effect of Bacillus licheniformis in combination with PPI triple therapy on the cure rate of Helicobacter pylori (H. pylori) and improvement of clinical symptoms.

METHODS: One hundred and twenty patients who were diagnosed with erosive gastritis or peptic ulcer with H. pylori infection by gastroscopy, rapid urease method and pathological staining at our hospital were randomly divided into three groups: triple therapy group (n = 40, treated with lansoprazole 30 mg bid + amoxicillin 1.0 bid + levofloxacin 0.5 QD), quadruple therapy group (n = 40, treated with bismuth pectin 0.2 bid + lansoprazole 30 mg bid + amoxicillin 1.0 bid + levofloxacin 0.5 QD), and combination treatment group (n = 40, treated with Bacillus licheniformis 0.5 bid + lansoprazole 30 mg bid + amoxicillin 1.0 bid + levofloxacin 0.5 QD). The triple therapy and quadruple therapy groups were treated for 7 d, and the treatment group continued taking Bacillus licheniformis capsules for an additional 14 d. Patients with gastric ulcer continued taking LAN 30 mg, once daily for 5 wk, and those with duodenal ulcer continued taking lansoprazole 30 mg, once daily for 3 wk.

RESULTS: H. pylori eradication rate was significantly higher in the Bacillus licheniformis group than in the triple therapy group (85% vs 70%, P < 0.05), but showed no significant difference between the Bacillus licheniformis group and quadruple therapy group (85% vs 82.5%, P > 0.05). The clinical symptoms were improved more significantly in the Bacillus licheniformis group than in the triple therapy group (97.5% vs 75.0%, P < 0.05); however, there was no significant difference in the percentage of patients showing symptom improvement between the Bacillus licheniformis group and quadruple therapy group (97.5% vs 95.0%, P > 0.05). The incidence of adverse reactions was significantly lower in the Bacillus licheniformis group than in the triple therapy group (2.5% vs 12.5%, P < 0.05) and quadruple therapy group 2 (2.5% vs 25.0%, P < 0.05).

CONCLUSION: Bacillus licheniformis can improve the eradication rate of H. pylori, alleviate clinical symptoms and reduce the incidence of adverse reactions in patients undergoing triple therapy.

Effect of Helicobacter pylori Eradication on the Development of Reflux Esophagitis and Gastroesophageal Reflux Symptoms: A Nationwide Multi-Center Prospective Study

Background/Aims

A two-year, prospective, nationwide multicenter study was undertaken to evaluate the effect of Helicobacter pylori eradication on the development of reflux esophagitis (RE) and gastroesophageal reflux disease (GERD) symptoms in the Korean population.

Methods

In total, 1,489 subjects without RE were enrolled at the outpatient clinics of 12 tertiary hospitals nationwide, and 452 subjects underwent follow-up (F/U) for 2 years to evaluate the development of RE and GERD symptoms.

Results

RE was found in 33 subjects (7.3% of 452 subjects) and 14 subjects (7.3% of 192 subjects) during the first and second year of F/U, respectively. H. pylori status was not associated with the development of RE. RE was found in six (9.0%) of 67 H. pylori-negative patients, in 26 (11.2%) of 233 eradicated subjects and in eight (7.0%) of 114 noneradicated subjects (p=0.532). Multivariate analysis showed that age ≥60 years (odds ratio [OR], 7.11; 95% confidence interval [CI], 1.92 to 26.41), alcohol consumption (OR, 4.43; 95% CI, 1.03 to 19.19) and F/U cholesterol levels ≥200 mg/dL (OR, 5.03; 95% CI, 1.32 to 19.17) were significant risk factors for the development of RE. There was no significant difference in the development of GERD symptoms or weight according to H. pylori status during the 2-year F/U.

Conclusions

Eradication of H. pylori did not affect the development of reflux esophagitis or GERD symptoms among patients in outpatient gastroenterology clinics in South Korea.

Effects of Helicobacter pylori eradication on gastroesophageal reflux disease

BACKGROUND AND AIMS

Helicobacter pylori infection appears to be a protective factor for gastroesophageal reflux disease (GERD). However, H. pylori is associated with the subtype of esophageal carcinoma, and long-term proton-pump inhibition usage would cause gastric atrophy in patients with persistent H. pylori infection, which is a precancerous lesion. The relationship between H. pylori infection and GERD is still unclear. We aimed to confirm whether the eradication of H. pylori would worsen or improve symptomatic or endoscopic GERD.

METHODS

A systematic review of the published data was undertaken, and a meta-analysis was performed to determine the effect of H. pylori eradication on the occurrence of symptomatic (heartburn, acid regurgitation) and endoscopically proven erosive (esophagitis) GERD in patients with or without pre-existing GERD.

RESULTS

A total of 11 articles met the inclusion criteria and thus were included in the meta-analysis. There was no significant difference in the frequency of symptomatic or endoscopically proven erosive GERD after the eradication between patients with H. pylori eradicated and those with persistent infection, regardless of follow-up period, location, or the baseline disease.

CONCLUSION

H. pylori eradication does not aggravate the clinical outcomes in terms of short-term and long-term posteradication occurrence of GERD. There is no association between H. pylori eradication and the development of GERD in the patients with different diseases, even those with GERD.

Effect of Helicobacter pylori infection and its eradication on reflux esophagitis and reflux symptoms

OBJECTIVES

We evaluated the association between current Helicobacter pylori infection and reflux esophagitis and the effect of H. pylori eradication on reflux esophagitis in a healthy screening population.

METHODS

A total of 10,102 subjects in a comprehensive screening cohort were enrolled, and 4,007 subjects had follow-up after a median of 2 years. Effects of H. pylori infection on reflux esophagitis were estimated with odds ratios (ORs) and 95% confidence intervals (CIs) using multiple logistic regression analysis. We evaluated the change in prevalence of reflux esophagitis and reflux symptoms after H. pylori eradication vs. persistence.

RESULTS

The prevalence of reflux esophagitis (as classified by the Los Angeles system) was 4.9% (490/10,102). Whereas the prevalence of reflux esophagitis was 6.4% (319/4,971) in subjects without H. pylori infection, it was 3.3% (171/5,131) in subjects with infection (P<0.001). H. pylori infection had a strong negative association with reflux esophagitis in multivariate analysis (OR 0.42; 95% CI, 0.34-0.51). Compared with the prevalence of reflux esophagitis in the persistent infection group, the prevalence of reflux esophagitis increased after successful H. pylori eradication (OR 2.34; 95% CI, 1.45-3.76; P<0.001), which was comparable to that of the H. pylori-negative group (OR 2.42; 95% CI, 1.73-3.36; P<0.001). However, reflux symptoms had no association with H. pylori infection or eradication.

CONCLUSIONS

In a healthy screening population, H. pylori infection had a strong negative association with reflux esophagitis, but H. pylori eradication increased the prevalence of erosive esophagitis to the level of H. pylori-negative individuals. Long-term clinical significance of newly developed erosive esophagitis after H. pylori eradication should be evaluated prospectively.

Is there an increased risk of GERD after Helicobacter pylori eradication?: a meta-analysis

OBJECTIVES

Some studies suggest that eradication of Helicobacter pylori (Hp) might increase the risk of gastroesophageal reflux disease (GERD) in a portion of patients. We aimed to conduct a meta-analysis to investigate this.

METHODS

A comprehensive, English, multiple-source literature search was performed from 1983 to February 2007. Only randomized controlled trial (RCT) and cohort studies comparing the prevalence of GERD in patients free from GERD at baseline with Hp eradication vs. those with persistent Hp were included. Quality of RCTs and cohorts was assessed by Jadad and New Castle-Ottawa scores, respectively. Meta-analysis of pooled odds ratios (ORs) was performed using Review Manager 4.2.10.

RESULTS

Twelve (7 RCTs and 5 cohorts) of 271 articles were included. In six RCTs using erosive GERD as outcome, the OR for the frequency of GERD in Hp eradicated group vs. persistent Hp group was 1.11 (0.81-1.53, P=0.52). In five RCTs using symptomatic outcome, the OR for the frequency of GERD in Hp eradicated group vs. persistent Hp was 1.22 (0.89-1.69, P=0.22). In cohort studies, the OR for the frequency of GERD in Hp eradicated group vs. persistent Hp was 1.37 (0.89-2.12; P=0.15). Test of heterogeneity was not significant for any analyses. The results were consistent in subgroup and sensitivity analyses, including cohort studies vs. RCTs, high-quality studies vs. low-quality studies, and use of endoscopic vs. symptomatic outcomes except for the subgroup of patients with peptic ulcer disease (PUD) in cohort studies (OR: 2.04 (1.08-3.85); P=0.03).

CONCLUSIONS

There is no association between Hp eradication and development of new cases of GERD in the population of dyspeptic patients. However, in cohort studies, there seems to be a twofold higher risk of development of erosive GERD in patients with PUD. The effect in RCTs of patients with PUD did not show a significant difference.

WITHDRAWN: Initial management strategies for dyspepsia

BACKGROUND

This review considers management strategies (combinations of initial investigation and empirical treatments) for dyspeptic patients. Dyspepsia was defined to include both epigastric pain and heartburn.

OBJECTIVES

To determine the effectiveness, acceptability, and cost effectiveness of the following initial management strategies for patients presenting with dyspepsia (a) Initial pharmacological therapy (including endoscopy for treatment failures). (b) Early endoscopy. (c) Testing for Helicobacter pylori (H. pylori )and endoscope only those positive. (d) H. pylori eradication therapy with or without prior testing.

SEARCH STRATEGY

Trials were located through electronic searches and extensive contact with trialists.

SELECTION CRITERIA

All randomised controlled trials of dyspeptic patients presenting in primary care.

DATA COLLECTION AND ANALYSIS

Data were collected on dyspeptic symptoms, quality of life and use of resources. An individual patient data meta-analysis of health economic data was conducted

MAIN RESULTS

Twenty-five papers reporting 27 comparisons were found. Trials comparing proton pump inhibitors (PPI) with antacids (three trials) and histamine H2-receptor antagonists (H2RAs) (three trials), early endoscopy with initial acid suppression (five trials), H. pylori test and endoscope versus usual management (three trials), H. pylori test and treat versus endoscopy (six trials), and test and treat versus acid suppression alone in H. pylori positive patients (four trials), were pooled. PPIs were significantly more effective than both H2RAs and antacids. Relative risks (RR) and 95% confidence intervals (CI) were; for PPI compared with antacid 0.72 (95% CI 0.64 to 0.80), PPI compared with H2RA 0.63 (95% CI 0.47 to 0.85). Results for other drug comparisons were either absent or inconclusive. Initial endoscopy was associated with a small reduction in the risk of recurrent dyspeptic symptoms compared with H. pylori test and treat (OR 0.75, 95% CI 0.58 to 0.96), but was not cost effective (mean additional cost of endoscopy US$401 (95% CI $328 to 474). Test and treat may be more effective than acid suppression alone (RR 0.59 95% CI 0.42 to 0.83).

AUTHORS' CONCLUSIONS

Proton pump inhibitor drugs (PPIs) are effective in the treatment of dyspepsia in these trials which may not adequately exclude patients with gastro-oesophageal reflux disease (GORD). The relative efficacy of histamine H2-receptor antagonists (H2RAs) and PPIs is uncertain. Early investigation by endoscopy or H. pylori testing may benefit some patients with dyspepsia but is not cost effective as part of an overall management strategy.

The effect of Helicobacter pylori eradication on dyspeptic symptoms, acid reflux and quality of life in patients with functional dyspepsia

BACKGROUND

The aims of this study were to investigate the effect of Helicobacter pylori eradication on gastroesophageal reflux, gastrointestinal symptoms and quality of life in patients with functional dyspepsia.

METHODS

20 H. pylori positive patients diagnosed as having functional dyspepsia according to Roma-II criteria completed the study period. Esophageal motility testing and pH recordings were obtained from each patient before and at the end of the study period. Each patient's gastrointestinal symptoms were evaluated according to Glasgow dyspepsia score. 36-Item short-form health survey (SF-36) and EDQ5 health survey were obtained form each patient.

RESULTS

H. pylori eradication was accomplished in 13 patients (65%). Glasgow dyspepsia symptom score improved in H. pylori eradicated patients (10.3 vs 7.5, p<0.05) compared to baseline. Fasting lower esophageal sphincter pressures increased (21.6 vs 25.4 mmHg, p<0.05) after H. pylori eradication Neither the amplitude of peristaltic contractions in the esophageal body (59.4 vs 57.7 mmHg, p=ns) nor the velocity of peristaltic contractions changed before and after eradication. The percent time of esophageal pH<4 (0.7 vs 2.6, p<0.001), reflux events longer than 5 min (0 vs 0.7, p<0.005) and total reflux number (10.3 vs 19.3, p<0.005) significantly increased after eradication therapy. In the SF-36 health-related quality of life survey, general health score was 3.5 vs. 3.4, physical activity 25.2 vs. 26.4, physical role 5.9 vs. 6.3, emotional pain 4.6 vs. 4.5, social activity 2.0 vs. 1.9, physical pain 3.4 vs. 3.0, vitality 32.3 vs. 34.6, and mental health 11.9 vs. 11.5, before and at the end of treatment (p=ns), respectively.

CONCLUSIONS

H. pylori eradication did not influence quality of life in patients with functional dyspepsia. Majority of the patients experienced a significant change in esophageal acid exposure after H. pylori eradication. H. pylori eradication significantly decreases gastrointestinal symptoms, however has no effect on quality of life in patients with functional dyspepsia.

Helicobacter pylori and gastroesophageal reflux disease: a review of this intriguing relationship

A possible association between gastroesophageal reflux disease (GERD) and Helicobacter pylori (H. pylori) infection has been the subject of study and debate in recent years. This review discusses the pathophysiological and immunological mechanisms implicated in this relationship. Although gastric secretion in the majority of H. pylori-infected individuals is unaltered, this review considers how the bacteria may interfere with gastric acid production and what role it may play in GERD. We also identify the epidemiological evidence that confirms that GERD develops after the infection has been eradicated. Lastly, we clarify how the host's immune response and bacterial virulence factors interfere with this relationship, explaining the highly conflicting results in the literature.

Helicobacter pylori eradication may induce de novo, but transient and mild, reflux esophagitis: Prospective endoscopic evaluation

BACKGROUNDS AND AIM

The effect on reflux esophagitis of eradicating Helicobacter pylori is variable and not fully defined. We previously reported that in patients who have reflux esophagitis associated with duodenal ulcer, a significant improvement in the pre-existing reflux esophagitis occurred after H. pylori was eradicated. In the present study, we asked whether H. pylori eradication leads to de novo development of reflux esophagitis in peptic ulcer patients.

METHODS

Prospective post-eradication evaluations were conducted in 1195 H. pylori-positive patients with peptic ulcer diseases who were confirmed not to have reflux esophagitis by endoscopic examination before eradication therapy. After eradication therapy, endoscopy and a urea breath test were performed yearly.

RESULTS

A total of 1187 patients were followed for up to 10.0 years (a mean of 3.6 years). Reflux esophagitis developed in 279 of 1000 patients cured of infection and in 26 of 187 patients who had persistent infection (P < 0.0001, Fisher's exact test). The esophagitis was mild (Los Angeles grade A) in most patients, transient in approximately one-half, and rarely necessitated long-term medication for the condition. Cure of infection, alcohol consumption, younger age, and high body mass index were identified as significant factors for the risk of developing non-transient reflux esophagitis.

CONCLUSIONS

Cure of H. pylori infection may increase the risk of developing reflux esophagitis in patients with peptic ulcer, but the esophagitis is mostly mild and transient, and long-term medication is rarely required. Thus, H. pylori eradication therapy need not be withheld for fear of provoking reflux esophagitis.

Helicobacter pylori and benign upper digestive disease

Acute infection with Helicobacter pylori causes hypochlorhydria and gastrointestinal upset. As the infection persists, patients develop chronic antral-predominant or pangastritis. Gastric and duodenal ulcers arise from chronic mucosal inflammation and disordered acid secretion in the stomach. With successful eradication of H. pylori, non-NSAID-related gastric and duodenal ulcers heal even without long-term acid suppression. More importantly, peptic ulcers and their complications rarely recur. Clearing H. pylori infection also reduces the risk of mucosal injury in NSAID and aspirin users; the protective effects are more pronounced in NSAID-naïve and aspirin users. H. pylori is unlikely to be the cause of gastro-oesophageal reflux disease. However, a patient's reflux symptoms may be more difficult to control after clearing the infection. Although there is little evidence to support a causal relationship between H. pylori and non-ulcer dyspepsia, treatment of the infection gives a modest improvement of symptoms.

Helicobacter pylori and non-malignant diseases

The prevalence of Helicobacter pylori-associated peptic ulcers, in particular duodenal ulcers, is decreasing following decreasing prevalence of H. pylori infection, while the frequency of non-steroidal anti-inflammatory drugs (NSAIDs)-induced and H. pylori-negative idiopathic ulcers is increasing. The incidence of bleeding ulcers has been stable during the last decades. Several putative H. pylori virulence genes, i.e., cag, vacA, babA, or dupA, as well as host-related genetic factors like IL-1beta and TNFalpha-gene polymorphism, have been proposed as risk factors for duodenal ulcer. H. pylori eradication may prevent NSAID complications, in particular, when it is performed before introduction of NSAIDs. There is a complex association between H. pylori and gastroesophageal reflux disease (GERD), and the impact of H. pylori eradication on the appearance of GERD symptoms depends on various host- and bacteria-related factors. Eradication of H. pylori in GERD is recommended in patients before instauration of a long-term PPI treatment to prevent the development of gastric atrophy. A small proportion (10%) of non-ulcer dyspepsia cases may be attributed to H. pylori and may benefit from eradication treatment. A test-and-treat strategy is more cost-effective than prompt endoscopy in the initial management of dyspepsia.

Advantages and disadvantages of lumping together gastroesophageal reflux disease and dyspepsia

PURPOSE OF REVIEW

The aim of this article is to identify and to balance the arguments in favor of and against lumping together gastroesophageal reflux disease and functional dyspepsia.

RECENT FINDINGS

In at least half of the patients diagnosed with gastroesophageal reflux disease no organic abnormalities are found. Hypersensitivity of the esophagus to various stimuli plays a key role in the genesis of symptoms in these patients. The association between symptoms and acid reflux events can be quantified by 24-h esophageal pH monitoring. It has also become possible to detect non-acid reflux, using the intraluminal impedance monitoring technique. Functional dyspepsia is still defined by a combination of symptoms for which no organic cause can be found. No positive diagnostic tools have yet become available and treatment with acid secretion inhibitors, Helicobacter pylori eradication or prokinetic drugs remains marginally effective.

SUMMARY

Gastroesophageal reflux disease is a well defined disease which can be diagnosed objectively with endoscopy or 24-h pH/impedance monitoring with symptom association analysis. Functional dyspepsia is a functional disorder for which no objective test has yet been discovered. Treatment of gastroesophageal reflux disease is based on objectively identified abnormalities and highly effective. Treatment of functional dyspepsia is empiric and marginally effective. For these reasons, the lumping together of gastroesophageal reflux disease and functional dyspepsia is not to be advised.

Initial management strategies for dyspepsia

BACKGROUND

This review considers management strategies (combinations of initial investigation and empirical treatments) for dyspeptic patients. Dyspepsia was defined to include both epigastric pain and heartburn.

OBJECTIVES

To determine the effectiveness, acceptability, and cost effectiveness of the following initial management strategies for patients presenting with dyspepsia: (a) Initial pharmacological therapy (including endoscopy for treatment failures). (b) Early endoscopy. (c) Testing for Helicobacter pylori (H. pylori )and endoscope only those positive. (d) H. pylori eradication therapy with or without prior testing.

SEARCH STRATEGY

Trials were located through electronic searches and extensive contact with trialists.

SELECTION CRITERIA

All randomised controlled trials of dyspeptic patients presenting in primary care.

DATA COLLECTION AND ANALYSIS

Data were collected on dyspeptic symptoms, quality of life and use of resources. An individual patient data meta-analysis of health economic data was conducted

MAIN RESULTS

Twenty-five papers reporting 27 comparisons were found. Trials comparing proton pump inhibitors (PPI) with antacids (three trials) and histamine H2-receptor antagonists (H2RAs) (three trials), early endoscopy with initial acid suppression (five trials), H. pylori test and endoscope versus usual management (three trials), H. pylori test and treat versus endoscopy (six trials), and test and treat versus acid suppression alone in H. pylori positive patients (four trials), were pooled. PPIs were significantly more effective than both H2RAs and antacids. Relative risks (RR) and 95% confidence intervals (CI) were; for PPI compared with antacid 0.72 (95% CI 0.64 to 0.80), PPI compared with H2RA 0.63 (95% CI 0.47 to 0.85). Results for other drug comparisons were either absent or inconclusive. Initial endoscopy was associated with a small reduction in the risk of recurrent dyspeptic symptoms compared with H. pylori test and treat (OR 0.75, 95% CI 0.58 to 0.96), but was not cost effective (mean additional cost of endoscopy US$401 (95% CI $328 to 474). Test and treat may be more effective than acid suppression alone (RR 0.59 95% CI 0.42 to 0.83).

AUTHORS' CONCLUSIONS

Proton pump inhibitor drugs (PPIs) are effective in the treatment of dyspepsia in these trials which may not adequately exclude patients with gastro-oesophageal reflux disease (GORD). The relative efficacy of histamine H2-receptor antagonists (H2RAs) and PPIs is uncertain. Early investigation by endoscopy or H. pylori testing may benefit some patients with dyspepsia but is not cost effective as part of an overall management strategy.

Helicobacter pylori and non-malignant diseases

This paper reviews new literature data from March 2004 to April 2005 about the association between Helicobacter pylori and non-malignant disease of the upper gastrointestinal tract. Eradication of H. pylori is indicated for all patients with non-malignant diseases associated with this pathogen. However, its effect is variable, ranging from the highest benefit in the cure of peptic ulcer disease to a small benefit in patients with non-ulcer dyspepsia. Test and treat strategy is still cost-effective for management of patients with uninvestigated dyspepsia. The only limitations of the strategy are the patient's age and the cost benefit ratio in case of low prevalence of the infection. H. pylori eradication is of value in chronic NSAID users, but is insufficient to prevent NSAID-related ulcer disease. In developed countries H. pylori eradication does not cause gastro-esophageal reflux disease (GORD), however, a negative association between H. pylori and GORD does exist, especially in Asia, but the nature of this relationship should be further clarified.