Non-ulcer dyspepsia and short term De-Nol therapy: a placebo controlled trial with particular reference to the role of Campylobacter pylori

Systematic review with meta-analysis: post-infectious functional dyspepsia

BACKGROUND

The prevalence of functional dyspepsia (FD) following infectious gastroenteritis has not been systematically reviewed.

AIM

To conduct a systematic review and calculate the summary odds ratio (OR) for the development of FD following infectious gastroenteritis, as compared to a control population.

METHODS

Published studies in PubMed, EmBASE, and Cochrane Database and abstracts from standard sources were screened for eligible studies. Data from studies meeting inclusion criteria were pooled for meta-analysis.

RESULTS

Nineteen studies were eligible for inclusion. The mean prevalence of FD following acute gastroenteritis (AGE) was 9.55% (FD, n = 909; AGE, n = 9517) in adult populations. The summary OR for the development of post-infectious FD was 2.54 (95% CI = 1.76-3.65) at more than 6 months after AGE, as compared to the prevalence in controls within the same population. This is compared with the summary OR (3.51; 95% CI = 2.05-6.00) for the development of post-infectious irritable bowel syndrome (IBS) in the same population at more than 6 months after AGE. There was significant statistical heterogeneity with an I(2) of 72.8% for the summary OR of post-infectious FD. Several pathogens, including Salmonella spp., Escherichia coli O157, Campylobacter jejuni, Giardia lamblia and Norovirus have been shown to be associated with post-infectious FD symptoms.

CONCLUSIONS

Infectious gastroenteritis is associated with an increased risk for subsequent dyspepsia as well as for irritable bowel syndrome. Post-infectious FD and post-infectious irritable bowel syndrome may represent different aspects of the same pathophysiology. Further studies will be needed to determine this.

WITHDRAWN: Eradication of Helicobacter pylori for non-ulcer dyspepsia

BACKGROUND

Helicobacter pylori (H pylori) is the main cause of peptic ulcer disease. The role of H pylori in non-ulcer dyspepsia is less clear.

OBJECTIVES

To determine the effect of H pylori eradication on dyspepsia symptoms in patients with non-ulcer dyspepsia.

SEARCH STRATEGY

Trials were identified through electronic searches of the Cochrane Controlled Trials Register (CCTR), MEDLINE, EMBASE, CINAHL and SIGLE, using appropriate subject headings and keywords, searching bibliographies of retrieved articles, and through contacts with experts in the fields of dyspepsia and with pharmaceutical companies.

SELECTION CRITERIA

All parallel group randomised controlled trials (RCTs) comparing drugs to eradicate H pylori with placebo or other drugs known not to eradicate H pylori for patients with non-ulcer dyspepsia.

DATA COLLECTION AND ANALYSIS

Data were collected on individual and global dyspeptic symptom scores, quality of life measures and adverse effects. Dyspepsia outcomes were dichotomised into minimal/resolved versus same/worse symptoms.

MAIN RESULTS

Twenty one randomised controlled trials were included in the systematic review. Eighteen trials compared antisecretory dual or triple therapy with placebo antibiotics +/- antisecretory therapy, and evaluated dyspepsia at 3-12 months. Seventeen of these trials gave results as dichotomous outcomes evaluating 3566 patients and there was no significant heterogeneity between the studies. There was a 10% relative risk reduction in the H pylori eradication group (95% CI = 6% to 14%) compared to placebo. The number needed to treat to cure one case of dyspepsia = 14 (95% CI = 10 to 25). A further three trials compared Bismuth based H pylori eradication with an alternative pharmacological agent. These trials were smaller and had a shorter follow-up but suggested H pylori eradication was more effective than either H2 receptor antagonists or sucralfate in treating non-ulcer dyspepsia.

AUTHORS' CONCLUSIONS

H pylori eradication therapy has a small but statistically significant effect in H pylori positive non-ulcer dyspepsia. An economic model suggests this modest benefit may still be cost-effective but more research is needed.

WITHDRAWN: Pharmacological interventions for non-ulcer dyspepsia

BACKGROUND

The commonest cause of upper gastrointestinal symptoms is non-ulcer dyspepsia (NUD) and yet the pathophysiology of this condition has been poorly characterised and the optimum treatment is uncertain. It is estimated that £450 million is spent on dyspepsia drugs in the UK each year.

OBJECTIVES

This review aims to determine the effectiveness of six classes of drugs (antacids, histamine H2 antagonists, proton pump inhibitors, prokinetics, mucosal protecting agents and antimuscarinics) in the improvement of either the individual or global dyspepsia symptom scores and also quality of life scores patients with non-ulcer dyspepsia.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2005), MEDLINE (1966 to January 2006), EMBASE (1988 to January 2006), CINAHL (1982 to January 2006), SIGLE, and reference lists of articles. We also contacted experts in the field and pharmaceutical companies. Trials were located through electronic searches of the Cochrane Controlled Trials Register (CCTR), MEDLINE, EMBASE, CINAHL and SIGLE, using appropriate subject headings and text words, searching bibliographies of retrieved articles, and through contacts with experts in the fields of dyspepsia and pharmaceutical companies.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing drugs of any of the six groups with each other or with placebo for non-ulcer dyspepsia (NUD).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility, trial quality and extracted data.

MAIN RESULTS

We included 73 trials: prokinetics (19 trials with dichotomous outcomes evaluating 3178 participants; relative risk reduction (RRR) 33%; 95% confidence intervals (CI) 18% to 45%), H(2)RAs (12 trials evaluating 2,183 participants; RRR 23%; 95% CI 8% to 35%) and PPIs (10 trials evaluating 3,347 participants; RRR 13%; 95% CI 4% to 20%) were significantly more effective than placebo. Bismuth salts (six trials evaluating 311 participants; RRR 40%; 95% CI -3 to 65%) were superior to placebo but this was of marginal statistical significance. Antacids (one trial evaluating 109 participants; RRR -2%; 95% CI -36% to 24%) and sucralfate (two trials evaluating 246 participants; RRR 29%; 95% CI -40% to 64%) were not statistically significantly superior to placebo. A funnel plot suggested that the prokinetic results could be due to publication bias or other small study effects.

AUTHORS' CONCLUSIONS

There is evidence that anti-secretory therapy may be effective in NUD. The trials evaluating prokinetic therapy are difficult to interpret as the meta-analysis result could have been due to publication bias. The effect of these drugs is likely to be small and many patients will need to take them on a long-term basis so economic analyses would be helpful and ideally the therapies assessed need to be inexpensive and well tolerated.

Pylera for the eradication of Helicobacter pylori infection

An ideal antibiotic regimen for Helicobacter pylori should achieve eradication rates of approximately 90%. Current 7-day triple therapy is successful in about two-thirds of patients. A novel treatment is required to achieve higher eradication with minimal induction of bacterial resistance. The aim of this article is to evaluate the safety and efficacy of a single triple capsule (Pylera) containing bismuth, metronidazole and tetracycline, given with omeprazole for the eradication of H. pylori infection. Extensive literature searches were conducted using PubMed data from 1982 to 2007. This search included headings of H. pylori, bismuth and eradication therapy. The triple capsule Pylera, when given with omeprazole, achieved eradication rates ranging between 84 and 97%. Eradication rates were similar for clarithromycin- and metronidazole-resistant strains. Eradication rates with an omeprazole, bismuth, metronidazole and tetracycline regimen appeared comparable for metronidazole-resistant and -sensitive strains. This effect is not seen with the use of triple therapy in cases of clarithromycin resistance. Clinical trials did not report any serious side effects from bismuth-based regimens and compliance was similar to standard triple therapy. Bismuth-based triple therapy using Pylera is a simplified, effective and well-tolerated regimen achieving cure rates of above 90%.

Adverse events with bismuth salts for Helicobacter pylori eradication: systematic review and meta-analysis

AIM

To assess the safety of bismuth used in Helicobacter pylori (H pylori) eradication therapy regimens.

METHODS

We conducted a systematic review and meta-analysis. MEDLINE and EMBASE were searched (up to October 2007) to identify randomised controlled trials comparing bismuth with placebo or no treatment, or bismuth salts in combination with antibiotics as part of eradication therapy with the same dose and duration of antibiotics alone or, in combination, with acid suppression. Total numbers of adverse events were recorded. Data were pooled and expressed as relative risks with 95% confidence intervals (CI).

RESULTS

We identified 35 randomised controlled trials containing 4763 patients. There were no serious adverse events occurring with bismuth therapy. There was no statistically significant difference detected in total adverse events with bismuth [relative risk (RR) = 1.01; 95% CI: 0.87-1.16], specific individual adverse events, with the exception of dark stools (RR = 5.06; 95% CI: 1.59-16.12), or adverse events leading to withdrawal of therapy (RR = 0.86; 95% CI: 0.54-1.37).

CONCLUSION

Bismuth for the treatment of H pylori is safe and well-tolerated. The only adverse event occurring significantly more commonly was dark stools.

Adverse events with bismuth salts for Helicobacter pylori eradication: Systematic review and meta-analysis

AIM: To assess the safety of bismuth used in Helicobacter pylori (H pylori) eradication therapy regimens.

METHODS: We conducted a systematic review and meta-analysis. MEDLINE and EMBASE were searched (up to October 2007) to identify randomised controlled trials comparing bismuth with placebo or no treatment, or bismuth salts in combination with antibiotics as part of eradication therapy with the same dose and duration of antibiotics alone or, in combination, with acid suppression. Total numbers of adverse events were recorded. Data were pooled and expressed as relative risks with 95% confidence intervals (CI).

RESULTS: We identified 35 randomised controlled trials containing 4763 patients. There were no serious adverse events occurring with bismuth therapy. There was no statistically significant difference detected in total adverse events with bismuth [relative risk (RR) = 1.01; 95% CI: 0.87-1.16], specific individual adverse events, with the exception of dark stools (RR = 5.06; 95% CI: 1.59-16.12), or adverse events leading to withdrawal of therapy (RR = 0.86; 95% CI: 0.54-1.37).

CONCLUSION: Bismuth for the treatment of H pylori is safe and well-tolerated. The only adverse event occurring significantly more commonly was dark stools.

The need for long-term treatment of peptic ulcer

Some 10% of the population in Western countries will suffer a duodenal ulcer or gastric ulcer at some time in their lives. Although there has been an improvement in the survival rate of patients with peptic ulcer haemorrhage, the mortality is still approximately 10%. There is evidence to suggest that peptic ulcer disease is a life-long condition and that ulcers remain active with an unchanged potential for complications such as haemorrhage and perforation. Over the past 15 years anti-ulcer drugs with different mechanisms of action have been developed, and their use results in complete healing of an ulcer in four to eight weeks. However, most patients experience recurrence of their peptic ulcer after discontinuation of the healing therapy. Studies of continuous H2-receptor antagonist therapy have shown that recurrence occurs less frequently than in untreated patients, is largely asymptomatic, and is rarely characterized by haemorrhagic complications. Limited data on therapy for the eradication of Helicobacter pylori suggest that this may be an alternative approach for selected patients. As protection afforded by H2-receptor antagonists remains undiminished over the course of several years and is also observed in ulcers which have bled in the past, the implementation of long-term management with these agents constitutes a rational policy.

Non-ulcer dyspepsia: myths and realities

Dyspepsia can be defined as the presence of upper abdominal pain or discomfort; other symptoms referable to the proximal gastrointestinal tract, such as nausea, early satiety, and bloating, may also be present. Symptoms may or may not be meal related. To be termed chronic, dyspepsia should have been present for three months or longer. Over half the patients who present with chronic dyspepsia have no evidence of peptic ulceration, other focal lesions, or systemic disease and are diagnosed as having non-ulcer (or functional) dyspepsia. Non-ulcer dyspepsia is a heterogeneous syndrome. It has been proposed that this entity can be subdivided into a number of symptomatic clusters or groupings that suggest possible underlying pathogenetic mechanisms. These groupings include ulcer-like dyspepsia (typical symptoms of peptic ulcer are present), dysmotility (stasis)-like dyspepsia (symptoms include nausea, early satiety, bloating, and belching that suggest gastric stasis or small intestinal dysmotility), and reflux-like dyspepsia (heartburn or acid regurgitation accompanies upper abdominal pain or discomfort). The aetiology of non-ulcer dyspepsia is not established, although it is likely a multifactorial disorder. Motility abnormalities may be important in a subset of dyspepsia patients but probably do not explain the symptoms in the majority. Epidemiological studies have not convincingly demonstrated an association between Helicobacter pylori and non-ulcer dyspepsia. Other potential aetiological mechanisms, such as increased gastric acid secretion, psychological factors, life-event stress, and dietary factors, have not been established as causes of non-ulcer dyspepsia. Management of non-ulcer dyspepsia is difficult because its pathogenesis is poorly understood and is confounded because of a high placebo response rate. Until more data are available, it seems reasonable that treatment regimens target the clinical groupings described above. Antacids are no more effective than placebo in non-ulcer dyspepsia, although a subgroup of non-ulcer dyspepsia patients with reflux-like or ulcer-like symptoms may respond to H2-receptor antagonists. However, there is no significant benefit of these agents over placebo in many cases. Bismuth has been shown to be superior to placebo in patients with H. pylori in a number of studies, but these trials had several shortcomings and others have reported conflicting findings. Sucralfate was demonstrated in one study to be superior to placebo, but this finding was not confirmed by another group of investigators. Prokinetic drugs appear to be efficacious, and may be most useful in patients with dysmotility-like and reflux-like dyspepsia.

Pharmacological interventions for non-ulcer dyspepsia

BACKGROUND

The commonest cause of upper gastrointestinal symptoms is non-ulcer dyspepsia (NUD) and yet the pathophysiology of this condition has been poorly characterised and the optimum treatment is uncertain. It is estimated that pound450 million is spent on dyspepsia drugs in the UK each year.

OBJECTIVES

This review aims to determine the effectiveness of six classes of drugs (antacids, histamine H(2) antagonists, proton pump inhibitors, prokinetics, mucosal protecting agents and antimuscarinics) in the improvement of either the individual or global dyspepsia symptom scores and also quality of life scores patients with non-ulcer dyspepsia.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2005), MEDLINE (1966 to January 2006), EMBASE (1988 to January 2006), CINAHL (1982 to January 2006), SIGLE, and reference lists of articles. We also contacted experts in the field and pharmaceutical companies. Trials were located through electronic searches of the Cochrane Controlled Trials Register (CCTR), MEDLINE, EMBASE, CINAHL and SIGLE, using appropriate subject headings and text words, searching bibliographies of retrieved articles, and through contacts with experts in the fields of dyspepsia and pharmaceutical companies.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing drugs of any of the six groups with each other or with placebo for non-ulcer dyspepsia (NUD).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility, trial quality and extracted data.

MAIN RESULTS

We included 73 trials: prokinetics (19 trials with dichotomous outcomes evaluating 3178 participants; relative risk reduction (RRR) 33%; 95% confidence intervals (CI) 18% to 45%), H(2)RAs (12 trials evaluating 2,183 participants; RRR 23%; 95% CI 8% to 35%) and PPIs (10 trials evaluating 3,347 participants; RRR 13%; 95% CI 4% to 20%) were significantly more effective than placebo. Bismuth salts (six trials evaluating 311 participants; RRR 40%; 95% CI -3 to 65%) were superior to placebo but this was of marginal statistical significance. Antacids (one trial evaluating 109 participants; RRR -2%; 95% CI -36% to 24%) and sucralfate (two trials evaluating 246 participants; RRR 29%; 95% CI -40% to 64%) were not statistically significantly superior to placebo. A funnel plot suggested that the prokinetic results could be due to publication bias or other small study effects.

AUTHORS' CONCLUSIONS

There is evidence that anti-secretory therapy may be effective in NUD. The trials evaluating prokinetic therapy are difficult to interpret as the meta-analysis result could have been due to publication bias. The effect of these drugs is likely to be small and many patients will need to take them on a long-term basis so economic analyses would be helpful and ideally the therapies assessed need to be inexpensive and well tolerated.

Eradication of Helicobacter pylori for non-ulcer dyspepsia

BACKGROUND

Helicobacter pylori (H pylori) is the main cause of peptic ulcer disease. The role of H pylori in non-ulcer dyspepsia is less clear.

OBJECTIVES

To determine the effect of H pylori eradication on dyspepsia symptoms in patients with non-ulcer dyspepsia.

SEARCH STRATEGY

Trials were identified through electronic searches of the Cochrane Controlled Trials Register (CCTR), MEDLINE, EMBASE, CINAHL and SIGLE, using appropriate subject headings and keywords, searching bibliographies of retrieved articles, and through contacts with experts in the fields of dyspepsia and with pharmaceutical companies.

SELECTION CRITERIA

All parallel group randomised controlled trials (RCTs) comparing drugs to eradicate H pylori with placebo or other drugs known not to eradicate H pylori for patients with non-ulcer dyspepsia.

DATA COLLECTION AND ANALYSIS

Data were collected on individual and global dyspeptic symptom scores, quality of life measures and adverse effects. Dyspepsia outcomes were dichotomised into minimal/resolved versus same/worse symptoms.

MAIN RESULTS

Twenty one randomised controlled trials were included in the systematic review. Eighteen trials compared antisecretory dual or triple therapy with placebo antibiotics +/- antisecretory therapy, and evaluated dyspepsia at 3-12 months. Seventeen of these trials gave results as dichotomous outcomes evaluating 3566 patients and there was no significant heterogeneity between the studies. There was a 10% relative risk reduction in the H pylori eradication group (95% CI = 6% to 14%) compared to placebo. The number needed to treat to cure one case of dyspepsia = 14 (95% CI = 10 to 25). A further three trials compared Bismuth based H pylori eradication with an alternative pharmacological agent. These trials were smaller and had a shorter follow-up but suggested H pylori eradication was more effective than either H2 receptor antagonists or sucralfate in treating non-ulcer dyspepsia.

AUTHORS' CONCLUSIONS

H pylori eradication therapy has a small but statistically significant effect in H pylori positive non-ulcer dyspepsia. An economic model suggests this modest benefit may still be cost-effective but more research is needed.

Nonulcer dyspepsia and Helicobacter pylori eradication in children

BACKGROUND

Controversy exists over Helicobacter pylori eradication therapy in the treatment of patients with nonulcer dyspepsia. The lack of pediatric studies has made it difficult to draw conclusions about the use of eradication in dyspeptic children. The aim of this study was to examine long-term symptom severity in pediatric patients with nonulcer dyspepsia and H pylori gastritis after H pylori eradication.

METHODS

Thirty-nine children (mean age, 9.0 years) with dyspepsia and H pylori gastritis were prospectively recruited. Severity of symptoms was graded before H pylori eradication. Each patient was followed up at 6, 12, and on average, 61.6 months after eradication, with reassessment of symptoms and H pylori status.

RESULTS

There was a significant reduction in the severity of symptoms at 6 and 12 months, and at long-term follow-up compared with the preeradication scores (all P < . 001). At long-term follow-up, reinfection with H pylori was associated with more severe symptoms than if the patients remained free of infection (P = .045).

CONCLUSIONS

This study has demonstrated a significant long-term improvement in nonulcer dyspepsia in children after eradication of H pylori. This provides further evidence for the consideration of H pylori eradication in pediatric patients presenting with nonulcer dyspepsia.

Eradication of Helicobacter pylori for non-ulcer dyspepsia

BACKGROUND

Helicobacter pylori (H pylori) is the main cause of peptic ulcer disease. The role of H pylori in non-ulcer dyspepsia is less clear.

OBJECTIVES

To determine the effect of H pylori eradication on dyspepsia symptoms in patients with non-ulcer dyspepsia.

SEARCH STRATEGY

Trials were identified through electronic searches of the Cochrane Controlled Trials Register (CCTR), MEDLINE, EMBASE, CINAHL and SIGLE, using appropriate subject headings and keywords, searching bibliographies of retrieved articles, and through contacts with experts in the fields of dyspepsia and with pharmaceutical companies. These searches were updated in October 2004.

SELECTION CRITERIA

All parallel group randomised controlled trials (RCTs) comparing drugs to eradicate H pylori with placebo or other drugs known not to eradicate H pylori for patients with non-ulcer dyspepsia.

DATA COLLECTION AND ANALYSIS

Data were collected on individual and global dyspeptic symptom scores, quality of life measures and adverse effects. Dyspepsia outcomes were dichotomised into minimal/resolved versus same/worse symptoms.

MAIN RESULTS

Seventeen randomised controlled trials were included in the systematic review. Fourteen trials compared antisecretory dual or triple therapy with placebo antibiotics +/- antisecretory therapy, and evaluated dyspepsia at 3-12 months. Thirteen of these trials gave results as dichotomous outcomes evaluating 3186 patients and there was no significant heterogeneity between the studies. There was a 8% relative risk reduction in the H pylori eradication group (95% CI = 3% to 12%) compared to placebo. The number needed to treat to cure one case of dyspepsia = 18 (95% CI = 12 to 48). A further three trials compared Bismuth based H pylori eradication with an alternative pharmacological agent. These trials were smaller and had a shorter follow-up but suggested H pylori eradication was more effective than either H2 receptor antagonists or sucralfate in treating non-ulcer dyspepsia.

AUTHORS' CONCLUSIONS

H pylori eradication therapy has a small but statistically significant effect in H pylori positive non-ulcer dyspepsia. An economic model suggests this modest benefit may still be cost-effective but more research is needed.

Pharmacological interventions for non-ulcer dyspepsia

BACKGROUND

The commonest cause of upper gastrointestinal symptoms is non-ulcer dyspepsia (NUD) and yet the pathophysiology of this condition has been poorly characterised and the optimum treatment is uncertain. It is estimated that 450 million pounds is spent on dyspepsia drugs in the UK each year.

OBJECTIVES

This review aims to determine the effectiveness of six classes of drugs (antacids, histamine H2 antagonists, proton pump inhibitors, prokinetics, mucosal protecting agents and antimuscarinics) in the improvement of either the individual or global dyspepsia symptom scores and also quality of life scores patients with non-ulcer dyspepsia.

SEARCH STRATEGY

Trials were located through electronic searches of the Cochrane Controlled Trials Register (CCTR), MEDLINE, EMBASE, CINAHL and SIGLE, using appropriate subject headings and text words, searching bibliographies of retrieved articles, and through contacts with experts in the fields of dyspepsia and pharmaceutical companies.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing drugs of any of the six groups with each other or with placebo for non-ulcer dyspepsia (NUD).

DATA COLLECTION AND ANALYSIS

Data were collected on dyspeptic symptom scores either individual or global symptom assessments and also quality of life scores and adverse effects.

MAIN RESULTS

A total of 11796 citations were obtained. 157 trials were retrieved and 98 trials fulfilled our eligibility criteria. However, subsequent data extraction was not possible in 31 trials. The final 67 trials were included in the meta-analysis. Prokinetics (14 trials with dichotomous outcomes generating 1053 patients; relative risk reduction [RRR] = 48%; 95% confidence intervals [CI] = 27% to 63%), H2RAs (11 trials generating 2,164 patients; RRR = 22%; 95% CI = 7% to 35%) and PPIs (8 trials generating 3,293 patients; RRR = 14%; 95% CI = 5% to 22%) were significantly more effective than placebo. Bismuth salts (6 trials generating 311 patients; RRR = 40%; 95% CI = -3 to 65%) were superior to placebo but this was of marginal statistical significance. Antacids (one trial generating 109 patients; RRR = -2%; 95% CI = -36% to 24%) and sucralfate (two trials generating 246 patients; RRR = 29%; 95% CI = -40% to 64%) were not statistically significantly superior to placebo. A funnel plot suggested that the prokinetic and H2RA results could be due to publication bias.

REVIEWERS' CONCLUSIONS

There is evidence that anti-secretory therapy may be effective in NUD. The trials evaluating prokinetic therapy are difficult to interpret as the meta-analysis result could have been due to publication bias. The effect of these drugs is likely to be small and many patients will need to take them on a long-term basis so economic analyses would be helpful and ideally the therapies assessed need to be inexpensive and well tolerated.

Helicobacter pylori infection treatment of nonulcer dyspepsia: an analysis of meta-analyses

BACKGROUND

Meta-analysis is often used to resolve uncertainty in magnitude of effect between studies. However, several meta-analyses investigating the association between Helicobacter pylori infection and nonulcer dyspepsia reported contradictory results.

GOALS

To perform a systematic review of the conflicting data in meta-analyses examining the association between H. pylori infection and nonulcer dyspepsia.

STUDY

Five meta-analyses were identified: three studied the relation between H. pylori treatment and nonulcer dyspepsia, one studied the relation between H. pylori eradication and nonulcer dyspepsia, and one reported both. Data on search strategy, study selection, study inclusion, data abstraction, reported results of included studies, and summarized effect estimates were collected.

RESULTS

Overall, 29 studies were included in the five meta-analyses. Nine studies (31%) were evaluated in more than one meta-analysis. There was no disagreement between the meta-analyses concerning the interpretation of outcome per investigated study; the results from seven (24%) studies showed improvement of dyspeptic symptoms after H. pylori treatment or eradication. The odds ratio of symptom relief in the control groups relative to the treated groups varied between 0.30 (95% CI = 0.2-0.5) to 0.88 (95% CI = 0.7-1.2). The proportion of patients' symptom free due to H. pylori treatment varied between 11% and 38%.

CONCLUSIONS

The reported conflicting results between the meta-analyses were mainly a result of differences in study selection (eligibility and quality criteria) and relatively small. In a subgroup of patients with nonulcer dyspepsia, H. pylori eradication is useful for relief of symptoms.

Helicobacter pylori and functional dyspepsia. What to do after the Maastricht II consensus meeting?

BACKGROUND

Despite many clinical studies, there is still much discussion on the relation between Helicobacter pylori and functional dyspepsia.

METHODS

Critical review of recommendations for H. pylori eradication in dyspepsia.

RESULTS

The debate can be separated into three major problems. First, how to identify the dyspeptic patient suffering from H. pylori infection. Second, is H. pylori infection causative for complaints in this patient? Third, what is the clinical course of functional dyspepsia after successful H. pylori eradication? In the recent Maastricht II consensus, it is strongly recommended that H. pylori-positive patients with functional dyspepsia should be treated with anti-H. pylori therapy. In this review, the pros and cons of H. pylori eradication in patients with functional dyspepsia are discussed. The reader can decide what is the best management of an individual patient.

CONCLUSIONS

This review gives the relevant background information allowing clinicians to decide what the best management is in individual H. pylori-positive patients with dyspepsia.

Does Helicobacter pylori eradication affect symptoms in nonulcer dyspepsia: a 5-year follow-up study

The role of Helicobacter pylori infection in nonulcer dyspepsia remains controversial. To date studies exploring the effect of H. pylori eradication on symptoms have reported conflicting results. Randomised control trials employing validated outcome measures have also been difficult to interpret because of several important issues such as the large placebo response seen in patients with nonulcer dyspepsia and both the natural variability in symptoms and symptom severity with time. The association of symptom improvement with resolution of gastritis has meant that the length of follow up employed in most studies has been insufficient. We report the findings of a randomised placebo controlled trial (n = 100), using a validated symptom questionnaire and 5 year follow up to determine the effect of H. pylori eradication on symptoms in nonulcer dyspepsia. In all 64 that were reviewed at 5 years there was a significant difference between patients who were H. pylori negative and those who remained positive with regard to complete symptom resolution, consumption of relevant medications and peptic ulcer disease development, in favour of active treatment. There was a trend for gradual symptom improvement over time irrespective of H. pylori status, which may reflect the natural history of this condition. For those who remained symptomatic at 5 years, there was no difference in symptom severity based on H. pylori status. The findings of this study support the use of H. pylori eradication in symptomatic patients with nonulcer dyspepsia both to induce symptom resolution and to prevent disease progression.

Efficacy of Helicobacter pylori eradication in uninvestigated chronic dyspeptic staff members of a large factory: a prospective, long-term, follow-up, workplace outcome study

BACKGROUND

Current European guidelines propose Helicobacter pylori eradication for the initial management of patients under 45 years with uninvestigated dyspepsia without alarm symptoms. Until now, no study has assessed this strategy in occupational medicine.

AIM

To investigate the outcome of H. pylori eradication in staff members of a large factory with uninvestigated chronic dyspepsia in a prospective, open, controlled, workplace outcome study in terms of the 1 year follow-up of dyspepsia and quality of life.

METHODS

In 267 subjects with uninvestigated chronic dyspepsia (229 males, mean age 42 years; range 22-62 years) H. pylori status was assessed by using the 13C-urea breath test at baseline. H. pylori-positive subjects were offered 1 week eradication therapy with omeprazole 20 mg b.i.d., clarithromycin 250 mg b.i.d., and metronidazole 400 mg b.i.d., and were retested after 2 months. Subjects with a negative 13C-urea breath test at 2 months were H. pylori-responders; subjects still H. pylori-positive at this time were H. pylori-nonresponders. H. pylori-negative subjects at baseline were included as a reference. Dyspeptic symptoms, quality of life and health care utilization were assessed by questionnaires at baseline (T0), and at 2 (T2) and 12 months (T12).

RESULTS

One hundred and eleven of 267 (41.65%) subjects were H. pylori-positive at baseline. The infection was cured in 85 of 94 (90.4%) subjects. Upper abdominal pain and dyspeptic symptoms were significantly reduced and quality of life significantly increased in H. pylori responder subjects at T12 compared to baseline and to reference subjects (P < 0.01). At T12 42.3% of H. pylori responder subjects showed complete relief of epigastric pain compared to 9.2% in the reference group (P < 0.001). Furthermore, disease-related absence from work, visits to family physicians, and antacid consumption significantly decreased in H. pylori responder subjects compared with reference subjects (P < 0.05).

CONCLUSION

These data suggest that an H. pylori test-and-treat strategy in occupational medicine is effective for improving uninvestigated dyspepsia and quality of life and it may reduce dyspepsia related health care costs at a level of occupational medicine.

Pretreatment gastric histology is helpful to predict the symptomatic response after H. pylori eradication in patients with nonulcer dyspepsia

This study aimed to test whether pretreatment gastric pathology in H. pylori-infected nonulcer dyspepsia (HpNUD) patients is relevant to and predictive of the symptomatic response after H. pylori eradication. Anti-H. pylori triple therapy was administered to 250 HpNUD patients, enrolled as the therapy group. In addition, 60 patients were enrolled as the control group, in which omeprazole was an alternatives to the triple therapy. Pretreatment gastric histology was evaluated thoroughly by the updated Sydney system. A [13C] urea breath test was also performed to evaluate the H. pylori eradication two months and 12 months later. For each patient, the baseline, month 2, and month 12 symptom scores were assessed for the month 2 or month 12 residual symptom ratio (RSR-2m or RSR-12m), calculated from: 100% x month 2 or month 12 score/baseline score. Based on either RSR-2m or RSR-12m, patients were categorized as good response (RSR < 50%), moderate response (50-70%), and poor response (> 70%) subgroups in both therapy and control groups to define the short-term and long-term symptomatic responses. Patients with successful H. pylori eradication in the therapy group showed a higher incidence of good symptomatic response (RSR < 50%) than those from the control group (month 2: 30.3 vs 12%, P < 0.05; month 12: 34.7 vs 17.1%, P < 0.05). Univariate and multivariate analysis disclosed that patients with a higher acute inflammation score (AIS) and the lowest incidence of lymphoid follicles (LF) at pretreatment gastric histology are predisposed to having a good symptom response after H. pylori eradication (P < 0.05). For HpNUD patients who have an AIS of more than three and an absence of LF at gastric histology, more than 85% had good short-term (month 2) and long-term (month 12) symptomatic relief after H. pylori eradication. In conclusion, nearly 30% of HpNUD patients can obtain symptomatic relief following H. pylori eradication. The pretreatment gastric histology of HpNUD can be helpful to monitor the symptomatic response after H. pylori eradication.

Helicobacter pylori eradication and standardized 3-month omeprazole therapy in functional dyspepsia

OBJECTIVES

The role of Helicobacter pylori in functional dyspepsia remains unclear. This study evaluated the long term consequences for symptoms and quality of life in patients with H. pylori-positive functional dyspepsia after H. pylori eradication therapy with a standardized 3-month omeprazole treatment.

METHODS

A total of 151 H. pylori-positive patients with functional dyspepsia were randomized to receive either eradication therapy or placebo-antibiotics. The initial medication was administered in a double-blinded fashion. In addition, to standardize acid suppression, every patient received omeprazole therapy for the first 3-month period. Dyspeptic symptoms were evaluated by a questionnaire every 3 months, and quality of life was measured by a validated RAND 36-item health survey 1.0 questionnaire at the beginning of the study and after 12 months of follow-up. As the main outcome measure, the scores of patients who had received H. pylori eradication therapy and omeprazole were compared with those who received placebo and omeprazole during the 12 months of follow-up.

RESULTS

A total of 136 patients completed the 1-yr follow-up. In all, 77 patients received eradication therapy and 74 patients remained as controls. After 12 months, the mean reduction in the dyspepsia score was 28.8% in patients with H. pylori eradication therapy and 21.7% in the control group. The reduction of dyspepsia was significant (p < 0.0001) in both groups compared to baseline value, but no statistically significant differences in changes of dyspeptic symptoms or in quality of life were demonstrated between the H. pylori eradication therapy group and controls after 1 yr. In both patient groups, regurgitation (p < 0.001) and heartburn (p < 0.01) revealed relapse after cessation of 3-month omeprazole treatment.

CONCLUSIONS

No clear differences in symptoms or in quality of life were found between patients treated with H. pylori eradication therapy and omeprazole compared with patients receiving placebo and omeprazole after 1 yr. Regardless of H. pylori status, omeprazole treatment reduced heartburn and regurgitation. The placebo effect on the symptoms of functional dyspepsia and on quality of life was marked.

Impaired postprandial gastric myoelectrical activity in Chinese patients with nonulcer dyspepsia

Using a homemade electrogastrography (EGG) system, we studied the characteristics of the myoelectrical rhythm in Chinese patients with nonulcer dyspepsia (NUD). Based on short-term Fourier transformation, recorded slow waves could be automatically analyzed to obtain the following parameters: dominant frequency/power, percent of normal frequency (2-4 cpm), power ratio, etc. EGG parameters, Helicobacter pylori status, histological examination of gastric mucosa, and dyspeptic symptoms were recorded in 27 NUD patients. Compared to 32 healthy controls, the Chinese NUD patients had abnormal postprandial EGG parameters including a lower percentage of regular 2-4 cpm slow waves (70.10 +/- 2.97% vs 79.08 +/- 2.95%, P < 0.05), a lower level of increment of dominant power (0.62, +/- 0.91 vs 3.76 +/- 0.58 dB, P < 0.05), lower power ratio (1.42 +/- 0.28 vs 2.79 +/- 0.39, P < 0.05) and a higher instability coefficient (0.36 +/- 0.03 vs 0.26 +/- 0.03, P < 0.05). However, Helicobacter pylori infection and its associated gastritis did not influence any EGG parameters in NUD patients. Six main dyspeptic symptoms and total symptom score had no correlation with any EGG parameters. In conclusion, Chinese NUD patients may have abnormal postprandial stomach myoelectrical activity, but these EGG abnormalities are not a direct result of Helicobacter pylori infection and its related gastritis and do not contribution to the dyspeptic symptoms.

Nonulcer dyspepsia. Current concepts and management

NUD is a common heterogeneous condition with a multifactorial cause. NUD is a cause of considerable morbidity with an annual incidence of 8% and similar incidence of spontaneous resolution. Its economic effects are considerable. The estimated annual cost to the community of NUD is $431 per patient for the initial 6 months after diagnosis. The annual Health Maintenance Organization (HMO) expenditure on acid-related disorders in one Northern California HMO was estimated to be $59.4 million, of which NUD represented a significant proportion. The association of H. pylori infection with NUD is controversial. There are strong epidemiologic evidence and supportive pathophysiological mechanisms to implicate H. pylori causally in a subset of cases. Treatment studies are likewise conflicting. Evidence suggests that treatment cannot guarantee improvement in all cases of H. pylori-related NUD but that a subset would benefit with complete symptom resolution in the long term. It is not possible currently to predict which patients would or would not respond to eradication therapy. The strength of evidence is such that empiric eradication therapy, based on noninvasive H. pylori testing, can be advocated in young patients with dyspepsia safely and effectively with resultant financial savings.

Role of anti-Helicobacter pylori treatment in H. pylori-positive and cytoprotective drugs in H. pylori-negative, non-ulcer dyspepsia: results of a randomized, double-blind, controlled trial in Asian Indians

BACKGROUND

The efficacy of anti-Helicobacter pylori treatment and cytoprotective drugs in H. pylori-positive and -negative non-ulcer dyspepsia (NUD), respectively, is debatable.

METHODS

In a randomized study, the efficacy of anti-H. pylori treatment versus sucralphate was tested in patients with NUD. One hundred and twelve patients with NUD, 62 positive and 50 negative for H. pylori were studied. Of 62 patients positive for H. pylori, 32 were treated with triple therapy (colloidal bismuth subcitrate, tetracycline and metronidazole) for 2 weeks and the remaining 30 were treated with sucralphate (1 g, q.i.d.) for 4 weeks. Of 50 patients negative for H. pylori, 25 each were treated with either sucralphate (1 g, q.i.d.) or ranitidine (150 mg, b.d.) for 4 weeks.

RESULTS

In patients with NUD and H. pylori infection, triple therapy eradicated H. pylori in 88% and was superior to sucralphate in producing symptom relief (81 vs 33%, P = 0.0003) and histological improvement in gastritis (73 vs 30%, P = 0.003). In the H. pylori-negative group, sucralphate was superior to ranitidine with regard to symptom relief (68 vs 36%, P = 0.04) and improvement in gastritis (44 vs 12%, P = 0.09). The symptomatic improvement persisted until 12 weeks after the start of treatment in triple therapy group only.

CONCLUSIONS

In patients with NUD associated with H. pylori, triple therapy was better than sucralphate in terms of symptomatic and histological improvement. However, sucralphate was superior to ranitidine in providing symptom relief in patients with H. pylori-negative NUD.

Helicobacter pylori-positive functional dyspepsia in elderly patients: comparison of two treatments

The association of Helicobacter pylori and functional dyspepsia is not well defined. The role of H. pylori on dyspeptic symptoms is still controversial. The aim of this study is to confirm the efficacy of H. pylori eradication by two different commonly used treatment regimens, as well as to examine the improvement of the dyspeptic symptoms by eradicating H. pylori. H. pylori functional dyspepsia is prevalent in people over 60 years old. In this age group we treated 126 patients with bismuth plus metronidazole and amoxicillin (group A, 67 patients) versus omeprazole plus amoxicillin (group B, 59 patients). Results were statistically analyzed utilizing the Wilcoxon signed-rank test, McNemer test and chi-square test; P < 0.05 was considered significant. Two months after the end of therapy we observed an eradication rate of 66.1% in group A vs 64.3% in group B. All treated patients showed improvement in symptomatology. Although there was no significant difference between patients in whom H. pylori was or was not eradicated within the respective groups, when examining all H. pylori-positive patients versus H. pylori-negative posttreatment patients, there was a significant reduction (P < 0.05) in all four symptoms of functional dyspepsia measured. In conclusion, we suggest that patients treated with H. pylori-eradicating therapeutic regimens have an improvement in functional dyspepsia symptoms. We shall prefer the dual therapy as compared to the triple therapy. We believe that eradicating treatment to eradicate H. pylori in the elderly patients with H. pylori-related functional dyspepsia will reduce health care costs by reducing the number of subsequent visits.

A systematic overview of the use of diary cards, quality-of-life questionnaires, and psychometric tests in treatment trials of Helicobacter pylori-positive and -negative non-ulcer dyspepsia

BACKGROUND

Our aim was to evaluate the use of diary cards, quality-of-life questionnaires, and psychometric tests in treatment trials of non-ulcer dyspepsia.

METHODS

Data sources were a Medline search (up to 1966) and a manual search of five gastrointestinal journals (up to 1980) for original, randomized, double-blind, placebo-controlled trials with at least 20 patients which evaluated treatment regimens for non-ulcer dyspepsia.

RESULTS

Of the 67 eligible studies, 31 used diary cards. Diary cards were used alone in 15 of the 31 studies (48%), whereas the others (52%) also used a physician assessment. The symptoms assessed by diary cards were epigastric pain (100%), nausea/vomiting (65%), heartburn (52%), belching (39%), regurgitation (29%), fullness (29%), and bloating (23%). Forty-five per cent also recorded antacid use. Severity of outcome measures was assessed by a visual analogue scale in 5 of the 31 studies (16%), Likert scales in 17 studies (55%), and unclear methods in 3 studies (10%). For statistical analysis daily averages of symptoms were used in 5 of the 31 studies (16%), weekly averages in 11 studies (35%), and 2-week intervals during the treatment period in the rest, with some studies using a combination (such as daily and weekly averages). Only 3 of the 31 studies (8%) checked for compliance with diary card data. None of the studies mention anything about missing data and how this was handled. One study evaluated quality of life questionnaires and one evaluated a psychometric test.

CONCLUSIONS

Non-ulcer dyspepsia treatment trials frequently use diary cards but need to be much clearer about how information was obtained and how it was used in the statistical analysis. Not much information is available to comment on the use of quality-of-life questionnaires or psychometric tests for evaluation of outcome measures.

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.

Relationship of Helicobacter pylori CagA(+) status to gastric juice vitamin C levels

BACKGROUND

To date it is not known whether gastric juice vitamin C levels are influenced by Helicobacter pylori CagA(+) strains. The aim of the present study, therefore, was to study the impact of H. pylori CagA status on gastric juice vitamin C levels.

MATERIALS AND METHODS

We studied 30 H. pylori(+) patients, and the results were compared with 10 endoscopically and histologically normal H. pylori(-) subjects (control group) who were similar to the H. pylori(+) group in terms of age and sex. In all patients, gastric juice vitamin C levels were determined and the severity of gastritis was graded on a scale of 0 (absent) to 3 (severe). CagA was determined by immunoblotting the sera from patients against H. pylori antigens.

RESULTS

Among 30 H. pylori(+) patients, 20 were CagA(+) and 10 CagA(-). In the entire group of H. pylori(+) patients, the median gastric juice vitamin C levels (mg L-1) were 16.35 (range 3.5-33.6) and were significantly lower (P < 0.001) than in the control group of H. pylori(-) patients [35.5 (23.1-50.2)]. In addition, in the entire group of H. pylori(+) patients there was a highly significant (P < 0.0001) inverse correlation between the gastritis activity score and the gastric juice vitamin C levels. In the group of H. pylori CagA(+) patients, the median levels of gastric juice vitamin C were 13.8 (3.5-31.2) and were significantly lower than the corresponding levels in both the H. pylori CagA(-) group [24.8 (22-33.6), P < 0.01] and the H. pylori(-) control group [35.5 (23.1-50.2), P < 0.001], the last groups being similar. Furthermore, the gastritis activity median score in the H. pylori CagA(+) group [2 (1-3)] was significantly higher (P < 0.05) than in the H. pylori CagA(-) group [1 (1-2)].

CONCLUSION

These data indicate that infection with CagA(+) H. pylori strains significantly lowers the gastric juice vitamin C levels in comparison with CagA(-) H. pylori strains, which might have a significant impact on gastric carcinogenesis.

Gastritis in the alcoholic: relationship to gastric alcohol metabolism and Helicobacter pylori

Chronic gastritis is common in the alcoholic. It is characterized by histological inflammation of the gastric mucosa and is associated with variable symptomatology. Its etiology is still the subject of debate. Recently, a new alcohol dehydrogenase isoenzyme, called sigma ADH, absent from the liver but predominant in the upper GI tract, has been fully characterized, its gene cloned, and it appears to play a major role in gastric ethanol metabolism. Indeed, it has now been established, both in vivo in experimental animals and in vitro in cultured human gastric cells, that alcohol is metabolized in the gastric mucosa, resulting in the production of acetaldehyde, a toxic metabolite. In addition, Helicobacter pylori infection is common in the alcoholic, resulting in the breakdown of urea to ammonia, another toxic product. A number of studies carried out over the last 40 years revealed that antibiotic treatment eradicates ammonia production and results in histological and symptomatic improvement in the majority of patients with alcoholic gastritis. Non-invasive tests for the detection of H. pylori are now available which will facilitate the large scale studies needed to confirm whether, in H. pylori -positive patients, antibiotics should become routine treatment for alcoholic gastritis.

Helicobacter pylori and functional dyspepsia: a real causal link?

This chapter reviews the evidence for a link between functional dyspepsia and Helicobacter pylori infection from three angles. In the section on pathophysiology, we evaluate how H. pylori could theoretically produce dyspeptic symptoms: many mechanisms can be proposed. In the discussion on epidemiology, we evaluate possible associations between the occurrence of symptoms and infection. Here, many studies claiming a coincidence or chronological sequence of infection and symptoms are criticized because of their poor design. In the section on the improvement of functional dyspepsia by the treatment of H. pylori infection, the conclusion is reached that if such an effect occurs at all--which is unlikely--it is very weak. The controversy on the link between H. pylori infection and functional dyspepsia is presently ongoing. Some authors are still trying to save an elegant concept that once looked so plausible but now has the facts against it.

Helicobacter pylori colonization does not influence the symptomatic response to prokinetic agents in patients with functional dyspepsia

Functional dyspepsia (FD) is very common, but the pathogenesis of Helicobacter pylori leading to FD is still debated. The aim of this study was first to evaluate the impact of H. pylori colonization on the efficacy of Paspertase (a metoclopramide plus exogenous enzymes regimen for FD patients) and, second, to compare the prevalence of H. pylori infection in FD patients with the general population. Seventy-four consecutive FD patients were enrolled undergoing Paspertase treatment. The symptomatic response was evaluated according to 1-4 scales of six main dyspeptic symptoms (i.e. epigastric pain/discomfort, early satiety, heartburn, nausea/vomiting, abdominal fullness/bloating, and belching). Nine hundred and seventy healthy subjects undergoing a paid physical check-up were included to study the status of H. pylori colonization. The demographic data and basal symptom scores between 43 H. pylori-positive and 31 H. pylori-negative patients were not significantly different. Total and individual symptom scores improved significantly after 4 weeks of Paspertase therapy (P < 0.05), irrespective of H. pylori infection. The prevalences of H. pylori were very similar in FD patients and the general population (58.1 vs 58.0%, NS). In conclusion, these observations suggest that H. pylori colonization is not significant in FD patients of Taiwan while a short-term prokinetic medication is effective for these patients, irrespective of H. pylori status.

Delayed gastric emptying by Helicobacter pylori lipopolysaccharide in conscious rats

The present study was carried out to investigate the possibility that lipopolysaccharide deprived from Helicobacter pylori may alter gastric motility. To address the question, we examined the effect of H. pylori lipopolysaccharide on gastric emptying in conscious rats. Gastric emptying was evaluated by the phenol red method. Time-course and dose-related effects of intraperitoneal administration of H. pylori lipopolysaccharide were investigated. Intraperitoneal injection of H. pylori lipopolysaccharide significantly suppressed gastric emptying of a liquid meal in a dose-dependent manner. The inhibitory action of H. pylori lipopolysaccharide was observed 2, 4, 8, or 12 hr after the injection. These results suggest for the first time that H. pylori lipopolysaccharide may suppress gastric emptying in a long-lasting fashion. It is also suggested that H. pylori may influence gastric function through its cell wall structure named lipopolysaccharide.

What role does Helicobacter pylori play in dyspepsia and nonulcer dyspepsia? Arguments for and against H. pylori being associated with dyspeptic symptoms

A major role for Helicobacter pylori gastritis in nonulcer dyspepsia (NUD) is controversial. Gastroduodenal dysfunction may be associated with H. pylori infection, but there is little evidence for a causal link with dyspepsia. Population-based studies with appropriate methodology have generally failed to confirm an association between H. pylori and NUD. Furthermore, no definite association between subgroups of NUD (ulcer-like, dysmotility-like, reflux-like, and nonspecific) and H. pylori has been identified however the subgroups have been defined, and no specific symptom pattern characterizes patients with H. pylori infection. Whether H. pylori-induced alterations of gastric physiology can explain NUD remains open to debate while we await the results of more specific experiments. Although acid secretion in response to gastrin-releasing peptide may be increased in a subset of NUD patients who are infected with H. pylori, uninfected patients with NUD have not been assessed and the results require confirmation. Most studies suggest no association between H. pylori and gastroduodenal motor or sensory dysfunction in NUD. Treatment trials have been unconvincing. The trials with bismuth therapy have not been adequately blinded. Furthermore, some studies suggest that H. pylori-negative patients with NUD may respond to bismuth treatment, although the results have not been uniform. Therapies aimed at curing H. pylori infection have produced mixed results, with small positive and negative trials. The trials that have used adequate outcome measures have more often than not been negative. Based on current evidence, H. pylori is not established to be of causal importance in NUD.

Gastric ethanol metabolism and gastritis: interactions with other drugs, Helicobacter pylori, and antibiotic therapy (1957-1997)--a review

The stomach provides some protection against the penetration of ethanol into the body by contributing to the metabolism of ethanol. The latter is attenuated by various drugs and, although the magnitude of this effect is still the subject of debate, patients should be warned of the corresponding possible increase in blood alcohol levels. Furthermore, oxidation of ethanol generates acetaldehyde, a toxic metabolite. In addition, chronic alcohol abuse seems to favor colonization by Helicobacter pylori, which produces ammonia that also contributes to the commonly associated chronic gastritis. Because antibiotics were shown over the last 4 decades to effectively eliminate gastric ammonia, they should be considered for the routine treatment of such chronic gastritis in the way they are now being used for ulcer therapy.

Eradication of Helicobacter pylori affects symptoms in non-ulcer dyspepsia

BACKGROUND

The relationship between Helicobacter pylori infection and non-ulcer dyspepsia is controversial.

METHODS

In a prospective, long-term, double-blind study we randomized 100 patients with non-ulcer dyspepsia and H. pylori infection to receive either of two treatment regimens: 1) bismuth-based triple therapy (n = 50) or 2) bismuth + placebo (n = 50).

RESULTS

Triple therapy: subjects who became H. pylori-negative (n = 42) showed a significant symptomatic response when interviewed at 8 weeks, 6 months, and 1 year (P < 0.01). This improvement was evident in the 'ulcer-like' dyspepsia group at all times (P < 0.01) but in the 'reflux-like' and 'motility-like' groups at 6 months only (P < 0.01). Those who remained H. pylori-positive showed no decrease in symptoms at 8 weeks, 6 months, and 1 year. Bismuth-placebo therapy: subjects who became H. pylori-negative (n = 7) showed an improvement in symptoms at 8 weeks, 6 months, and 1 year. Those who continued to harbour the infection after treatment (n = 42) showed an insignificant improvement in the motility and non-specific groups only.

CONCLUSION

This study shows that eradication of H. pylori results in a significant long-term reduction in symptoms of non-ulcer dyspepsia.

The British Society of Gastroenterology Diamond Jubilee. March 1997

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Cisapride in functional dyspepsia in general practice. A placebo-controlled, randomized, double-blind study

BACKGROUND

Functional dyspepsia is recognized as a common disorder in clinical practice. The aim of this study was to determine the efficacy and adverse effects of cisapride compared to a placebo in patients from a general practice with functional dyspepsia (FD). Secondly we investigated whether Helicobacter pylori-positive FD patients present with specific symptoms and determined the efficacy of cisapride for FD patients with H. pylori.

METHODS

In a placebo-controlled double-blind study, patients were randomized to receive fixed doses of either cisapride (10 mg three times daily) or placebo. Symptoms were evaluated after 2 and 4 weeks of treatment. The selection of FD patients,collection of data, and evaluation of symptoms as well as adverse effects were performed by general practitioners. Dyspeptic patients were referred to the Gastroenterology Department in order to exclude ulcers, oesophagitis, pancreatitis and gallstones. Biopsies of gastric mucosa were taken for histological examination and H. pylori culture.

PATIENTS

121 patients entered this study (61 took cisapride, 60 placebo). There were 113 patients (56 cisapride, 57 placebo) available for analysis of the efficacy and 120 patients (61 cisapride, 59 placebo) for evaluation of adverse effects.In total 102 biopsies were tested for the presence of gastritis by histological examination. There were 30 H. pylori-positive cultures among 111 patients.

RESULTS

After 4 weeks a statistically significant reduction in symptoms was found, but it was similar in the two groups. No symptoms specific for H. pylori-positive patients were found. There was not a significant difference in the response to cisapride between H. pylori-positive and H. pylori-negative patients. The difference in overall (63%) response in the cisapride group and the 44% response in the placebo group did not reach statistical significance.

CONCLUSIONS

No significant difference was found between placebo and cisapride in the treatment of FD in general practice. H. pylori-positive patients did not present with specific symptoms nor did they exhibit a different response to cisapride.

Eradication of Helicobacter pylori and long-term outcome of functional dyspepsia. A clinical endoscopic study

The aim of this study was to assess the effect of colloidal bismuth subcitrate (CBS) and metronidazole on Helicobacter pylori eradication and on the course of symptoms due to functional dyspepsia. Forty-one patients with functional dyspepsia were entered into the study and randomized to treatment with CBS (120 mg four times a day) for four weeks combined with metronidazole (250 mg four times a day) for one week (group A, N = 21) or matching placebo (group B, N = 20). The severity of gastritis and of bacterial colonization and the symptom score was assessed by endoscopy and clinical evaluation at baseline and after four, eight, and 24 weeks from the start of the treatment. With intent-to-treat analysis eradication was achieved in 16/25 (64%) patients in group A and in 6/24 (25%) in group B. At eight and 24 weeks the gastritis score was significantly lower only in those patients with eradication. No change was seen in patients in whom the bacteria was not eradicated. The symptom score at eight weeks was considerably lower both in patients with eradication and in those with infection. However, at 24 weeks a gradual decrease in the symptom score in patients with eradication and a worsening of symptoms in controls was observed. No differences were observed between patients with ulcerlike and those with dysmotility-like dyspepsia. The study confirms the need for a long observation period after antibacterial treatment in patients with functional dyspepsia and suggests that Helicobacter pylori-eradicating treatment improves the course of this functional syndrome.

Helicobacter pylori infection and dyspepsia

It has proved remarkably difficult to confirm or refute an association between Helicobacter pylori-induced gastritis and non-ulcer dyspepsia for several reasons. Dyspepsia has not been defined adequately and current definitions include a variety of symptoms that probably reflect a number of underlying pathophysiological processes. Dyspepsia is a symptom complex, rather than a specific disease entity, and cannot be easily identified. There are probably many causes of dyspepsia, and if H. pylori does cause symptoms, it may produce different symptoms in different people. However, little is known about variations in host susceptibility and H. pylori virulence, or their potential effect on symptomatology. In addition, the mechanisms responsible for dyspeptic symptoms are unknown, regardless of whether or not there is concomitant H. pylori-induced inflammation. A possible aetiological role for H. pylori in dyspepsia has been sought in three major types of study. Epidemiology studies have suggested that H. pylori is not a major cause of non-ulcer dyspepsia. However, both dyspepsia and H. pylori are common, and the studies cannot account for many of the variables detailed above. Pathophysiological studies have commonly reported a variety of motor and sensory 'abnormalities' in association with H. pylori, but none has been confirmed or reproduced. In eradication studies, there is continuing debate as to whether dyspeptic symptoms diminish with treatment. This is partly because of the high placebo-response rate and partly because many treatment regimens have not cured the infection. Suppression of bacterial growth may not affect symptoms significantly, if they are due to mucosal inflammation, and symptom resolution may take many weeks or months following cure of H. pylori and the associated gastritis. Recent findings have shown that symptom reduction is more evident 1 year after eradication of H. pylori than after 4 weeks. There is a continuing and urgent need for well-designed studies to assess the long-term effect of H. pylori and its cure on both gastrointestinal function and dyspeptic symptoms.

Nature of non-ulcer dyspepsia and related conditions

To date, the precise role of Helicobacter pylori in the pathogenesis of NUD remains uncertain. There is some evidence to suggest that the organism is implicated in specific subgroups (mostly the ulcer-like form), but it is not enough for any firm conclusions to be drawn as to the importance of the bacterium as a cause of dyspeptic symptoms or as to the efficacy of anti-infective regimens in the treatment of NUD. Large, well-designed prospective studies with a long-term follow-up are needed to establish which subgroups of dyspeptic patients may benefit most from eradication of H. pylori.

Role of Helicobacter pylori in gastrointestinal disease: implications for primary care of a revolution in management of dyspepsia

The majority of patients with dyspepsia are managed in general practice. However, most of the literature on Helicobacter pylori and its association with gastrointestinal disease has originated from secondary care. This review summarizes the role of H pylori in dyspepsia from the perspective of primary care and suggests a new strategy for the management of dyspeptic patients in this setting. Recent meta-analyses and consensus statements have supported the use of eradication therapy as first-line treatment of peptic ulceration. Studies from primary care have supported the use of eradication therapy in patients who have H pylori related peptic ulcer disease and require long-term H2-antagonist medication, on both clinical benefit and cost-effectiveness grounds. Of the many regimens proposed for the eradication of H pylori, the best evidence supports a triple combination of bismuth, metronidazole and tetracycline. Regimens using proton pump inhibitors may be more acceptable to patients but lack good evidence from trials. Use of a positive serum enzyme-linked immunoabsorbent assay for H pylori antibodies as a criterion for endoscopic investigation has been shown to result in a 23% reduction in endoscopic workload. Further research should answer questions of importance to general practitioners, such as the role of eradication therapy in patients with nonulcer dyspepsia and the effectiveness of eradication of H pylori in the prevention of gastric cancer.

Dyspeptic symptoms and gastric emptying of solids in patients with functional dyspepsia. Role of Helicobacter pylori infection

BACKGROUND

Our aim was to investigate the relation between dyspeptic symptoms, gastric emptying of digestible and indigestible solids, and Helicobacter pylori infection in patients with functional dyspepsia.

METHODS

We used isotopic labeling and radiologic techniques to study gastric emptying of a solid meal and of 10 radiopaque indigestible solids in 50 healthy volunteers and 50 patients with functional dyspepsia. In addition, we determined the presence of seven symptoms of dyspepsia and added the score for each symptom to obtain an index of dyspepsia for each patient.

RESULTS

Seventy-eight per cent of our dyspeptic patients had gastroparesis to a solid meal, and 68% to indigestible solids. We found no apparent relation between gastroparesis or H. pylori infection and dyspeptic symptoms separately or as an index of dyspepsia. Moreover, the presence of the bacteria was not related to gastroparesis to a solid meal or to indigestible solids.

CONCLUSIONS

We conclude that neither symptoms of dyspepsia nor H. pylori appears to be related to gastroparesis to solids. H. pylori infection is not related to dyspeptic symptoms.

Does Helicobacter pylori infection increase gastric sensitivity in functional dyspepsia?

The role of Helicobacter pylori infection in the pathogenesis of functional dyspepsia is debated. It is known that a substantial fraction of dyspeptic patients manifest a low discomfort threshold to gastric distension. This study investigated the symptomatic pattern in 27 H pylori positive and 23 H pylori negative patients with chronic functional dyspepsia, and potential relations between infection and gastric hyperalgesia. Specific symptoms (pain, nausea, vomiting, bloating/fullness, early satiety) were scored from 0 to 3 for severity and frequency (global symptom scores: 0-15). The mechanical and perceptive responses to gastric accommodation were evaluated with an electronic barostat that produced graded isobaric distensions from 0 to 20 mm Hg in 2 mm Hg steps up to 600 ml. Gastric compliance (volume/pressure relation) and perception (rating scale: 0-10) were quantified. Standard gastrointestinal manometry and recorded phasic pressure activity at eight separate sites during fasting and postprandially were also assessed. H pylori positive and H pylori negative patients manifested similar severity and frequency of specific symptoms and global symptom scores (mean (SEM)) (severity: 9.5 (2.0) v 9.0 (2.1); frequency: 10.8 (2.0) v 9.7 (2.2)). No differences were seen either in gastric compliance (53 (4) ml/mm Hg v 43 (3) ml/mm Hg) or in gastric perception of distension (slope: 0.50 (0.05) v 0.53 (0.06)). Postprandial antral motility was significantly decreased in H pylori positive patients (two hours motility index: 10.4 (0.6) v 12.6 (0.5); p < 0.05). It is concluded that H pylori infected patients with functional dyspepsia present no distinctive symptoms by comparison with H pylori negative counterparts and H pylori infection is associated with diminished postprandial antral motility but it does not increase perception of gastric distension.

Review article: functional dyspepsia--should treatment be targeted on disturbed physiology?

In patients who present with chronic unexplained upper abdominal pain or discomfort (functional dyspepsia), therapy should ideally be targeted on correcting the individual's disturbed pathophysiology. Here, putative mechanisms implicated in functional dyspepsia and potential approaches to therapy are critically reviewed in order to determine if targeting treatment is of value. Pharmacological therapies reviewed include those that aim to correct disordered gastric emptying (e.g. cisapride, dopaminergic receptor antagonists, macrolides), reduce visceral hypersensitivity (e.g. somatostatin analogues, cholecystokinin antagonists, opioid agonists, serotonin type 3 receptor antagonists), reduce gastric acid secretion (e.g. H2-blockers, acid pump inhibitors), cure Helicobacter pylori infection, enhance muscosal defence (e.g. sucralfate, bismuth) or modify central nervous system processes. It is concluded that the imperfectly understood pathophysiology of functional dyspepsia contributes to the paucity of established efficacious therapies.

Helicobacter pylori infection and gastric juice vitamin C levels. Impact of eradication

H. pylori has recently been recognized as a novel risk factor of gastric cancer, but its precise role in gastric carcinogenesis is as yet unknown. The aim of the present study was to assess the relationship between H. pylori infection and vitamin C levels in gastric juice and also to examine whether eradication of H. pylori could have any impact on these levels. Gastric juice and plasma vitamin C levels were measured in 88 dyspeptic patients who had an upper gastrointestinal endoscopy. In the subgroup of H. pylori-positive patients, eradication was attempted with triple therapy. This subgroup was studied on two occasions, ie, before and after treatment. There were 58 H. pylori-positive and 30 -negative patients. Gastric juice vitamin C levels in H. pylori-positive patients were statistically lower (P < 0.001) than the levels in the H. pylori-negative patients. Triple therapy achieved eradication in 45 patients (77.6%) of the 58 H. pylori-positive patients. Before H. pylori was eradicated in these 45 patients gastric juice vitamin C levels were significantly (P < 0.001) lower than those after eradication, the latter being no different than the group of 30 H. pylori-negative patients. There was a significant (P < 0.001) improvement of gastritis after eradication, which paralleled the elevation of gastric juice vitamin C levels. No difference was noted in plasma vitamin C levels between H. pylori-negative and -positive patients or in the latter before and after H. pylori treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term prospective study of Helicobacter pylori in nonulcer dyspepsia

Helicobacter pylori is present in up to 87% of patients with nonulcer dyspepsia. This study assessed the effect of eradicating Helicobacter pylori infection on the symptoms of nonulcer dyspepsia at four weeks and one year after treatment. Dyspepsia was assessed on the frequency and severity of six symptoms [epigastric pain (night and day), nausea and vomiting, upper abdominal discomfort, and regurgitation] where each symptom was scored from 0 to 4. Helicobacter pylori status was assessed before treatment and four weeks after treatment with histology and microbiology, and at one year with a carbon-13 urea breath test. Eighty-three patients (23 males, 60 females; mean age 56.3 years; mean symptom duration 3.6 months) with nonulcer dyspepsia and Helicobacter pylori infection entered the study. Seventy-five were available at one year follow-up. Four weeks after treatment, the mean symptom score improved in those with eradication (6.95-2.3, P = 0.01, N = 41) or persistent infection (6.69-3.0, P = 0.015, N = 42). At one year, those with persistent Helicobacter pylori infection (N = 38, score 5.24) had a higher score than those remaining clear of infection (N = 24, score 1.4, P < 0.0001) and those with reinfection (N = 13, score 2.2, P < 0.0001). In addition, persistent Helicobacter pylori infection was associated with more additional treatments than those with eradication (34/38 versus 4/37, P < 0.001). These results suggest that Helicobacter pylori plays an important role in the symptoms of nonulcer dyspepsia.

Distinct profiles of gastritis in dyspepsia subgroups. Their different clinical responses to gastritis healing after Helicobacter pylori eradication

BACKGROUND

A contribution of Helicobacter pylori gastritis to the pathogenesis of non-ulcer dyspepsia (NUD) remains uncertain.

METHODS

Administration of an appropriate clinical questionnaire followed by endoscopy allowed us to select, among 139 outpatients with dyspepsia, 87 non-ulcer dyspepsia patients with more severe and group-distinctive symptoms, 35 of whom were classified as having ulcer-like (ULD). 38 as dysmotility-like (DLD), and 14 as reflux-like dyspepsia (RLD). Biopsy specimens were evaluated for H. pylori gastritis in accordance with the Sydney system. The 70 H. pylori-positive cases were treated with omeprazole, 20 mg twice daily, and amoxycillin, 1 g three times daily for 2 weeks.

RESULTS

Higher rates of H. pylori colonization were found histologically in the gastric mucosa of ULD (91%) and RLD (86%) than in that of DLD (68%) or asymptomatic (42%) patients. ULD differed from RLD patients in their higher score of antritis activity. Three and 6 months after H. pylori eradication ULD (but not DLD) showed significant regression of dypspetic symptoms scores.

CONCLUSIONS

It seems likely that H. pylori gastritis, with special reference to active antritis, is among causative factors of ULD. Its role in the pathogenesis of RLD and DLD needs further investigation.

Basic and clinical aspects of visceral hyperalgesia

Although physiological stimuli in the healthy gastrointestinal tract are generally not associated with conscious perception, chronic abdominal discomfort and pain are the most common symptoms resulting in patient visits with gastroenterologists. Symptoms may be associated with inflammatory conditions of the gut or occur in the form of so-called functional disorders. The majority of patients with functional disorders appear to primarily have inappropriate perception of physiological events and altered reflex responses in different gut regions. Recent breakthroughs in the neurophysiology of somatic and visceral sensation are providing a series of plausible mechanisms to explain the development of chronic hyperalgesia within the human gastrointestinal tract. A central concept to all these mechanisms is the development of hyperexcitability of neurons in the dorsal horn, which can develop either in response to peripheral tissue irritation or in response to descending influences originating in the brainstem. Taking clinical characteristics and the concept of central hyperexcitability into account, a model is proposed by which abdominal pain from chronic inflammatory conditions of the gut and functional bowel disorders such as noncardiac chest pain, nonulcer dyspepsia, and irritable bowel syndrome could develop by multiple mechanisms either alone or in combination.

Helicobacter pylori in functional dyspepsia and normal controls

BACKGROUND

The aim of this study was to examine whether Helicobacter pylori status can identify a specific subset of patients with functional dyspepsia (FD) and erosive prepyloric changes (EPC).

METHODS

Anamnestic, somatic, and psychologic data were collected from 87 patients with functional dyspepsia and 77 normal control persons. Presence of H. pylori infection was assessed by the 14C-urea breath test.

RESULTS

H. pylori infection increased with age. Thirty-four per cent of the patients were H. pylori-positive, compared with 36% of the control persons. The patients had higher scores than the normal control persons on psychologic measures regardless of H. pylori status. Of 27 variables analyzed, age was the only factor that discriminated between H. pylori-positive and -negative patients.

CONCLUSIONS

For most patients with FD and EPC the presence of H. pylori infection is probably a consequence of age, and it does not seem to help us in the search for factors that can identify a subset of patients within our group of FD patients.

A critique of therapeutic trials in Helicobacter pylori-positive functional dyspepsia

BACKGROUND/AIMS

Approximately 50% of patients with functional dyspepsia have Helicobacter pylori infection; it remains controversial whether this infection causes chronic symptoms, but rigorously conducted therapeutic trials should establish whether H. pylori plays a role in functional dyspepsia. The aim here was to determine whether the trials published over the past 10 years were methodologically adequate to establish a role for this infection in functional dyspepsia.

METHODS

A broad-based Medline search to identify all treatment trials published between 1984 and 1993 was performed. All functional dyspepsia trials were systematically analyzed for potential design strengths and weaknesses.

RESULTS

Sixteen trials were included; 8 reported that anti-H. pylori therapy was efficacious and 8 failed to detect a statistically significant benefit. However, in all studies one or more serious methodological weakness was identified, including nonrandomized, non-placebo-controlled designs, lack of maintenance of blindness, application of inadequate outcome measures, failure to eradicate infection and follow up patients after therapy, and inadequate study power.

CONCLUSIONS

There is a pressing need for well-designed trials in H. pylori-positive dyspepsia, and practical suggestions are provided based on a review of the published literature.