Nonulcer Dyspepsia and Helicobacter Pylori Infection:
To Treat or Not to Treat

Contributor: Dr. D. Bair

The bacterial infection Helicobacter pylori (H. pylori) is the main cause of ulcers in the upper gastrointestinal tract. In Canada 30-40% of the population is infected with H. pylori. However only 15% of these people will develop peptic ulcer disease. Ulcers are a common cause of dyspepsia. More than 40% of visits to a gastroenterologist are for dyspepsia. However, most patients with dyspepsia have no evidence of ulcers or other abnormalities after appropriate investigation. This large group of patients are said to have nonulcer dyspepsia (NUD), also known as functional dyspepsia.

It is not clear whether H. pylori infections contribute to symptoms in patients with non-ulcer dyspepsia. Many studies have been performed to assess whether the treatment of H. pylori infections with antibiotics (eradication) improves symptoms in patients with nonulcer dyspepsia. Unfortunately, studies have shown conflicting results, and many early studies were not well designed. For this reason two different reviewers have recently combined the results of the best available studies and performed statistical analyses on these grouped data (meta-analysis) in an attempt to clarify this question.

One such study (Laine et al. Annals of Internal Medicine 2001;134:361-369) identified methodologically sound studies that assessed comparable patient outcomes (similar measurements such as symptom reduction or the disapperance of ulcers). This analysis suggested that, after one month, there was no significant difference in symptoms between those with NUD who were treated with an H. pylori eradication regimen, compared to those who received no active treatment (placebo).

The second review (Moayyedi et al.The Cochrane Library, Issue 3, 2001) looked at 12 previous studies and concluded that 9% of patients with nonulcer dyspepsia would have minimal or no symptoms of dyspepsia more than 3 months after treatment for helicobacter pylori. The size of this treatment effect is small at best. These data suggest that fifteen patients would need to be treated to cure one case of nonulcer dyspepsia.

The difference in outcome between these reviews is likely related to the fact that the Moayyedi study included 4 studies not available to Laine's group at the time of their analysis. The influence of these trials may explain the different conclusions reached in that study. Furthermore, previous studies have suggested that it may take many months for the symptomatic benefit of H. pylori eradication to become apparent. Therefore, the longer duration of patient follow up in the Moayyedi study may again partly explain the finding of benefit of treatment in that review.

In summary, treatment of Helicobacter pylori may reduce symptoms of nonulcer dyspepsia. However the majority of these patients are unlikely to experience symptomatic improvement and even these benefits are likely to be delayed. Currently most major treatment guidelines therefore recommend only the "consideration of treatment" in this setting.

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