Eradication of Helicobacter pylori in patients with non-ulcer dyspepsia

Socio-demographic characteristics of patients with diagnosed functional dyspepsia

INTRODUCTION

The term "dyspepsia" comes from the Greek words "dys' and 'peptin", which maen "ill digestion" or indigestion, although this set of symptoms in the adult clinic has little to do with the digestion or absorption process, and refers more to ailments related to the upper section of the gastrointestinal tract.

AIM

Assessment of the frequency of functional dyspepsia diagnosis, the characteristics of the group and an attempt to identify the accompanying symptoms, assessment of histological lesions and an attempt to answer question about the efficiency of anti-secretory and eradication therapy.

MATERIAL AND METHODS

The study involved patients reporting for gastrofiberscopic examination due to dyspeptic ailments. A total of 230 patients were examined, including 140 women and 90 men, above 18 years of age. They underwent endoscopic examination, and a selected group with functional dyspepsia (FD), analysed using the 'Gast' questionnaire, underwent eradication therapy or proton pump inhibitors. Statistical analysis involved χ(2) and Fischer's test.

RESULTS

The study involved 230 individuals with dyspeptic disorders. The largest age group was 46-60 years. These patients reported due to their ailments mostly in autumn and winter. The differentiated group with FD included 53 patients (23% of the clinical population). 69.8% of the FD group was infected with Helicobacter pylori (with 81.2% of the whole population, respectively). Individuals with FD reported improvement more often after being administered drugs to decrease gastric secretion, more often declared post-elementary education and suffered from non-gastric ailments yet still described their state of health as good. No positive therapeutic effect of eradication was noticed during the 6-month observation.

CONCLUSIONS

Due to the very high ratio of subjects with functional dyspepsia, also observed in the study sample, and the influence of civilization progress, we should expect increasing frequency of occurrence of this problem.

Systematic review and meta-analysis from Chinese literature: the association between Helicobacter pylori eradication and improvement of functional dyspepsia

OBJECTIVES

To evaluate the effect of eradicating Helicobacter pylori on dyspeptic symptoms in patients with functional dyspepsia in China.

DATA SOURCES

Randomized controlled trials conducted in China and those published between 1989 and April 2007.

REVIEW METHODS

The articles were retrieved from Chinese biomedicine Web database and Chinese scientific Journals database using proper MESH headings and assessed by two independent investigators according to established inclusion criteria. The characteristics of chosen articles were displayed for further analysis, and summary odds ratio were calculated to determine the overall effect of H. pylori eradication. All the data were entered and analyzed using REVIEW MANAGER 4.1, and p < .05 was defined as statistically significant in all analysis.

RESULTS

Seven qualified trials were enrolled, and the summary odds ratio for improvement in dyspeptic symptoms in patients with functional dyspepsia in whom H. pylori was eradicated was 3.61 (95%CI: 2.62, 4.98, p < .00001). The difference in the follow-up period did not influence the final outcomes.

CONCLUSIONS

An improvement in dyspeptic symptoms occurred among Chinese patients with functional dyspepsia in whom H. pylori was eradicated.

Role of Helicobacter pylori in functional dyspepsia

The aetiology of dyspepsia is unknown in the majority of patients. Helicobacter pylori (H pylori) is the cause in a subset of patients. A non invasive test to assess the presence of H pylori is recommended in the management of patients under the age of 50 presenting to a family practitioner with dyspepsia. A urea breath test or a stool antigen test are the most reliable non invasive tests. Eradication of H pylori will reduce the risk to the patient with dyspepsia of developing a peptic ulcer, reduce the complication rate if prescribed non-steroid anti-inflammatory drugs and later reduce the risk of gastric cancer. The recommended treatment for non ulcer dyspepsia associated with a H pylori infection should be a 10-d course of treatment with a PPI and two antibiotics. Treatment efficacy should be assessed four weeks after completing treatment with a urea breath test or a stool antigen test.

Cure of Helicobacter pylori infection does not improve symptoms in non-ulcer dyspepsia patients-a double-blind placebo-controlled study

BACKGROUND

It remains controversial whether the cure of H. pylori infection improves NUD symptoms.

AIM

To conduct a double-blind placebo-controlled single centre study with concealed allocation to investigate this question.

PATIENTS AND METHODS

Ninety NUD patients with H. pylori infection were randomly assigned to either the treatment group (50 patients) or placebo group (40 patients). The treatment group received omeprazole, amoxycillin, clarithromycin and the placebo group received omeprazole and placebos for 7 days. Symptoms were assessed every week for up to 12 weeks after completion of medication by a symptom questionnaire. Alteration of histological parameters for gastritis was also evaluated.

RESULTS

The infection was cured in 41 out of 48 patients in the treatment group and none in the placebo group. There was no significant difference in the mean symptom scores at any assessment point up to 12 weeks between the treatment and placebo groups. Regarding histological parameters, activity and inflammation, not atrophy or intestinal metaplasia, were significantly improved in the treatment group.

CONCLUSION

Although histological parameters were significantly improved in the treatment group, there was no significant improvement in symptoms of NUD in the treatment group compared to placebo.

Functional dyspepsia and Helicobacter pylori infection: a recent consensus up to 1999

With accumulated evidence for a close relationship between Helicobacter pylori infection and many gastric disorders, the idea that this infection may invoke dyspeptic symptoms appears realistic. If curative therapy for H. pylori can bring about relief of symptoms in these patients, we would possess a new therapeutic tool for functional dyspepsia. Although there have been many clinical trials on this issue, the benefits of H. pylori treatment have been controversial. However, several large-scale clinical studies have been very recently published, and suggest a specific direction on this clinical question. From these results, the current consensus is that H. pylori infection does not directly affect symptoms in patients with functional dyspepsia. However, most clinical trials have been performed on Western populations, and there are few reports from Asian countries. Our recent study on the Japanese population also supported the consensus, that is, a negative relationship between H. pylori infection and symptoms in functional dyspepsia patients.

Is Helicobacter pylori associated with non-ulcer dyspepsia and will eradication improve symptoms? A meta-analysis

OBJECTIVES

To examine the association between Helicobacter pylori infection and non-ulcer dyspepsia, and to assess the effect of eradicating H pylori on dyspeptic symptoms in patients with non-ulcer dyspepsia.

DESIGN

Systematic review and meta-analysis of (a) observational studies examining the association between Helicobacter pylori infection and non-ulcer dyspepsia (association studies), and (b) therapeutic trials examining the association between eradication of H pylori and dyspeptic symptoms in patients with non-ulcer dyspepsia (eradication trials).

DATA SOURCES

Randomised controlled trials and observational studies conducted worldwide and published between January 1983 and March 1999.

MAIN OUTCOME MEASURES

Summary odds ratios and summary symptom scores.

RESULTS

23 association studies and 5 eradication trials met the inclusion criteria. In the association studies the summary odds ratio for H pylori infection in patients with non-ulcer dyspepsia was 1.6 (95% confidence interval 1.4 to 1.8). In the eradication trials the summary odds ratio for improvement in dyspeptic symptoms in patients with non-ulcer dyspepsia in whom H pylori was eradicated was 1.9 (1.3 to 2.6).

CONCLUSIONS

Some evidence shows an association between H pylori infection and dyspeptic symptoms in patients referred to gastroenterologists. An improvement in dyspeptic symptoms occurred among patients with non-ulcer dyspepsia in whom H pylori was eradicated.

Treatment of dyspepsia

Dyspepsia is a condition that is commonly seen by family physicians and gastroenterologists in clinical practice. However, there is little consensus on how dyspepsia should be treated. Some of the issues that require consideration are: Who seeks medical help? What types of physicians do patients choose to see? Do different types of physicians see the same types of patients? Do different types of physicians treat dyspepsia differently? What causes dyspepsia? In addition, the definition of dyspepsia and the symptoms associated with it vary from region to region, creating problems when discussing these issues on an international basis. In this review, the above issues are discussed, with particular attention to the impact of Helicobacter pylori infection and gastric dysmotility. Recommendations for treatment are made, and predictions of how dyspepsia will be treated in the future are given.

Antibody response to specific H. pylori antigens in functional dyspepsia, duodenal ulcer disease, and health

OBJECTIVE

The relationship between H. pylori and functional dyspepsia remains controversial. The aim of this study was to identify a potential link between the antibody response to specific H. pylori antigens and functional dyspepsia.

METHODS

A total of 50 consecutive patients with functional dyspepsia, 50 patients with duodenal ulcer (DU), and 150 healthy blood donor control subjects with no history of peptic ulceration were studied. H. pylori status was determined by IgG antibodies using a validated ELISA. In H. pylori-positive subjects, antibodies against specific H. pylori antigens were identified by Western blot.

RESULTS

All DU patients (100%; 95%; CI, 93-100), 30 of 50 patients with functional dyspepsia (60%; 95% CI, 45-74) and 65 of 150 (43.3%; 95% CI, 34.3-51) blood donor controls tested positive for H. pylori. Forty-six of 50 (92%; 95% CI, 81-98) DU patients tested positive for the 91 kDa antigen (vacA) compared with 46 of 65 (69%; 95% CI, 58-81) control subjects and 22 of 30 (73%; 95% CI, 54-88) functional dyspepsia patients (p < 0.01 DU versus controls). Similarly, the 120 kDa antigen (cagA) tended (p < 0.15) to be more prevalent in DU patients (82%; 95% CI, 69-91) compared with controls (69%; 95% CI, 57-80) but not functional dyspepsia (77%; 95% CI, 57-90). No specific H. pylori antigens were associated with dyspepsia subgroups.

CONCLUSION

No specific H. pylori antigens are linked to functional dyspepsia.

Dyspepsia: current understanding and management

Dyspepsia, defined as "pain or discomfort centered in the upper abdomen" is reported by one in four adults in Western societies. The most important causes are non-ulcer (functional) dyspepsia, peptic ulcer, gastroesophageal reflux, and, rarely, gastric cancer. Persons with heartburn alone are not considered to have dyspepsia. The division of dyspepsia into symptom-based subgroups (ulcer-like, dysmotility-like, reflux-like, and unspecified dyspepsia) has proven to be of doubtful value for the clinician, as it has a low predictive value for identifying the causes of dyspepsia. Upper endoscopy remains the "gold standard" test; ultrasound and blood tests have a low yield. The role of Helicobacter pylori in peptic ulcer disease is well known, but the clinical role of the infection in non-ulcer dyspepsia remains very controversial. In uninvestigated dyspeptic patients who are H. pylori infected based on a non-invasive test, empiric anti-H. pylori therapy is a reasonable and probably cost-effective option. In documented non-ulcer dyspepsia, prokinetics are superior to placebo while antisecretory therapy is of less certain efficacy.

Adding once-daily omeprazole 20 mg to metronidazole/amoxicillin treatment for Helicobacter pylori gastritis: a randomized, double-blind trial showing the importance of metronidazole resistance

OBJECTIVE

We compared the Helicobacter pylori eradication rate after a 14-day treatment with amoxicillin 500 mg t.i.d. and metronidazole 500 mg t.i.d. with or without omeprazole 20 mg once daily.

METHODS

This was a randomized, controlled trial in which omeprazole was given in double-blind fashion. Patients with H. pylori-associated gastritis were enrolled in four centers in Canada from July 1991 to January 1994. Eradication of H. pylori was assessed by histological evaluation and culture of endoscopic biopsies obtained from the antrum and corpus of the stomach.

RESULTS

The H. pylori eradication rate was 73% (33 of 45) in the omeprazole-amoxicillin-metronidazole group, compared with 66% (31 of 47) in the amoxicillin-metronidazole group. This 7% difference was not statistically significant (p = 0.43, 95% confidence interval for difference -11% to 26%). Metronidazole primary resistance in the prestudy cultures was found more frequently in the omeprazole-amoxicillin-metronidazole group than in the amoxicillin-metronidazole group. Resistance to metronidazole was an important predictor of treatment failure. The H. pylori eradication rate was 61% (19 of 31) for patients infected with metronidazole-resistant H. pylori strains, compared with 91% (30 of 33) eradication for those infected with metronidazole-sensitive strains (p < 0.01). Vaginal candidiasis was reported in four patients.

CONCLUSIONS

The H. pylori eradication rate was higher (73%) for omeprazole-amoxicillin-metronidazole than for the dual antibiotic therapy given without omeprazole (66%); however, this difference was not statistically significant. Metronidazole resistance significantly reduces H. pylori eradication rates.

Helicobacter pylori infection in non-ulcer dyspeptic and ulcer patients. Determinants and consequences in 'real life'

BACKGROUND

Infection rates are high in patients with ulcer disease, but even non-ulcer dyspepsia (NUD) patients have Helicobacter pylori infection. The Notodden Helicobacter study is an 'outcome study' of clinical practice in a local hospital. The study may identify factors associated with infection and evaluate whether H. pylori infection predicts symptoms in both ulcer disease and NUD.

METHODS

Base-line results on infection, symptoms, endoscopy, and treatment were registered in 587 ulcer and NUD patients. H. pylori status was assessed with a rapid urease test. Questionnaire data (5-43 months after treatment) give information about symptoms. Regression models to identify H. pylori status were developed.

RESULTS

Ulcer patients (H. pylori +/-) were similar to infected NUD patients. In contrast, uninfected NUD patients were younger, had less severe symptoms, and used less medication than other patients. In NUD, infection rate increased with epigastric pain, male sex, and age.

CONCLUSION

From a local hospital's point of view, H. pylori-infected NUD patients are like ulcer patients with regard to symptoms and demographics. The results suggest that H. pylori infection may give dyspeptic symptoms through other mechanisms than ulcer. We propose a division of the NUD group into HINUD (Helicobacter-infected NUD) and NINUD (non-infected NUD).

A risk-benefit assessment of drugs used in the eradication of Helicobacter pylori infection

Helicobacter pylori is the cause of chronic active gastritis and predisposes to peptic ulcer disease (PUD). Furthermore, H. pylori is linked to the pathogenesis of gastric lymphoma and gastric cancer. However, treatment of this infection has proven difficult. In the last decade, many antimicrobial compounds have been studied extensively as monotherapy as well as in combination with bismuth or acid-suppressive drugs. The individual drugs and the most important eradication regimens are discussed with special regard to their risks. In the past, highly complex multidrug regimens, fear of adverse effects and frequent eradication failures have hampered the broad acceptance of H. pylori-eradication therapies. Recently, new 1-week, low-dose combination regimens of 2 antibacterials with a proton pump inhibitor have consistently achieved eradication rates of 90% and more with an acceptably low rate of adverse effects. One week's standard triple therapy [tripotassium dicitrato bismuthate (or bismuth salicylate plus metronidazole plus tetracycline or amoxicillin) has been shown to be highly effective and tolerated better in combination with a proton pump inhibitor. This regimen is, however, more complex and has more adverse effects. Therefore, it is not recommended as first-line therapy. Equipped with these therapies physicians can now be strongly encouraged to use H. pylori eradication as the therapy of choice for patients with PUD and even extend this treatment to other H. pylori-associated disease conditions.

A simple, rapid, and highly reliable capsule-based 14C urea breath test for diagnosis of Helicobacter pylori infection

BACKGROUND

Since the urea breath test (UBT) indirectly detects gastric Helicobacter pylori infection by measuring urease activity, the possibility of false-positive results due to other urease-producing bacteria cannot be excluded. Previous studies have shown that increased 14CO2 activity in early breath samples could be attributed to urea hydrolysis in the oropharynx. For that reason, reliable assessment of H. pylori status is hampered for at least 20 min after administration of a 14C-urea drink.

METHODS

To overcome this problem we have developed a modified breath test in which 111kBq 14C-urea is supplied in a gelatin capsule, which prevents release of 14C before reaching the stomach. Our modified 14C UBT was evaluated in 100 healthy volunteers, and results were compared with those from enzyme-linked immunosorbent assay serology.

RESULTS

The study showed a 99% concordance between the two noninvasive tests. When a biometric method for determination of cut-off values between positive and negative UBT results with the smallest possible arbitrariness was used, the calculated statistical probability of a false diagnosis was lowest in the 10-min breath sample (0.20%), and 100% sensitivity and specificity was achieved. Our capsule method was also compared with the urea drink method and was found more reliable because no overlapping in 14CO2 activity occurred between H. pylori-positive and -negative subjects, whereas conventional breath testing showed overlapping during the whole 30-min test period. Our study also showed that a fatty test meal lowers the 14CO2 excretion the first 20 min and may adversely affect the accuracy of a rapid UBT.

CONCLUSIONS

Supplying the 14C-urea in a capsule obviates the problem of false-positive results in early breath samples and makes it possible to diagnose H. pylori infection with 99.8% reliability from a single 10-min breath sample, without the use of a test meal of adjustments for assumed individual CO2 production.

Eradication of Helicobacter pylori and its effect in peptic ulcer disease

Since Helicobacter pylori was first cultured 10 years ago, there have been remarkable changes in our approach to the therapy of peptic ulcer disease. We now know that 90% of duodenal ulcer patients and 70% of all gastric ulcer patients are infected with H. pylori. Evidence is presented that the relapse rate of both duodenal and gastric ulcers can be substantially reduced if the bacterium is eradicated from the patient's stomach. Some of the anti-H. pylori eradication regimens currently available are discussed, with particular emphasis on the relative merits of standard triple therapy and an omeprazole/amoxycillin combination.