Rates of dyspepsia one year after Helicobacter pylori screening and eradication in a Danish population

Risk of Esophageal Adenocarcinoma After Helicobacter pylori Eradication Treatment in a Population-Based Multinational Cohort Study

BACKGROUND & AIMS

Helicobacter pylori infection is associated with a decreased risk of esophageal adenocarcinoma, and the decreasing prevalence of such infection might contribute to the increasing incidence of this tumor. We examined the hypothesis that eradication treatment of H pylori increases the risk of esophageal adenocarcinoma.

METHODS

This population-based multinational cohort, entitled "Nordic Helicobacter Pylori Eradication Project (NordHePEP)," included all adults (≥18 years) receiving H pylori eradication treatment from 1995-2018 in any of the 5 Nordic countries (Denmark, Finland, Iceland, Norway, and Sweden) with follow-up throughout 2019. Data came from national registers. We calculated standardized incidence ratios (SIRs) with 95% confidence intervals (CIs) by dividing the cancer incidence in the exposed cohort by that of the entire Nordic background populations of the corresponding age, sex, calendar period, and country. Analyses were stratified by factors associated with esophageal adenocarcinoma (ie, education, comorbidity, gastroesophageal reflux, and certain medications).

RESULTS

Among 661,987 participants who contributed 5,495,552 person-years after eradication treatment (median follow-up, 7.8 years; range, 1-24 years), 550 cases of esophageal adenocarcinoma developed. The overall SIR of esophageal adenocarcinoma was not increased (SIR = 0.89; 95% CI, 0.82-0.97). The SIR did not increase over time after eradication treatment, but rather decreased and was 0.73 (95% CI, 0.61-0.86) at 11-24 years after treatment. There were no major differences in the stratified analyses. The overall SIR of esophageal squamous cell carcinoma, calculated for comparison, showed no association (SIR = 0.99; 95% CI, 0.89-1.11).

CONCLUSIONS

This absence on an increased risk of esophageal adenocarcinoma after eradication treatment of H pylori suggests eradication is safe from a cancer perspective.

The Fear of Gastric Cancer in Patients with Dyspepsia: Challenge in Specialist Care Gastroenterology

BACKGROUND

Dyspepsia is one of the most common complaints in gastroenterology. While its etiology is usually benign, rare cases of malignancy have to be identified. Individualized risk stratification is essential for cost-effective management of dyspepsia. Here, we discuss the challenges of investigating dyspepsia at the specialist level and provide a framework for rational workup and surveillance strategies.

SUMMARY

Causes of dyspepsia can be functional or organic, including gastritis, peptic ulcers, or malignancy. H. pylori gastritis represents a specific entity of dyspepsia and increases the risk of gastric cancer. H. pylori eradication can improve symptoms in a subset of patients and reduce gastric cancer risk. In young patients without alarm features, malignancy is rare, and noninvasive testing for H. pylori is appropriate. In elder patients and those with alarm features, high-quality endoscopy is the method of choice to rule out malignancy. Advanced corpus-predominant atrophic gastritis with or without intestinal metaplasia represent precancerous lesions.

KEY MESSAGES

Symptom assessment requires to distinguish dyspepsia of functional or organic origin. Risk stratification in dyspeptic patients is based on age, alarm features, and H. pylori status. Noninvasive test-and-treat is recommended in patients with low gastric cancer risk, while endoscopy is recommended in individuals at increased risk. H. pylori infection should be eradicated in order to obtain a symptomatic benefit and reduce gastric cancer risk. Advanced preneoplastic lesions require endoscopic surveillance.

Helicobacter pylori eradication for the prevention of gastric neoplasia

BACKGROUND

Gastric cancer is the third most common cause of cancer death worldwide. Individuals infected with Helicobacter pylori have a higher likelihood of developing gastric cancer than individuals who are not infected. Eradication of H. pylori in healthy asymptomatic individuals in the general population may reduce the incidence of gastric cancer, but the magnitude of this effect is unclear.

OBJECTIVES

To assess the effectiveness of eradication of H. pylori in healthy asymptomatic individuals in the general population in reducing the incidence of gastric cancer.

SEARCH METHODS

We identified trials by searching the Cochrane Central Register of Controlled Trials (CENTRAL; 2020, Issue 1), MEDLINE (1946 to February 2020), and EMBASE (1974 to February 2020). We handsearched reference lists from trials selected by electronic searching to identify further relevant trials. We handsearched published abstracts from conference proceedings from the United European Gastroenterology Week (published in Gut) and Digestive Disease Week (published in Gastroenterology) between 2001 and 2019. We contacted members of the Cochrane Upper Gastrointestinal and Pancreatic Diseases Review Group and experts in the field and asked them to provide details of outstanding clinical trials and any relevant unpublished materials.

SELECTION CRITERIA

We analysed randomised controlled trials comparing at least one week of H. pylori therapy with placebo or no treatment in preventing subsequent development of gastric cancer in otherwise healthy and asymptomatic H. pylori-positive adults. Trials had to follow up participants for at least two years and needed to have at least two participants with gastric cancer as an outcome. We defined gastric cancer as any gastric adenocarcinoma, including intestinal (differentiated) or diffuse (undifferentiated) type, with or without specified histology.

DATA COLLECTION AND ANALYSIS

We collected data on incidence of gastric cancer, incidence of oesophageal cancer, deaths from gastric cancer, deaths from any cause, and adverse effects arising due to therapy.

MAIN RESULTS

Six trials met all our eligibility criteria and provided extractable data in the previous version. Following our updated search, one new RCT was identified, meaning that seven trials were included in this updated review. In addition, one previously included trial provided fully published data out to 10 years, and another previously included trial provided fully published data out to 22 years of follow-up. Four trials were at low risk of bias, one trial was at unclear risk, and two trials were at high risk of bias. Six trials were conducted in Asian populations. In preventing development of subsequent gastric cancer, H. pylori eradication therapy was superior to placebo or no treatment (RR 0.54, 95% confidence interval (CI) 0.40 to 0.72, 7 trials, 8323 participants, moderate certainty evidence). Only two trials reported the effect of eradication of H. pylori on the development of subsequent oesophageal cancer. Sixteen (0.8%) of 1947 participants assigned to eradication therapy subsequently developed oesophageal cancer compared with 13 (0.7%) of 1941 participants allocated to placebo (RR 1.22, 95% CI 0.59 to 2.54, moderate certainty evidence). H. pylori eradication reduced mortality from gastric cancer compared with placebo or no treatment (RR 0.61, 95% CI 0.40 to 0.92, 4 trials, 6301 participants, moderate certainty evidence). There was little or no evidence in all-cause mortality (RR 0.97, 95% CI 0.85 to 1.12, 5 trials, 7079 participants, moderate certainty evidence). Adverse events data were poorly reported.

AUTHORS' CONCLUSIONS

We found moderate certainty evidence that searching for and eradicating H. pylori reduces the incidence of gastric cancer and death from gastric cancer in healthy asymptomatic infected Asian individuals, but we cannot necessarily extrapolate this data to other populations.

The cost effectiveness of Helicobacter pylori population screening-economic evaluation alongside a randomised controlled trial with 13-year follow-up

BACKGROUND

Helicobacter pylori eradication improves dyspeptic symptoms in 8%-10%, prevents peptic ulcer and may reduce the risk of gastric cancer. Availability of a high quality diagnostic test and an effective treatment makes population screening and eradication of Helicobacter pylori an attractive option.

AIM

To evaluate the cost effectiveness of Helicobacter pylori population screening and eradication.

METHODS

Cost effectiveness analysis and cost utility analysis alongside randomised controlled trial with 13 years follow-up. The evaluation has a societal perspective. A random general population sample of 20 011 individuals aged 40-65 were randomised and invited in 1998-1999; 12 530 were enrolled and, of these, 8658 have been successfully followed up at 1, 5, and 13 years after intervention. Questionnaires included the quality of life instrument SF-36. From SF-36 responses an SF-6D score was derived and used for calculation of quality-adjusted life years. Register data on costs, use of health care resources and medication were obtained for all randomised individuals. The intervention was an invitation to Helicobacter pylori screening by in-office blood test; positive tests were validated by ¹³ C-urea breath test. Those who tested positive were offered eradication therapy. Main outcome measures were Incremental cost per quality-adjusted life year and life-years gained.

RESULTS

Helicobacter pylori population screening and eradication with 13 years follow-up was not effective in regards to quality of life and the cost per screened person was higher than not screening (mean difference 11 269 DKK [95% CI: 3175-19 362]). The probability of being cost-effective was 80% at a threshold of 400 000 DKK (approximately 53,800 Euros) of willingness-to-pay per life-year gained.

CONCLUSIONS

Helicobacter pylori population screening and eradication with 13 years follow-up was not effective in regards to quality of life and the cost of screening was higher than not screening.

The epidemiology of Helicobacter pylori infection in Europe and the impact of lifestyle on its natural evolution toward stomach cancer after infection: A systematic review

BACKGROUND

Helicobacter pylori is a recognized cause of stomach cancer, but only a fraction of infected subjects develop cancer. This systematic review 1, summarizes the prevalence of infection with this bacterium in Europe; and 2, reviews the possible impact of particular lifestyles in progression from infection to stomach cancer.

MATERIALS AND METHODS

A systematic literature search was conducted in two databases by two independent investigators. Studies describing prevalence of infection among European healthy adult populations and worldwide studies analyzing the impact of lifestyle factors in association with H. pylori on stomach cancer risk were included.

RESULTS

Variable H. pylori infection prevalence was observed depending on region and study period. The lowest infection prevalences were found in Northern Europe, while the highest were in Eastern and Southern Europe, up to 84% in Portugal and Poland. Studies on smoking, salt, and meat consumption demonstrated increased risks of developing stomach cancer among H. pylori-infected individuals, while studies relating the intake of fruit, vegetables, and vitamins demonstrated decreased risks, but the levels of significance differed importantly between studies. No significant interaction could be found for alcohol consumption or physical activity.

CONCLUSIONS

Recent data showed remaining high H. pylori infection rates in several European regions. This systematic review suggests that a number of correctable lifestyle factors could impact the disease progression toward H. pylori-associated stomach cancer. However, additional research is required to determine the potential role of targeted interventions in reducing stomach cancer development after H. pylori infection.

Effects of Community Screening for Helicobacter pylori: 13-Year Follow-Up Evaluation of a Randomized Controlled Trial

BACKGROUND & AIMS

Helicobacter pylori eradication improves the prognosis of peptic ulcer disease (PUD), dyspepsia, and possibly gastric cancer. H pylori screening tests are accurate and eradication therapy is effective. H pylori population screening seems attractive. The aim of this study was to evaluate the long-term effect of H pylori population screening and eradication on dyspepsia prevalence and the incidence of PUD, and as secondary outcomes to assess the effect on health care consumption and quality of life.

METHODS

At baseline in 1998 to 1999, 20,011 individuals aged 40 to 65 years were randomized to H pylori screening and eradication or a control group with no screening. Both groups received a questionnaire on dyspepsia and quality of life. Register data were obtained for all randomized individuals.

RESULTS

The baseline questionnaire response rate was 63%. Of the 5749 individuals screened, 1007 (17.5%) were H pylori positive. Complete symptom data were obtained for 8658 (69%) individuals after 13 years. Dyspepsia prevalence decreased in both groups during the follow-up period, but multivariate analysis showed no effect of H pylori screening and eradication (adjusted odds ratio, 0.93; 95% confidence interval, 0.82-1.04); compared with usual care. Intention-to-treat and per-protocol analyses of register data provided similar results. H pylori screening neither reduced PUD incidence significantly (adjusted odds ratio, 0.88; 95% confidence interval, 0.70-1.11) nor did it have a beneficial effect on health care consumption. H pylori screening had no long-term effect on quality of life.

CONCLUSIONS

This randomized clinical trial with 13 years of follow-up evaluation, designed to provide evidence on the effect of H pylori population screening, showed no significant long-term effect when compared with usual care in this low-prevalence area. ClinicalTrials.gov identifier: NCT02001727.

Randomized clinical trial: the impact of gastrointestinal risk factor screening and prophylactic proton pump inhibitor therapy in patients receiving dual antiplatelet therapy

OBJECTIVE

Dual antiplatelet therapy reduces the risk of ischemic complications after acute coronary syndrome, but increases the risk of bleeding including upper gastrointestinal bleeding (UGIB).The aim of this study was to examine the effect of screening for risk of UGIB and prophylactic proton pump inhibitor (PPI) treatment in dual-antiplatelet-treated patients at risk of UGIB and to assess the significance of dual antiplatelet therapy compliance for cardiovascular events.

PATIENTS AND METHODS

In a register-based randomized-controlled trial, 2009 patients were included at the time of first percutaneous coronary intervention and randomized to either screening or control. Screened high-risk patients were prescribed pantoprazole 40 mg during the 1-year after percutaneous coronary intervention.

RESULTS

The incidence of UGIB was 0.8 versus 1.3% in screened patients and controls, respectively (P=0.381).Significantly fewer screened patients (5.4%) than controls (8.0%) underwent upper gastrointestinal endoscopy (P=0.026). Screened patients (2.9%) had significantly fewer events of unstable angina pectoris than controls (4.7%) (P=0.036) and a higher compliance to dual antiplatelet therapy (88.3 vs. 85.0%) (P=0.035), but no statistically difference was observed in the incidences of myocardial infarction and all-cause mortality (1.0 vs. 1.5%) (P=0.422).

CONCLUSION

Screening for risk factors for UGIB and subsequent prophylactic PPI treatment did not significantly reduce the incidence of UGIB. Prescription of PPI was associated with a higher compliance with dual antiplatelet therapy and decreases the risk of recurrent cardiovascular events.

Current prevalence of Helicobacter pylori infection in patients with dyspepsia treated in Warsaw, Poland

INTRODUCTION

The prevalence of Helicobacter pylori (Hp) infection in patients with dyspepsia has important clinical and epidemiological implications. However, the current prevalence of Hp infection among patients within Poland is unknown; the last data were collected a decade ago and the majority of previous studies showed the prevalence to be between 60% and 100%.

AIM

To establish the current prevalence of Hp infection among patients with dyspepsia in Warsaw, Poland.

MATERIAL AND METHODS

The study group comprised 148 patients (126 women and 22 men) with dyspepsia, treated in two outpatient clinics in Warsaw. The mean age in the group that tested positive for Hp was 45.8 years (SD = 14.86; median = 51; min = 19; max = 64). They were tested for Hp infection with a urea breath test that uses 13C-enriched urea and isotope ratio mass spectrometry.

RESULTS

Helicobacter pylori infection was found in 53 patients (44 women and 9 men), i.e. in 35.8% of the whole study group. We did not find any significant relationship between Hp infection and the patients' age, gender, or their body mass index.

CONCLUSIONS

The current prevalence of Hp infection among patients with dyspepsia treated in Warsaw is 35.8%. However, our data suggest almost a two-fold fall in the prevalence of Hp infection compared to the previous Polish studies.

Helicobacter pylori eradication for the prevention of gastric neoplasia

BACKGROUND

Gastric cancer is the third most common cause of cancer death worldwide. Individuals infected with Helicobacter pylori have a higher likelihood of developing gastric cancer than individuals who are not infected. Eradication of H. pylori in healthy asymptomatic individuals in the general population may reduce the incidence of gastric cancer, but the magnitude of this effect is unclear.

OBJECTIVES

To assess the effectiveness of eradication of H. pylori in healthy asymptomatic individuals in the general population in reducing the incidence of gastric cancer.

SEARCH METHODS

We identified trials by searching the Cochrane Central Register of Controlled Trials (CENTRAL; 2013, Issue 11), MEDLINE (1946 to December 2013), and EMBASE (1974 to December 2013). We handsearched reference lists from trials selected by electronic searching to identify further relevant trials. We handsearched published abstracts from conference proceedings from the United European Gastroenterology Week (published in Gut) and Digestive Disease Week (published in Gastroenterology) between 2001 and 2013. We contacted members of the Cochrane Upper Gastrointestinal and Pancreatic Diseases Review Group and experts in the field and asked them to provide details of outstanding clinical trials and any relevant unpublished materials.

SELECTION CRITERIA

We analysed randomised controlled trials comparing at least one week of H. pylori therapy with placebo or no treatment in preventing subsequent development of gastric cancer in otherwise healthy and asymptomatic H. pylori-positive adults. Trials had to follow up participants for at least two years and needed to have at least two participants with gastric cancer as an outcome. We defined gastric cancer as any gastric adenocarcinoma, including intestinal (differentiated) or diffuse (undifferentiated) type, with or without specified histology.

DATA COLLECTION AND ANALYSIS

We collected data on incidence of gastric cancer, incidence of oesophageal cancer, deaths from gastric cancer, deaths from any cause, and adverse effects arising due to therapy.

MAIN RESULTS

Six trials met all our eligibility criteria and provided extractable data. Three trials were at low risk of bias, one trial was at unclear risk, and two trials were at high risk of bias. Five trials were conducted in Asian populations. In preventing development of subsequent gastric cancer, H. pylori eradication therapy was superior to placebo or no treatment (6 trials, 6497 participants, risk ratio (RR) of developing subsequent gastric cancer 0.66; 95% confidence interval (CI) 0.46 to 0.95; moderate-quality evidence). Only one trial reported effect of eradication of H. pylori on development of subsequent oesophageal cancer (2 (0.2%) among 817 participants assigned to eradication therapy, compared with 1 (0.1%) of 813 participants allocated to placebo; RR 1.99; 95% CI 0.18 to 21.91). The effect of H. pylori eradication on preventing death from gastric cancer compared with placebo or no treatment was uncertain due to wide confidence intervals (3 trials, 4475 participants, RR 0.67; 95% CI 0.40 to 1.11; moderate-quality evidence). There was no evidence of an effect on all-cause mortality (4 trials, 5253 participants, RR 1.09; 95% CI 0.86 to 1.38; moderate-quality evidence). Adverse events data were poorly reported.

AUTHORS' CONCLUSIONS

We found limited, moderate-quality evidence that searching for and eradicating H. pylori reduces the incidence of gastric cancer in healthy asymptomatic infected Asian individuals, but we cannot necessarily extrapolate this data to other populations.

Global prevalence of, and risk factors for, uninvestigated dyspepsia: a meta-analysis

OBJECTIVES

Many cross-sectional surveys have reported the prevalence of uninvestigated dyspepsia, but there has been no recent systematic review of data from all studies to determine its global prevalence and risk factors.

DESIGN

MEDLINE, EMBASE and EMBASE Classic were searched (until January 2014) to identify population-based studies that reported the prevalence of uninvestigated dyspepsia in adults (≥ 15 years old); dyspepsia was defined using symptom-based criteria or questionnaires. The prevalence of dyspepsia was extracted for all studies and according to the criteria used to define it. Pooled prevalence, according to study location and certain other characteristics, ORs and 95% CIs were calculated.

RESULTS

Of the 306 citations evaluated, 103 reported the prevalence of uninvestigated dyspepsia in 100 separate study populations, containing 312,415 subjects. Overall pooled prevalence in all studies was 20.8% (95% CI 17.8% to 23.9%). The prevalence varied according to country (from 1.8% to 57.0%) and criteria used to define dyspepsia. The greatest prevalence values were found when a broad definition of dyspepsia (29.5%; 95% CI 25.3% to 33.8%) or upper abdominal or epigastric pain or discomfort (20.4%; 95% CI 16.3% to 24.8%) were used. The prevalence was higher in women (OR 1.24; 95% CI 1.13 to 1.36), smokers (OR 1.25; 95% CI 1.12 to 1.40), non-steroidal anti-inflammatory drug (NSAID) users (OR 1.59; 95% CI 1.27 to 1.99) and Helicobacter pylori-positive individuals (OR 1.18; 95% CI 1.04 to 1.33).

CONCLUSIONS

The overall pooled prevalence of uninvestigated dyspepsia was 21%, but varied among countries and according to the criteria used to define its presence. Prevalence is significantly higher in women, smokers, NSAID users and H. pylori-positive individuals, although these associations were modest.

From ischochymia to gastroparesis: proposed mechanisms and preferred management of dyspepsia over the centuries

Dyspeptic symptoms are common with most patients suffering functional disorders that remain a therapeutic challenge for medical practitioners. Within the last three decades, gastric infection, altered motility, and hypersensitivity have gained and lost traction in explaining the development of functional dyspepsia. Considering these shifts, the aim of this review was to analyze changing understanding of and approaches to dyspepsia over a longer time period. Monographs, textbooks, and articles published during the last three centuries show that our understanding of normal gastric function has improved dramatically. With increased insight came new ideas about disease mechanisms, diagnostic options, and treatments. Despite shifts over time, the importance of functional abnormalities was recognized early on and explained in the context of societal influences and stressors, anxieties, and biological influences, thus resembling the contemporary biopsychosocial model of illness. Symptoms were often attributed to changes in secretion, motility, and sensation or perception with technological innovation often influencing proposed mechanisms and treatments. Many of the principles or even agents applied more than a century ago are still part of today's approach. This includes acid suppression, antiemetics, analgesics, and even non-pharmacologic therapies, such as gastric decompression or electrical stimulation of the stomach. This historical information does not only help us understand how we arrived at our current state of knowledge and standards of care, it also demonstrates that enthusiastic adoption of various competing explanatory models and the resulting treatments often did not survive the test of time. In view of the benign prognosis of dyspepsia, the data may function as a call for caution to avoid the potential harm of overly aggressive approaches or treatments with a high likelihood of adverse effects.

Helicobacter pylori eradication therapy to prevent gastric cancer in healthy asymptomatic infected individuals: systematic review and meta-analysis of randomised controlled trials

OBJECTIVES

To determine whether searching for Helicobacter pylori and treating with eradication therapy leads to a reduction in incidence of gastric cancer among healthy asymptomatic infected individuals.

DESIGN

Systematic review and meta-analysis of randomised controlled trials.

DATA SOURCES

Medline, Embase, and the Cochrane central register of controlled trials were searched through to December 2013. Conference proceedings between 2001 and 2013 were hand searched. A recursive search was performed with bibliographies of relevant studies. There were no language restrictions.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials examining the effect of at least seven days of eradication therapy on subsequent occurrence of gastric cancer in adults who tested positive for Helicobacter pylori but otherwise healthy and asymptomatic were eligible. The control arm had to receive placebo or no treatment. Subjects had to be followed for ≥ 2 years.

MAIN OUTCOME MEASURES

Primary outcome, defined a priori, was the effect of eradication therapy on the subsequent occurrence of gastric cancer expressed as a relative risk of gastric cancer with 95% confidence intervals.

RESULTS

The search strategy identified 1560 citations, of which six individual randomised controlled trials were eligible. Fifty one (1.6%) gastric cancers occurred among 3294 individuals who received eradication therapy versus 76 (2.4%) in 3203 control subjects (relative risk 0.66, 95% confidence interval 0.46 to 0.95), with no heterogeneity between studies (I(2)=0%, P=0.60). If the benefit of eradication therapy was assumed to persist lifelong the number needed to treat was as low as 15 for Chinese men and as high as 245 for US women.

CONCLUSIONS

These data provide limited, moderate quality evidence that searching for and eradicating H pylori reduces the incidence of gastric cancer in healthy asymptomatic infected Asian individuals, but these data cannot necessarily be extrapolated to other populations.

Treatment for Helicobacter pylori infection and risk of Parkinson's disease in Denmark

BACKGROUND AND PURPOSE

It has been speculated that gastrointestinal infection with Helicobacter pylori (HP) contributes to the development of Parkinson's disease (PD). We used nationwide Danish registers to investigate this hypothesis.

METHODS

 We identified 4484 patients with a first time PD diagnosis between 2001 and 2008 from the Danish National Patient Register (DNPR) and 22, 416 population controls from the Danish Civil Registration System (CRS). Information on drug use was obtained from the National Prescription Registry (NPR). We used logistic regression to compute odds ratios (OR) for the association between treatment for HP and risk of PD.

RESULTS

Prescriptions for HP-eradication drugs and proton pump inhibitors (PPI) 5 or more years prior to the diagnosis of PD were associated with a 45% and 23% increase in PD risk, respectively. Hospitalizations and outpatient visits for gastritis and peptic/duodenal ulcers, however, were not associated with PD.

CONCLUSIONS

  Our population-based study suggests that chronic HP infections and/or gastritis contribute to PD or that these are PD-related pathologies that precede motor symptoms.

Helicobacter pylori and risk of upper gastrointestinal bleeding among users of selective serotonin reuptake inhibitors

BACKGROUND

A number of studies have reported a possible association between use of selective serotonin reuptake inhibitors (SSRIs) and serious upper gastrointestinal bleeding (UGB). We conducted this case-control study to assess if Helicobacter pylori (H. pylori) potentiates the risk of serious UGB in SSRI users.

MATERIAL AND METHODS

A population-based case-control study was conducted in the county of Funen, Denmark. Cases were 53 SSRI users with serious UGB whose H. pylori status on their bleeding date could be established. Controls (n = 723) were selected among subjects who participated in a population H. pylori screening study, and who were users of SSRIs. Data on drug exposure and medical history were retrieved from a prescription database and the county's patient register. Confounders were controlled for by unconditional logistic regression.

RESULTS

H. pylori infection increased the risk of serious UGB in patients using SSRI with an adjusted odds ratio (OR) of 2.73 (95% confidence interval (CI), 1.17-6.36). The adjusted OR for serious UGB among users of non-steroidal anti-inflammatory drugs (NSAIDs) and acetylsalicylic acid (ASA) were 3.91 (95% CI, 2.03-7.52) and 3.00 (95% CI, 0.94-9.54), respectively.

CONCLUSION

H. pylori infection increases the risk of SSRI-related serious UGB.

Chemoprevention for gastric cancer

Gastric cancer remains the fourth commonest cancer, and the second commonest cause of cancer death, globally. Chemopreventive strategies to reduce the incidence of gastric cancer are required, particularly as the number of deaths per year is likely to rise for the foreseeable future. There is some evidence that population screening and treatment for Helicobacter pylori in high-risk populations may reduce incidence of gastric cancer. Trials studying the effect of anti-oxidants and selenium are conflicting. A recent meta-analysis demonstrated that aspirin use led to a reduced risk of gastric cancer after 10-20 years of follow-up. There is little convincing evidence that statins have any effect on risk of gastric cancer. More trials on chemoprevention for gastric cancer are therefore urgently required.

Clinical trial: prolonged beneficial effect of Helicobacter pylori eradication on dyspepsia consultations - the Bristol Helicobacter Project

BACKGROUND

Chronic infection of the stomach with Helicobacter pylori is widespread throughout the world and is the major cause of peptic ulcer disease and gastric cancer. Short-term benefit results from community programmes to eradicate the infection, but there is little information on cumulative long-term benefit.

AIM

To determine whether a community programme of screening for and eradication of H. pylori infection produces further benefit after an initial 2-year period, as judged by a reduction in GP consultations for dyspepsia.

METHODS

A total of 1517 people aged 20-59 years, who were registered with seven general practices in Frenchay Health District, Bristol, had a positive (13)C-urea breath test for H. pylori infection and were entered into a randomized double-blind trial of H. pylori eradication therapy. After 2 years, we found a 35% reduction in GP consultations for dyspepsia (previously reported). In this extension to the study, we analysed dyspepsia consultations between two and 7 years after treatment.

RESULTS

Between two and 7 years after treatment, 81/764 (10.6%) of participants randomized to receive active treatment consulted for dyspepsia, compared with 106/753 (14.1%) of those who received placebo, a 25% reduction, odds ratio 0.84 (0.71, 1.00), P = 0.042.

CONCLUSIONS

Eradication of H. pylori infection in the community gives cumulative long-term benefit, with a continued reduction in the development of dyspepsia severe enough to require a consultation with a general practitioner up to at least 7 years. The cost savings resulting from this aspect of a community H. pylori eradication programme, in addition to the other theoretical benefits, make such programmes worthy of serious consideration, particularly in populations with a high prevalence of H. pylori infection.

The impact of body mass index and Helicobacter pylori infection on gastro-oesophageal reflux symptoms: a population-based study in Northern Norway

OBJECTIVE

Increased body mass index (BMI) has been proposed as a risk factor for gastro-oesophageal reflux symptoms. The aim of this study was to evaluate the effect of BMI and Helicobacter pylori on reflux symptoms in an adult population.

MATERIAL AND METHODS

For this cross-sectional, population-based study from Bodø and Sørreisa communities in Northern Norway, a total of 3927 adults were invited to complete a questionnaire on gastrointestinal symptoms and to provide stool samples for the assessment of H. pylori. Reflux symptoms were considered present when a reflux syndrome score was > or =2 according to the Gastrointestinal Symptom Rating Scale (GSRS).

RESULTS

The response rate was 44.2%, and 44.7% of the respondents were male. Age-adjusted prevalences were: for overweight, 35.6% (95% CI (32.4%; 38.8%)); for obesity, 10.0% (8.4%; 11.6%); for H. pylori: 21.2% (19.1%; 23.9%) and for reflux symptoms: 21.7% (19.5%; 23.9%). In the logistic regression analyses, H. pylori and smoking were not risk factors for reflux symptoms, whereas male gender (OR 4.78 (95%CI (1.88; 12.1)), age (1.01 (1.00; 1.03)) and overweight (1.51 (1.14; 2.00)) were. When stratified by gender, overweight and age were independent risk factors for reflux symptoms in females only, whereas H. pylori infection was protective against such symptoms in men. Models including these parameters could only explain 3% of the variations in reflux symptoms.

CONCLUSIONS

BMI is an independent risk factor for gastro-oesophageal reflux symptoms among healthy female adults, but contributes only to a minor part of the variation in these symptoms. H. pylori is protective against reflux symptoms in men.

A "screen-and-treat" approach for Helicobacter pylori infection: a population-based study in Vammala, Finland

BACKGROUND

To accelerate the decline of Helicobacter pylori infection, and to study the significance of the possible risk factors for H. pylori infection in Finland, we started a voluntary H. pylori"screen-treat-retest-and-retreat" program for all young adults at primary health care in Vammala, Finland after a pilot study in 1994 including 504 subjects aged 15-75.

MATERIALS AND METHODS

A total of 3326 aged 15-40 in 1996, and 716 aged 15 and 584 aged 45 in 1997-2000 were screened for H. pylori using serology. Helicobacter pylori positive were treated, cure was verified by serology.

RESULTS

The eradication rates were 93.8%, 82.2%, and 77.6% per protocol in pilot study in 1994, in subjects invited in 1996 and 1997-2000, respectively. Helicobacter pylori seroprevalence rates were calculated to have decreased from 36% to 14% in pilot study, from 12% to 4% among subjects invited in 1996, from 3% to 2% among subjects aged 15 and from 27% to 12% among subjects aged 45 in 1997-2000. An epidemiologic questionnaire in 1996 revealed that crowding in the childhood household, low education of the mother, current smoking and alcohol consumption, unfavorable housing conditions, and sick leaves due to dyspepsia were independently associated with H. pylori infection.

CONCLUSIONS

This intervention with high participation rates resulted in a significant decline in calculated H. pylori seroprevalence rates. Although the low prevalence of H. pylori infection may limit the cost efficiency of the program, the intervention is expected to reduce the burden of H. pylori-associated diseases.

Gastroesophageal reflux symptoms in a Danish population: a prospective follow-up analysis of symptoms, quality of life, and health-care use

OBJECTIVES

The prevalence of gastroesophageal reflux symptoms (GERS) in the population is high; however, data on long-term follow-up and incidence of GERS in the population are sparse. This study describes the long-term natural history of GERS, the related health-care use, and quality of life in a population followed up for 5 years.

METHODS

A total of 10,000 randomly selected inhabitants, 40-65 years old, received, as a part of a controlled trial of Helicobacter pylori screening and treatment (control group), a mailed questionnaire regarding demographic data, gastrointestinal symptoms (the Gastrointestinal Symptom Rating Scale (GSRS)), and quality of life (the Short-Form 36-Item Health Survey (SF-36)) at inclusion and after 5 years. GERS was defined as a mean score > or =2 in the reflux dimension in the GSRS. Information on use of health-care resources was drawn from the questionnaires and registers.

RESULTS

In all, 6,781 individuals answered the first questionnaire and 5-year symptom data were complete for 5,578 (82.3%) of them. The mean age at inclusion was 52.4 years, 48% were men. At inclusion, 22% reported GERS. During follow-up, symptoms resolved in 43%, of whom 10% received acid inhibitory treatment at 5-year follow-up. The incidence of GERS was 2.2% per year. Health-care use during follow-up was significantly higher in individuals with GERS at baseline than in individuals without GERS. Quality of life at 5-year follow-up was lower in individuals with GERS at inclusion than in individuals without GERS at inclusion.

CONCLUSIONS

GERS are prevalent, long lasting, and associated with an impaired quality of life and substantial health-care use.

Effect of a community screening for Helicobacter pylori: a 5-Yr follow-up study

BACKGROUND

Helicobacter pylori (H. pylori) screening and eradication may reduce the incidence of gastric cancer, AND AIMS: peptic ulcer, and ulcer complications, and it may reduce symptoms in a small proportion of individuals with functional dyspepsia. This study aimed to assess the effect of community H. pylori screening and treatment on the prevalence of dyspepsia, and as secondary outcomes, the effect on dyspepsia-related health-care consumption and quality of life over 5 yr.

METHODS

In 1998-1999, individuals aged 40-65 yr were randomized to H. pylori screening and treatment or to the control group. Five years later, the participants were sent a questionnaire to assess the prevalence of dyspepsia and quality of life. In addition, we obtained information from registers on the use of endoscopies and prescription medication. An economic evaluation was done alongside the randomized trial.

RESULTS

Of 12,530 participants attending the study at baseline, 11,065 (88%) were traced and contacted at the 5-yr follow-up. The response rate was 94%. At baseline, 17.5% in the screened group were H. pylori-positive. The absolute reduction in dyspepsia during the first year was 4% in the screened group, whereas no change was observed in the unscreened group; this rate remained constant during the next 4 yr. Quality of life did not change. A small effect was found for dyspepsia-related consultations and sick leave days, but not on the prescription rate of ulcer drugs. A 33% lower ulcer incidence (107 ulcers vs 148 ulcers) was seen in the screened group compared to the unscreened group.

CONCLUSION

A population H. pylori screening and treatment program in an H. pylori low-prevalence area had only a modest, but insignificant, effect on the rate of dyspepsia, and a modest, significant effect on the consultation rate and sick leave days for dyspepsia, but resulted in a decreased ulcer incidence. The intervention resulted in an increased cost due to H. pylori screening and treatment.

Cost-effectiveness analysis between primary and secondary preventive strategies for gastric cancer

OBJECTIVE

The present study is done to assess the relative cost-effectiveness, optimal initial age, and interscreening interval between primary and secondary prevention strategies for gastric cancer.

METHODS

Base-case estimates, including variables of natural history, efficacy of intervention, and relevant cost, were derived from two preventive programs targeting a high-risk population. Cost-effectiveness was compared between chemoprevention with (13)C urea breath testing followed by Helicobacter pylori (H. pylori) eradication and high-risk surveillance based on serum pepsinogen measurement and confirmed by endoscopy. The main outcome measure was cost per life-year gained with a 3% annual discount rate.

RESULTS

The incremental cost-effectiveness ratio (ICER) for once-only chemoprevention at age 30 years versus no screening was U.S. $17,044 per life-year gained. Eradication of H. pylori at later age or with a periodic scheme yielded a less favorable result. Annual high-risk screening at age of 50 years versus no screening resulted in an ICER of U.S. $29,741 per life-year gained. The ICERs of surveillance did not substantially vary with different initial ages or interscreening intervals. Chemoprevention could be dominated by high-risk surveillance when the initial age was older than 44 years. Otherwise, chemoprevention was more cost-effective than high-risk surveillance, either at ceiling ratios of U.S. $15,762 or up to U.S. $50,000. The relative cost-effectiveness was most sensitive to the infection rate of H. pylori and proportion of early gastric cancer in all detectable cases.

CONCLUSIONS

Early H. pylori eradication once in lifetime seems more cost-effective than surveillance strategy. However, the choice is still subject to the risk of infection, detectability of early gastric cancer, and timing of intervention.

Eradication therapy for Helicobacter pylori

Eradication therapy for Helicobacter pylori is recommended in a number of clinical conditions. In this article, we discuss the epidemiology and cellular mechanisms that result in antimicrobial resistance, the results of current eradication therapies, and new approaches to the management of Helicobacter pylori infection.

Agreement of decision analyses and subsequent clinical studies in infectious diseases

PURPOSE

Decision analysis techniques can compare management strategies when there are insufficient data from clinical studies to guide decision making. We compared the outcomes of decision analyses and subsequent clinical studies in the infectious disease literature to assess the validity of the conclusions of the decision analyses.

METHODS

A search strategy to identify decision analyses in infectious disease topics published from 1990 to 2005 was developed and performed using PubMed. Abstracts of all identified articles were reviewed, and infectious disease-related decision analyses were retained. Subsequent clinical trials and observational studies that corresponded to these decision analyses were identified using prespecified search strategies. Clinical studies were considered a match for the decision analysis if they assessed the same patient population, intervention, and outcome. Agreement or disagreement between the conclusions of the decision analysis and clinical study were determined by author review.

RESULTS

The initial PubMed search yielded 318 references. Forty decision analyses pertaining to 29 infectious disease topics were identified. Of the 40, 16 (40%) from 13 infectious disease topics had matching clinical studies. In 12 of 16 (75%), conclusions of at least 1 clinical study agreed with those of the decision analysis. Three of the 4 decision analyses in which conclusions disagreed were from the same topic (management of febrile children).

CONCLUSIONS

There was substantial agreement between the conclusions of decision analyses and clinical studies in infectious diseases, supporting the validity of decision analysis and its utility in guiding management decisions.

Helicobacter pylori infection and gender: a meta-analysis of population-based prevalence surveys

Although most of Helicobacter pylori-related diseases are associated with male gender, the role of gender as a risk factor for H. pylori infection is still debated. To assess the true association between H. pylori and gender, we conducted a meta-analysis of large, population-based studies where the measure of association had been adjusted at least for age and socioeconomic status, and obtained primary data from authors when information on gender associations were not presented. In 18 adult populations, the test of heterogeneity was not significant and male gender was significantly associated with H. pylori infection (summary odds ratio [OR] 1.16 [95% confidence interval (CI) 1.11, 1.22]). In 10 pediatric populations, the test of heterogeneity was of borderline significance, and the summary OR computed using a random effect model was close to 1 (summary OR 1.03 [95% CI 0.91, 1.17]). This study confirms the male predominance of H. pylori infection in adults as a global and homogeneous phenomenon; such predominance is not apparent in children. Differential antibiotic exposure or differential protective immunity between genders may explain the different results observed between children and adult studies.

Quality of life in patients with functional dyspepsia: Short- and long-term effect of Helicobacter pylori eradication with pantoprazole, amoxicillin, and clarithromycin or cisapride therapy: A prospective, parallel-group study

BACKGROUND

Quality of life (QOL) is impaired in functional dyspepsia (FD). Little is known about the effects of different therapies on the QOL profile in patients with this condition.

OBJECTIVES

The aims of this study were to measure baseline QOL in patients with FD and to assess changes in QOL over time associated with Helicobacter pylori eradication and prokinetic treatment. The primary and secondary end points were the improvement in QOL 6 weeks and 1 year after successful eradication of the infection or prokinetic therapy.

METHODS

This 1-year, single-center, prospective, open-label, controlled, parallel-group trial was conducted at the Department of Gastroenterology, Ferencvdros Health Centre, Budapest, Hungary. The Functional Digestive Disorder Quality of Life (FDDQoL) Questionnaire (MAPI Research Institute, Lyon, France) was translated and validated previously in Hungarian. Male and female subjects aged 20 to 60 years were enrolled and classified as H pylori positive (HP+), H pylori negative (HP-) with FD, or healthy (control group). The HP+ patients received pantoprazole 40 mg BID + amoxicillin 1000 mg BID + clarithromycin 500 mg BID for 7 days, followed by on-demand ranitidine (150-300 mg/d) for 1 year. The HP- patients received the prokinetic cisapride 10 mg TID for 1 month, followed by on-demand cisapride (10-20 mg/d) for 1 year. The FDDQoL questionnaire was completed by all 3 groups on enrollment, at 6 weeks, and 1 year.

RESULTS

A total of 101 HP+ patients, 98 HP- patients, and 123 healthy controls were included in the study (185 women, 137 men; mean age, 39.0 ears). The mean (SD) baseline QOL scores were significantly lower in the HP+ group (53.3 [9.6]; 95% CI, 54.4-58.2) and the HP- groups (50.0 [9.8]; 95% CI, 58.0-62.0) compared with that in healthy controls (76.2 [8.7]; 95% CI, 74.6-77.8) (both, P < 0.001). Analysis of the short-term domain scores found that the HP+ group had significantly decreased scores in 6 of 8 domains: daily activities (P = 0.005), anxiety level (P = 0.02), diet (P = 0.008), sleep (P < 0.001), discomfort (P = 0.004), and disease control (P = 0.02); the HP- group had significantly decreased scores in 5 of 8 domains: daily activities (P < 0.001), diet (P = 0.004), sleep (P = 0.005), discomfort (P < 0.001), and disease control (P = 0.02). Eradication of the infection was successful in 77/101 (76.2%) of the patients on intent-to-treat analysis and 77/94 (81.9%) on per-protocol analysis. Eradication was associated with an increase in mean (SD) QOL score to 70.8 (10.7) at 6 weeks (95% CI, 63.3-73.2; P < 0.001 vs baseline) and to 75.3 (9.3) at 1 year (95% CI, 73.2-77.5; P= 0.05 vs 6 weeks). In the HP- group, the QOL score increased to 73.3 (9.7) (95% CI, 71.3-75.4; P < 0.001 vs baseline) at 6 weeks of cisapride treatment and to 76.5 (8.5) at 1 year (95% CI, 74.5-78.4; P = 0.06 vs 6 weeks). Most of the impaired domain scores improved significantly after both treatments. The short-term effect size was 1.48 in HP+ and 1.35 in HP- patients. Adverse events (AEs) occurred in 22 (21.8%) patients in the HP+ group (nausea, 8 [7.9%] patients; diarrhea, 5 [5.0%]; loss of appetite, 5 [5.0%]; stomatitis, 5 [5.0%]; abdominal pain, 4 [4.0%]; bloating, 4 [4.0%]; headache, 4 [4.0%]; vomiting, 4 [4.0%]; constipation, 3 [3.0%]; and vaginitis, 3 [3.0%]). In HP- cases, AEs occurred in 9 (9.2%) patients (abdominal cramps, 7 [7.1%]; diarrhea, 4 [4.1%]; and nausea, 3 [3.1%]).

CONCLUSION

In this study in patients with FD and healthy controls, eradication of H pylori infection in infected patients and cisapride treatment in uninfected patients reversed low QOL scores during the 1-year follow-up period.

Complicated and uncomplicated peptic ulcers in a Danish county 1993-2002: a population-based cohort study

Peptic ulcer epidemiology changes as the proportion of Helicobacter pylori infected people decreases, use of nonsteroidal anti-inflammatory drugs (NSAID) increases, and the proportion of elderly persons increases.

OBJECTIVES

To describe incidence and prognosis of uncomplicated and complicated peptic ulcer patients in Funen County 1993-2002.

METHODS

Data on endoscopies, gastric and duodenal operations, and related peptic ulcer diagnoses were extracted from four population-based databases covering a period from 1974 to 2002. All citizens of Funen County (population 470,000) who between 1993 and 2002 had a peptic ulcer diagnosed for the first time were identified.

RESULTS

Between 1993 and 2002 the incidence of uncomplicated duodenal ulcer decreased from 0.55/1,000 person-years (95% CI 0.49-0.62) to 0.37 (0.31-0.43), uncomplicated gastric ulcer decreased from 0.56 (0.49-0.63) to 0.40 (0.34-0.46), and perforated ulcer decreased from 0.14 (0.11-0.18) to 0.08 (0.06-0.11). The incidence of bleeding peptic ulcer was stable with 0.55 (0.49-0.62) in 1993 and 0.57 (0.51-0.64) in 2002. The proportion of possible NSAID-related incident peptic ulcers increased from 320/827 (39%) in 1993 to 363/686 (53%) in 2002 (p < 0.01). A total of 3,233 patients with incident complicated peptic ulcer (9,927 person-years) and 4,421 patients with incident uncomplicated peptic ulcer (17,773 person-years) was followed for up to 10 yr. The first month following newly diagnosed complicated ulcer the standardized mortality rate was 37.1 (33.4-41.1) during the next 11 months it was 5.1 (4.6-5.6), and in the following years it was 2.6 (2.4-2.8). The corresponding figures for incident uncomplicated peptic ulcer was 11.6 (9.6-13.9), 4.0 (3.6-4.4), and 2.5 (2.3-2.7).

CONCLUSION

During the period, incidence of peptic ulcers decreased and an increasing proportion was related to NSAID. Mortality is high.

Risk factors for dyspepsia in a general population: non-steroidal anti-inflammatory drugs, cigarette smoking and unemployment are more important than Helicobacter pylori infection

OBJECTIVE

Dyspepsia, a common condition in the community, affects quality of life and imposes costs on both the individual and the community. Several factors including Helicobacter pylori, acetylic salicylic acid (ASA)/non-steroidal anti-inflammatory drugs (NSAIDs) use, low-dose ASA use, alcohol consumption, cigarette smoking and social status might be responsible.

MATERIAL AND METHODS

A cross-sectional study from the inclusion (intervention group) of a general population study evaluating rates of dyspepsia after H. pylori screening and eradication was carried out. A total of 10,007 individuals aged 40-64 years received questionnaires and an invitation to take part in H. pylori screening. Information on dyspepsia (the gastrointestinal symptom rating scale (GSRS) and "most bothersome symptom"), use of ASA/NSAIDs, use of low-dose ASA, lifestyle factors and level of education and employment status was obtained from the questionnaire. Dyspepsia was defined as a score of =2 in the GSRS dimension abdominal pain syndrome (aps), allowing for a maximum of one light problem score in any of the 3 items in the dimension to be overlooked.

RESULTS

In all, 5749/10,007 individuals participated in the study; 24.9% reported dyspepsia. In a multiple logistic regression analysis H. pylori infection was found to be a risk factor for dyspepsia, odds ratio (OR) 1.21 (CI; 1.03-1.42). However, the highest ORs for dyspepsia were: for daily use of ASA/NSAIDs 2.33 (CI; 1.72-3.15), unemployment 2.18 (CI; 2.86-2.56) and cigarette smoking =20 g/day 1.55 (CI; 1.29-1.86).

CONCLUSIONS

H. pylori infection is a significant risk factor for dyspepsia although of less importance than ASA/NSAIDs use, unemployment and heavy smoking.

Impact of Helicobacter pylori eradication on dyspepsia, health resource use, and quality of life in the Bristol helicobacter project: randomised controlled trial

OBJECTIVE

To determine the impact of a community based Helicobacter pylori screening and eradication programme on the incidence of dyspepsia, resource use, and quality of life, including a cost consequences analysis.

DESIGN

H pylori screening programme followed by randomised placebo controlled trial of eradication.

SETTING

Seven general practices in southwest England.

PARTICIPANTS

10,537 unselected people aged 20-59 years were screened for H pylori infection (13C urea breath test); 1558 of the 1636 participants who tested positive were randomised to H pylori eradication treatment or placebo, and 1539 (99%) were followed up for two years.

INTERVENTION

Ranitidine bismuth citrate 400 mg and clarithromycin 500 mg twice daily for two weeks or placebo.

MAIN OUTCOME MEASURES

Primary care consultation rates for dyspepsia (defined as epigastric pain) two years after randomisation, with secondary outcomes of dyspepsia symptoms, resource use, NHS costs, and quality of life.

RESULTS

In the eradication group, 35% fewer participants consulted for dyspepsia over two years compared with the placebo group (55/787 v 78/771; odds ratio 0.65, 95% confidence interval 0.46 to 0.94; P = 0.021; number needed to treat 30) and 29% fewer participants had regular symptoms (odds ratio 0.71, 0.56 to 0.90; P = 0.05). NHS costs were 84.70 pounds sterling (74.90 pounds sterling to 93.91 pounds sterling) greater per participant in the eradication group over two years, of which 83.40 pounds sterling (146 dollars; 121 euro) was the cost of eradication treatment. No difference in quality of life existed between the two groups.

CONCLUSIONS

Community screening and eradication of H pylori is feasible in the general population and led to significant reductions in the number of people who consulted for dyspepsia and had symptoms two years after treatment. These benefits have to be balanced against the costs of eradication treatment, so a targeted eradication strategy in dyspeptic patients may be preferable.

Prevalence, clinical spectrum and atypical symptoms of gastro-oesophageal reflux in Argentina: a nationwide population-based study

BACKGROUND

Population-based data on gastro-oesophageal reflux in Latin America are lacking.

AIM

To assess gastro-oesophageal reflux symptom prevalence, clinical spectrum and association with the atypical symptoms in our country.

METHODS

Gastro-oesophageal reflux self-report questionnaires validated at Mayo Clinic, USA, were submitted to a sample of 1000 residents (aged 18-80 years) from 17 representative geographical areas of Argentina. The samples were selected and stratified according to age, gender, geographical areas and size of town of residence provided by the Argentine Bureau of Statistics and Census.

RESULTS

The overall prevalence of any typical gastro-oesophageal reflux symptom experienced in the previous year was 61.2% (95% CI, 57.9-64.6), the prevalence of frequent gastro-oesophageal reflux symptoms was 23.0% (95% CI, 20.1-25.9) and the prevalence of gastro-oesophageal reflux disease was 11.9% (95% CI, 9.6-14.1). Frequent gastro-oesophageal reflux symptoms were associated with dysphagia (OR 2.12, 95% CI, 1.27-3.54, P < 0.01), globus (OR 2.22, 95% CI, 1.35-3.66, P < 0.01) and non-cardiac chest pain (OR 1.55, 95% CI, 1.04-2.31, P < 0.05).

CONCLUSIONS

In Argentina, typical symptoms of gastro-oesophageal reflux are highly prevalent at the national level, and frequent gastro-oesophageal reflux symptoms are significantly associated with dysphagia, globus and non-cardiac chest pain.

Review article: Helicobacter pylori and gastro-oesophageal reflux disease

Epidemiological studies demonstrate a negative association between Helicobacter pylori infection and gastro-oesophageal reflux disease and its complications. This might represent a protective effect because of the tendency for H. pylori infection to lower gastric acid secretion with advancing age. However, studies of the effect of H. pylori eradication on gastro-oesophageal reflux disease have failed to show any worsening of gastro-oesophageal reflux disease symptoms. Several interactions between H. pylori and proton-pump inhibitor therapy used to treat gastro-oesophageal reflux disease need to be considered. Helicobacter pylori infection improves the control of gastric acidity by proton-pump inhibitors and this produces a small advantage in clinical control of reflux disease. The infection prevents rebound acid hypersecretion occurring when proton-pump inhibitor therapy is discontinued. However, concerns have been expressed that the body gastritis induced by proton-pump inhibitor therapy in H. pylori-infected subjects might increase the risk of gastric cancer. At present, it is unclear whether H. pylori should be eradicated in gastro-oesophageal reflux disease patients.

Seroprevalence of Helicobacter pylori among children in Sana'a, Yemen

BACKGROUND

Helicobacter pylori infection is primarily acquired in early childhood. Its transmission routes are debated. The aims of this study were to determine the seroprevalence of anti-H. pylori immunoglobulin G (IgG) in Yemeni children under 10 years of age, the potential risk factors for contracting H. pylori infection and co-infection of H. pylori with intestinal parasites.

METHODS

Enzyme-labeled immunosorbent assay was used to determine the H. pylori prevalence rate among 572 healthy volunteers aged less than 10 years. Formalin ether concentration methods were used to test the prevalence of intestinal parasites (intestinal roundworms and tapeworms). In addition, we interviewed participants regarding potential risk factors for contracting H. pylori infection.

RESULTS

The seroprevalence of H. pylori antibodies was 9%. The prevalence according to age varied from 0% in children under 2 years to 12.5% in age group 9-10 years. There was a correlation between the amounts of positive antibodies and increasing age. The prevalence rate of H. pylori antibodies was also significantly associated with the practice of drinking water from reused plastic jerry cans, with poor mouth hygiene and with co-infection by intestinal parasites.

CONCLUSION

The prevalence of H. pylori antibodies in Yemen among children under 10 years of age is higher than that reported from other regions for the same age groups. Yemen shares some but not all potential risk factors for H. pylori infection with countries in which similar socioeconomic conditions are found. A possible way of eliminating H. pylori from the population would be via public health measures, i.e. preventing the reuse of plastic jerry cans, and improving sanitation and the standard of living.

Indicaciones y consecuencias de la erradicación de Helicobacter pylori en la enfermedad por reflujo gastroesofágico

Several epidemiological data indicate that H. pylori infection prevalence in patients with gastroesophageal reflux disease (GERD) is lower than that reported in respective controls, which would suggest that the organism plays a protective role against this disease. On the other hand, most studies demonstrate that the presence of the infection in patients with GERD does not negatively affect the therapeutic efficacy of proton pump inhibitors (PPIs), and, in case of negatively influencing it, the effects are not clinically relevant and are easily controllable with standard antisecretory treatment. Therefore, the decision to administer H. pylori eradication treatment to a patient should not be influenced by the concomitant presence of GERD. In most cases, H. pylori eradication does not seem to induce GERD development, and it does not seem to worsen GERD when it was already present. Nevertheless, when the gastritis pattern is unknown before the antibiotic administration, the effect of H. pylori eradication on gastric acid secretion and the incidence of GERD is unpredictable. In the exceptional cases in which H. pylori eradication could have negative effects on GERD, its clinical relevance will be limited, and reflux symptoms or endoscopic esophagitis will favourably respond to the standard PPI antisecretory treatment. Therefore, again, when H. pylori eradication is indicated in a particular patient, the concomitant diagnosis of GERD should not change our attitude. Finally, is has recently been recommended to eradicate H. pylori infection in those patients with GERD needing long-term treatment with PPI, as some studies have reported that these drugs induce, in presence of the organism, an atrophic gastritis, with the consequent risk of gastric cancer. However, most of these studies have important methodological defects, and several authors have reported contrary results. In any case, the appearance in the gastric mucosa of clinically relevant lesions, such as intestinal metaplasia, dysplasia or adenocarcinoma, in patients treated with PPI for several years, has not yet been demonstrated, although this could simply be a problem of time. This question seems to be too controversial to be answered with the available data, and we should wait until new studies clarify this topic. In the meantime, as it occurs with any controversial indication, the decision of the doctor facing a patient infected by H. pylori and needing maintenance therapy with PPIs should be assessed on a case by case basis.

Measurement and expression of risk: optimizing decision strategies

A significant proportion of the >6 million articles published annually present data in terms of risk and risk reduction. While the measurement of risk and risk reduction is often straightforward, there are a variety of ways that risk may be expressed. Risk is defined as the rate of an occurrence of a particular disease or adverse event and is determined by the number of events divided by the person-years or number of individuals in the at-risk population. The portrayal of risk can be achieved using different techniques but is typically provided in demographic maps, time-trend charts, or incidence bar graphs. Risk can be expressed in relative terms such as relative risk or absolute measures such as attributable risk or number needed to treat. Understanding risk determination as well as the differences in risk depiction and expression is necessary to ascertain the relevance of the data to one's clinical practice as well as to make optimal clinical and pharmacoeconomic treatment decisions. A review of terms, together with examples, is presented, such that clinicians evaluating the medical literature will be able to identify differences in the way that risk-related results are expressed and optimize the application of such evidence to their practice.

Helicobacter pylori public health implications

Population Helicobacter pylori screening and treatment has the potential to dramatically reduce global gastric cancer mortality. There is overwhelming evidence that the infection is a major cause of distal gastric adenocarcinoma. There is also randomized controlled trial evidence that H. pylori eradication reverses or ameliorates histological changes in the gastric mucosa that are important in carcinogenesis. Preliminary randomized controlled trial data suggest that screening and treatment may reduce the risk of gastric cancer although the number of cancer cases was small. Population H. pylori screening and treatment will also reduce mortality from peptic ulcer complications and reduce the burden of dyspepsia in the community. The reduction in health service dyspepsia costs means that this could be the first programme to pay for itself. From a scientific perspective, we still have insufficient evidence to conclude the benefits of population H. pylori screening are greater than the possible harms and we need more randomized controlled trial data. From a public health perspective however, sometimes screening programmes are developed with imperfect information. The medical community should be consistent and if we are instituting other population screening programmes without randomized controlled trial evidence then H. pylori testing and treatment should also be considered.

Helicobacter pylori and nonmalignant diseases

This paper reviews the new literature from the past year on the association between colonization with Helicobacter pylori and non-malignant disease of the upper gastrointestinal tract. This issue has, in the past year, remained a topic of wide research interest yielding many important new data. These data show that H. pylori eradication is the most effective therapy for peptic ulcer disease, but that a considerable proportion of ulcer patients remain to have dyspeptic symptoms. The discussion on the interaction between H. pylori and NSAID use in the etiology of ulcer disease has not yet been settled. Several studies, both from Asia and Europe, now reported that H. pylori eradication has a minimal effect on the primary prevention of ulcer disease in NSAID users, but eradication appears of relevance for the secondary prevention of ulcer disease in addition to proton pump inhibitor maintenance therapy. Various studies brought further support for the hypothesis that H. pylori eradication is of some benefit for patients with non-ulcer dyspepsia, although the effects are limited. The prevalence of H. pylori is lower among GERD patients than among controls, but H. pylori eradication has not been consistently shown to increase the risk for the newly development of GERD in an individual subject undergoing H. pylori eradication. The discussion on H. pylori and GERD should not preclude us from treating H. pylori-infected patients for accepted clinical indications. In patients using proton pump inhibitors for GERD, H. pylori eradication leads to a resolution of their corpus-predominant pangastritis, without impairing the efficacy of PPI therapy.

Randomised controlled trial of effects of Helicobacter pylori infection and its eradication on heartburn and gastro-oesophageal reflux: Bristol helicobacter project

OBJECTIVES

To investigate the effects of Helicobacter pylori infection and its eradication on heartburn and gastro-oesophageal reflux.

DESIGN

Cross sectional study, followed by a randomised placebo controlled trial.

SETTING

Seven general practices in Bristol, England.

PARTICIPANTS

10,537 people, aged 20-59 years, with and without H pylori infection (determined by the (13)C-urea breath test).

MAIN OUTCOME MEASURES

Prevalence of heartburn and gastro-oesophageal acid reflux at baseline and two years after treatment to eradicate H pylori infection.

RESULTS

At baseline, H pylori infection was associated with increased prevalence of heartburn (odds ratio 1.14, 95% confidence interval 1.05 to 1.23) but not reflux (1.05, 0.97 to 1.14). In participants with H pylori infection, active treatment had no effect on the overall prevalence of heartburn (0.99, 0.88 to 1.12) or reflux (1.04, 0.91 to 1.19) and did not improve pre-existing symptoms of heartburn or reflux.

CONCLUSIONS

H pylori infection is associated with a slightly increased prevalence of heartburn but not reflux. Treatment to eradicate H pylori has no net benefit in patients with heartburn or gastro-oesophageal reflux.

Personal view: to treat or not to treat? Helicobacter pylori and gastro-oesophageal reflux disease - an alternative hypothesis

Helicobacter pylori causes acute on chronic gastritis and is responsible for most peptic ulcers and gastric cancer. However, recent papers have suggested that it may protect against gastro-oesophageal reflux, Barrett's oesophagus and oesophageal cancer. Furthermore, the rapid increase in gastro-oesophageal reflux disease, Barrett's oesophagus and adenocarcinoma of the oesophagus in the developed world has been attributed by some to the falling prevalence of H. pylori. These considerations have led to the suggestion that H. pylori infection should not necessarily be treated, especially in patients with gastro-oesophageal reflux disease. Conversely, data from prospective randomized studies have shown that H. pylori eradication does not cause gastro-oesophageal reflux disease in patients with duodenal ulcer or in the normal population, nor does it worsen the outcome of pre-existing gastro-oesophageal reflux disease. Therefore, although H. pylori is negatively associated with gastro-oesophageal reflux disease, its eradication does not induce the disease. A hypothesis is presented suggesting that the increased prevalence of gastro-oesophageal reflux disease is a result of rising acid secretion in the general population, which, in turn, is a consequence of the increased linear height (a predictor of acid secretion). The greater acid secretion could also explain the decline in the prevalence of H. pylori and perhaps account for the inverse relationship between H. pylori and gastro-oesophageal reflux disease. These considerations are explored in discussing whether H. pylori infection should be treated in infected patients presenting with gastro-oesophageal reflux disease.