The management of dyspepsia: a systematic review

The Effect of Helicobacter pylori Eradication on Gastric Wall Thickness in Patients Undergoing Laparoscopic Sleeve Gastrectomy

PURPOSE

The most important cause affecting the thickness of the gastric wall other than the tumor is chronic gastritis caused by Helicobacter pylori (Hp), which is most frequently detected in the antrum. This study aims to investigate the effect of bismuth-based treatment (BBT) combined with proton pump inhibitor (PPI) on wall thicknesses measured in the postoperative gastric specimen and early postoperative complications in patients with Hp-positive pre-LSG endoscopic gastric biopsies.

MATERIALS AND METHODS

The patients who underwent LSG procedure for morbid obesity were divided into three groups as follows: Hp-negative, Hp-positive without eradication treatment, and Hp-positive, and LSG was performed after eradication treatment. Macroscopic and microscopic gastric wall thickness measurements were made at a distance of 1 cm from the proximal surgical margin, from the middle part of the specimen, and 1 cm from the distal surgical margin in the gastric specimen and the results were compared.

RESULTS

A total of 132 patients were included in the study, 44 patients in each group. Microscopically measured antrum mucosal thickness was found to be statistically significantly higher in group 2 compared to other groups (groups 1.15, 1.35, 1.16 mm, respectively, p = 0.000). There was no difference between the groups in terms of early complications such as bleeding, wound site infection, or leakage from the staple line within the first 28 days after surgery.

CONCLUSION

This study found that LSG had no effect on early complications due to Hp positivity or eradication of Hp.

KEY POINTS

• The presence of HP increases the wall thickness of the gastric antrum mucosa. • After HP eradication, stomach antrum wall thickness returns to normal. • HP eradication before LSG reduces the wall thickness of the gastric antrum mucosa. • It was determined that HP scanning and eradication before LSG had no effect on postoperative complications.

A validation study of the Italian Short-Form Leeds Dyspepsia Questionnaire

Assessment of symptoms should be one of the main outcome measures in dyspepsia clinical trials. This requires a reliable, valid and responsive questionnaire that measures the frequency and severity of dyspeptic symptoms. The Short-Form Leeds Dyspepsia Questionnaire (SF-LDQ) has been proven to fulfil these criteria in its original version in the English language. The aim of the study was to assess the internal consistency, reliability, validity and responsiveness of the Italian version of the SF-LDQ in primary and secondary care. Unselected primary and secondary care patients completed the Italian version of the SF-LDQ. Test-retest reliability was assessed after 2 days. Validity was measured by comparison with diagnosis made by physicians. Responsiveness was determined before and after treatment for endoscopically proven disease. The SF-LDQ was administered to 311 patients in primary care and 179 in secondary care patients. Internal consistency, as judged by the Cronbach's α, was 0.90. Pearson's correlation coefficient for test-retest reliability was 0.92. The SF-LDQ had a sensitivity of 80% and a specificity of 82%. A highly significant response to change was also observed (p = 0.001). The Italian SF-LDQ is a reliable, valid and responsive self-completed outcome measure for quantifying the frequency and severity of dyspeptic symptoms.

Does patient blood glucose monitoring improve diabetes control? A systematic review of the literature

OBJECTIVE

The purpose of this systematic review was 2-fold: first, to perform a comprehensive review of relevant studies on the impact of self-monitoring of blood glucose (SMBG) on HbA1c levels for patients with type 2 diabetes mellitus and, second, to explore mediators and moderators within a self-regulation framework.

DATA SOURCES

Five databases-Medline, PsychInfo, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing & Allied Health Literature (CINAHL)-were searched.

STUDY SELECTION

Cross-sectional, longitudinal, and randomized control trials from 1990 to 2006, which included patients with type 2 diabetes not on insulin, were reviewed. In total, 6,769 studies were screened for inclusion, 89 were retrieved for detailed analysis, and 29 met criteria for inclusion in the review.

DATA EXTRACTION

Data on the impact of SMBG on HbA1c, potential mediators and moderators, study design and participants, and limitations of each study were retrieved.

DATA SYNTHESIS

Twenty-nine studies were included in this review: 9 cross-sectional studies, 9 longitudinal studies, and 11 randomized controlled trials. Evidence from the cross-sectional and longitudinal studies was inconclusive. Evidence from randomized controlled trials suggests that SMBG may lead to improvements in glucose control. Very few studies examined potential mediators or moderators of SMBG on HbA1c levels.

CONCLUSIONS

SMBG may be effective in controlling blood glucose for patients with type 2 diabetes. There is a need for studies that implement all the components of the process for self-regulation of SMBG to assess whether patient use of SMBG will improve HbA1c levels.

External validation of a measurement tool to assess systematic reviews (AMSTAR)

BACKGROUND

Thousands of systematic reviews have been conducted in all areas of health care. However, the methodological quality of these reviews is variable and should routinely be appraised. AMSTAR is a measurement tool to assess systematic reviews.

METHODOLOGY

AMSTAR was used to appraise 42 reviews focusing on therapies to treat gastro-esophageal reflux disease, peptic ulcer disease, and other acid-related diseases. Two assessors applied the AMSTAR to each review. Two other assessors, plus a clinician and/or methodologist applied a global assessment to each review independently.

CONCLUSIONS

The sample of 42 reviews covered a wide range of methodological quality. The overall scores on AMSTAR ranged from 0 to 10 (out of a maximum of 11) with a mean of 4.6 (95% CI: 3.7 to 5.6) and median 4.0 (range 2.0 to 6.0). The inter-observer agreement of the individual items ranged from moderate to almost perfect agreement. Nine items scored a kappa of >0.75 (95% CI: 0.55 to 0.96). The reliability of the total AMSTAR score was excellent: kappa 0.84 (95% CI: 0.67 to 1.00) and Pearson's R 0.96 (95% CI: 0.92 to 0.98). The overall scores for the global assessment ranged from 2 to 7 (out of a maximum score of 7) with a mean of 4.43 (95% CI: 3.6 to 5.3) and median 4.0 (range 2.25 to 5.75). The agreement was lower with a kappa of 0.63 (95% CI: 0.40 to 0.88). Construct validity was shown by AMSTAR convergence with the results of the global assessment: Pearson's R 0.72 (95% CI: 0.53 to 0.84). For the AMSTAR total score, the limits of agreement were -0.19+/-1.38. This translates to a minimum detectable difference between reviews of 0.64 'AMSTAR points'. Further validation of AMSTAR is needed to assess its validity, reliability and perceived utility by appraisers and end users of reviews across a broader range of systematic reviews.

A second-order simulation model of the cost-effectiveness of managing dyspepsia in the United States

BACKGROUND

The "gold-standard'' evidence of effectiveness for a clinical practice guideline is the randomized controlled trial (RCT), although RCTs have a limited ability to explore potential management strategies for a chronic disease where these interact over time. Modeling can be used to fill this gap, and models have become increasingly complex, with both dynamic sampling and representation of second-order uncertainty to provide more precise estimates. However, both simulation modeling and probabilistic sensitivity analysis are rarely used together. The objective of this study was to explore uncertainty in controversial areas of the 2005 American Gastroenterology Association position statement on the management of dyspepsia.

METHODS

Individual sampling model, incorporating a second-order probabilistic sensitivity analysis.

POPULATION

US adult patients presenting in primary care with dyspepsia. Interventions compared: empirical acid suppression, test and treat for Helicobacter pylori, initial endoscopy, acid suppression then endoscopy, test and treat then proton pump inhibitor (PPI) then endoscopy.

OUTCOMES

Cost-effectiveness, quality-adjusted life years, and costs in US dollars from a societal perspective, measured over a 5-year period.

DATA SOURCES

mainly Cochrane meta-analyses.

RESULTS

Endoscopy was dominated at all ages by other strategies. PPI therapy was the most cost-effective strategy in 30-year-olds with a low prevalence of H. pylori. In 60-year-olds, H. pylori test and treat was the most cost-effective option.

CONCLUSIONS

Acid suppression alone was more cost-effective than either endoscopy or H. pylori test and treat in younger dyspepsia patients with a low prevalence of infection.

Cost-effectiveness analysis of two management strategies for dyspepsia

OBJECTIVES

To compare the cost-effectiveness of endoscopy and empirical proton pump inhibition (PPI) therapy for management of dyspepsia in primary care.

METHODS

A randomized controlled trial, including prospective collection of economic resource data, was conducted in general practice from June 2000 to August 2002, Aarhus County, Denmark. We randomly assigned 368 dyspeptic patients from thirty-two general practices to treatment with omeprazol 40 mg for 2 weeks (n=184) or endoscopy (n=184). The study adopted a societal perspective, and the year of costing was 2006.

OUTCOME MEASURES

days free of dyspeptic symptoms and proportion of patients with dyspepsia after 1 year based on patients' and general practitioners' (GPs) assessment. Costs were estimated from patient and GP questionnaires and from medical records.

RESULTS

The incremental cost-effectiveness (CE) ratio for 1 day free of dyspeptic symptoms using the endoscopy strategy was euro/day 154 compared with the PPI strategy. The incremental CE ratio for one person free of dyspeptic symptoms after 1 year using the endoscopy strategy was euro13,905 based on the patients' evaluation, and the incremental CE ratio for one person free of predominant symptoms after 1 year was euro5,990 according to the GPs' evaluation. The PPI strategy was both cheaper and more effective than the endoscopy strategy when reflux was the predominant symptom.

CONCLUSIONS

A strategy using empirical antisecretory PPI therapy should be recommended if the alternative is an endoscopy strategy for managing dyspeptic patients in general practice, especially if reflux was the predominant symptom.

The Short-Form Leeds Dyspepsia Questionnaire validation study

BACKGROUND

Assessment of symptoms should be the primary outcome measure in dyspepsia clinical trials. This requires a reliable, valid and responsive questionnaire that measures the frequency and severity of dyspepsia. The Leeds Dyspepsia Questionnaire fulfils these characteristics, but is long and was not designed for self-completion, so a shorter questionnaire was developed (the Short-Form Leeds Dyspepsia Questionnaire).

AIM

To assess the acceptability, interpretability, internal consistency, reliability, validity and responsiveness of the Short-Form Leeds Dyspepsia Questionnaire in primary and secondary care.

METHODS

Unselected primary and secondary care patients completed the Short-Form Leeds Dyspepsia Questionnaire. Test-retest reliability was assessed after 2 days. Validity was measured by comparison with general practitioners' diagnosis. Sensitivity analysis and logistic regression were employed to determine the most valid scoring system. Responsiveness was determined before and after treatment for endoscopically proven disease.

RESULTS

The Short-Form Leeds Dyspepsia Questionnaire was administered to 388 primary care and 204 secondary care patients. The Pearson coefficient for test-retest reliability was 0.93. The Short-Form Leeds Dyspepsia Questionnaire had a sensitivity of 77% and a specificity of 75%. A highly significant response to change was observed (P < 0.005).

CONCLUSIONS

The Short-Form Leeds Dyspepsia Questionnaire is a reliable, valid and responsive self-completed outcome measure for quantifying the frequency and severity of dyspepsia symptoms, which is shorter and more convenient than the Leeds Dyspepsia Questionnaire.

Economic evaluation of empirical antisecretory therapy versus Helicobacter pylori test for management of dyspepsia: a randomized trial in primary care

OBJECTIVES

An economic evaluation was performed of empirical antisecretory therapy versus test for Helicobacter pylori in the management of dyspepsia patients presenting in primary care.

METHODS

A randomized trial in 106 general practices in the County of Funen, Denmark, was designed to include prospective collection of clinical outcome measures and resource utilization data. Dyspepsia patients (n = 722) presenting in general practice with more than 2 weeks of epigastric pain or discomfort were managed according to one of three initial management strategies: (i) empirical antisecretory therapy, (ii) testing for Helicobacter pylori, or (iii) empirical antisecretory therapy, followed by Helicobacter pylori testing if symptoms improved. Cost-effectiveness and incremental cost-effectiveness ratios of the strategies were determined.

RESULTS

The mean proportion of days without dyspeptic symptoms during the 1-year follow-up was 0.59 in the group treated with empirical antisecretory therapy, 0.57 in the H. pylori test-and-eradicate group, and 0.53 in the combination group. After 1 year, 23 percent, 26 percent, and 22 percent, respectively, were symptom-free. Applying the proportion of days without dyspeptic symptoms, the cost-effectiveness for empirical treatment, H. pylori test and the combination were 12,131 Danish kroner (DKK), 9,576 DKK, and 7,301 DKK, respectively. The incremental cost-effectiveness going from the combination strategy to empirical antisecretory treatment or H. pylori test alone was 54,783 DKK and 39,700 DKK per additional proportion of days without dyspeptic symptoms.

CONCLUSIONS

Empirical antisecretory therapy confers a small insignificant benefit but costs more than strategies based on test for H. pylori and is probably not a cost-effective strategy for the management of dyspepsia in primary care.

Effect of age-related changes in gastric physiology on tolerability of medications for older people

Studies specifically examining the effect of age upon the stomach are limited and frequently uncontrolled for the high prevalence of Helicobacter pylori in this age group. Age-related changes in gastric physiology such as reduced mucosal protection, gastric blood flow and impaired repair mechanisms may all impact upon gastrointestinal adverse effects and how older people tolerate medicines. Understanding how the upper gastrointestinal tract changes with advancing age could allow interventions that lead to more appropriate prescribing for older people, potentially reduce adverse effects, increase compliance with treatment regimens, and may allow older people to take medications that they would not otherwise tolerate. This review emphasises how the stomach changes with age, and how understanding this will aid clinicians when prescribing medications with potential gastrointestinal adverse effects to older people.

Idiopathic dyspepsia

Idiopathic dyspepsia refers to pain and/or discomfort perceived in the epigastrium that is not secondary to organic, systemic, or metabolic diseases. Symptoms may overlap with those of gastroesophageal reflux disease and irritable bowel syndrome. Gastrointestinal motor disorders, hypersensitivity to mechanical or chemical stimuli, and psychosocial factors can act individually or in concert to induce the symptoms of dyspepsia. Accordingly, there is no single therapy, and treatment must be individualized. Eradication of Helicobacter pylori infection rarely achieves symptom improvement. Treatment of idiopathic dyspepsia should begin by reassuring the patient about the benign nature of the syndrome and educating them on the knowledge that has been achieved in recent years regarding potential causes of the syndrome. Both prokinetic and antisecretory drugs have been reported to improve dyspeptic symptoms, but results are not completely convincing. Although well-designed studies demonstrate superiority of proton pump inhibitors over placebo, it should be noted that patients with nonerosive gastroesophageal reflux disease were invariably included; when these patients are excluded, the benefit of antisecretory medications is questionable. We suggest that patients with idiopathic dyspepsia be initially treated according to the predominant symptom. Those with epigastric pain/burning should receive a trial with standard doses of proton pump inhibitors for 4 to 8 weeks, whereas prokinetic patients should be prescribed at recommended doses for similar periods of time to patients with nonpainful dyspeptic symptoms such as posprandial fullness, early satiety, nausea, or vomiting. Nonresponders may benefit from combination therapies or short trials with higher doses of drugs. Visceral analgesics and antidepressants can also be prescribed alone or in combinations with other therapeutic strategies. Recent studies demonstrate utility for psychologic therapy and hypnotherapy, although truly controlled studies are difficult in this area. Herbal medicines deserve further evaluation.

Symptom-based outcome measures for dyspepsia and GERD trials: a systematic review

BACKGROUND

Symptom assessment using questionnaires has been recommended as the primary outcome measure in clinical gastroesophageal reflux and dyspepsia trials. Questionnaires should have proven reliability, validity, and responsiveness, and may assess the frequency and/or severity of dyspepsia symptoms. Although a number of measures have been developed, it remains unclear which of these should be used in new trials.

OBJECTIVE

To describe existing questionnaire outcome measures that assess symptoms of gastroesophageal reflux dyspepsia for use in clinical trials.

METHODS

Studies were identified from Medline, Embase, the Cochrane library, and reference lists. The inclusion criterion was that the study assessed a questionnaire, which measured the frequency or severity of dyspepsia or gastroesophageal reflux symptoms, in a sample of patients.

RESULTS

No direct comparison between questionnaires was possible due to methodological heterogeneity. Thirty-seven studies describing 26 questionnaires met the inclusion criteria. Twelve were unidimensional (assessed symptoms only) and 14 were multidimensional (also assessed quality of life). Eleven questionnaires assessed both frequency and severity of dyspepsia, and 10 had proven reliability, validity, and responsiveness. No studies compared different questionnaires.

CONCLUSIONS

Future gastroesophageal reflux and dyspepsia clinical trials should use unidimensional or multidimensional outcome measures that assess both the frequency and severity of symptoms, and have proven reliability, validity, and responsiveness. Further research is necessary to compare existing outcome measures to determine which are the most reliable, valid, and responsive instruments.

Dyspepsia management in primary care: a management trial

The aim was to evaluate the outcomes associated with four initial management strategies in new patients presenting to primary care physicians with dyspepsia. Patients with new symptoms (no alarm features) were randomised to empirical therapy (n = 11), Helicobacter pylori (HP) serology (n = 8), HP breath testing (n = 11) or oesophagogastroduodenoscopy (n = 13). Dyspepsia and health-related quality of life were assessed using standardised questionnaires at entry, 6 and 24 weeks post-trial enrollment. Outcomes were assessed by structured telephone interview every 6 weeks. In the initial HP testing arms, 21% were positive; 27% in the oesophagogastroduodenoscopy arm had inflammatory changes without ulcers at baseline. The majority (67%) received over the counter medication after initial management. Symptom-free status was similarly common in all groups (p = 0.49); only 20% pursued further evaluation. Total billed charges were higher in the oesophagogastroduodenoscopy group (US 2077 dollars) vs. empirical therapy (US 512 dollars), despite excluding the charge for initial oesophagogastroduodenoscopy, but overall, no effects on total medical charges were detected (p = 0.10). Regardless of initial management, most patients remained symptomatic, yet did not return for health care visits or undergo endoscopies. The cost of upfront endoscopy may not be the best choice for patients presenting with new dyspepsia.

Assessing heterogeneity in meta-analyses of Helicobacter pylori infection-related clinical studies: a critical appraisal

OBJECTIVE

To critically assess the meta-analyses of Helicobacter pylori infection-related clinical studies, particularly the handling of between-study heterogeneity.

METHODS

A qualitative, all-language, systematic literature search was performed in Medline, PubMed, BioMed Central and Embase up to February 2003, supplemented by a manual search of major relevant journals. Assessment was according to modified criteria for literature searching, eligibility criteria, validity assessment, data extraction and presentation. Five parameters were used to assess the quality of the meta-analyses in handling between-study heterogeneity.

RESULTS

Of 84 potentially relevant citations, 47 were systematic reviews and of them 38 were meta-analyses. Of these 38 studies, 15 (39.5%) had conducted a literature search of multiple databases and 34 (89.5%) had conducted a supplementary manual search. The eligibility criteria were clearly presented in 81.6% of studies, but the quality of the primary studies was assessed in only 26.3%. The process and strategy for data extraction was reported in 57.9% of all studies; 19 (50%) studies planned statistical tests of between-study homogeneity and the results were reported in 18, but the level of statistical significance was reported in only 11 (57.9%). The selection of and justification for a statistical model was presented in 39.5% and 26.3% of studies, respectively. Among the 11 meta-analyses in which statistical between-study heterogeneity was reported, 54.5% ignored the statistical findings and proceeded to pool the study results. The implications of between-study heterogeneity were discussed in only 8 studies.

CONCLUSIONS

Many methodological flaws were identified in the meta-analyses of H. pylori-related clinical studies, particularly for assessing, reporting and interpreting between-study heterogeneity. This warrants consistent and urgent adherence by reviewers and journal editors to the methodological guidelines for meta-analyses.

[Prospective validation of a clinical scoring system for the diagnosis of organic dyspepsia]

BACKGROUND AND OBJECTIVE

Predictive symptomatic scoring models have been proposed to select patients with dyspepsia, who may be candidates to endoscopy. In a previous study performed by gastroentrologists from our group, we obtained three scales of symptoms to predict organic dyspepsia, peptic ulcer and esophagitis, respectively. Here we analyze the reproducibility of those scoring models of symptoms when used either by other gastroenterologists or general practitioners.

PATIENTS AND METHOD

It was a clinical prospective study of 230 patients from the Viladecans hospital area (120 from primary healthcare and 110 from the gastroenterologist's consultation). The three validation scales were performed in each patient. Then, we performed a diagnostic gastroscopy which allowed to classify patients into those with organic dyspepsia (ulcer, esophagitis, cancer) or those with functional dyspepsia. We calculated the overall predictive accuracy for the gastroenterologist and the general practitioner and for the three diagnoses (organic dyspepsia, ulcer or esophagitis) using the C statistic.

RESULTS

Discriminative capacities were 0.75 and 0.82 for organic dyspepsia, 0.78 and 0.86 for ulcer disease, and 0.78 and 0.82 for esophagitis, for the general practitioner and the gastroenterologist, respectively. In this validation study, the best cut-off value, namely the one combining good sensitivity and specificity, was found to be 7.

CONCLUSIONS

A correct predictive capacity of the symptomatic score models when used by other gastroenterologists or by primary healthcare practioners confirms its reproducibility and transferability. The use of predictive symptomatic score models in everyday clinical practice can allow to rationalize the referral for endoscopy in our local setting.

Economic evaluation of Helicobacter pylori eradication in the CADET-Hp randomized controlled trial of H. pylori-positive primary care patients with uninvestigated dyspepsia

BACKGROUND

Adult Helicobacter pylori-positive patients by 13C-urea breath test with uninvestigated dyspepsia symptoms were randomized to 1-week eradication treatment with omeprazole, metronidazole and clarithromycin (OMC) vs. omeprazole and placebo antimicrobials (OPP) in the Canadian Adult Dyspepsia Empiric Treatment-H. pylori-positive (CADET-Hp) study.

AIM

To perform an economic evaluation of this 1-year study.

METHODS

Following blind eradication treatment, family practitioners managed patients according to their usual practices. Health resource utilization information was collected prospectively. From the mean costs of the health resources consumed and the treatment outcomes, the incremental cost-effectiveness ratios and incremental net benefits of eradication treatment vs. OPP were determined.

RESULTS

Eradication therapy significantly improved dyspepsia symptoms (treatment success: OMC, 50%; OPP, 36%; P = 0.02). The incremental cost-effectiveness ratio of OMC vs. OPP was - 387 Canadian dollars (CAD$) per treatment success (90% CI, - CAD$1707, CAD$607), indicating a lower cost with treatment success. The incremental net benefit analysis showed that H. pylori eradication was cost-effective if the willingness-to-pay value exceeded a nominal figure of CAD$100 from a health service perspective or CAD$607 from the societal perspective.

CONCLUSION

In uninvestigated patients presenting with dyspepsia at the primary care level, eradication of H. pylori in those who are H. pylori positive leads to a cost-effective improvement in dyspepsia symptoms compared with a strategy of not eradicating H. pylori in these patients.

Adjusting for publication bias in the presence of heterogeneity

It is known that the existence of publication bias can influence the conclusions of a meta-analysis. Some methods have been developed to deal with publication bias, but issues remain. One particular method called 'trim and fill' is designed to adjust for publication bias. The method, which is intuitively appealing and comprehensible by non-statisticians, is based on a simple and popular graphical tool called the funnel plot. We present a simulation study designed to evaluate the behaviour of this method. Our results indicate that when the studies are heterogeneous (that is, when they estimate different effects), trim and fill may inappropriately adjust for publication bias where none exists. We found that trim and fill may spuriously adjust for non-existent bias if (i) the variability among studies causes some precisely estimated studies to have effects far from the global mean or (ii) an inverse relationship between treatment efficacy and sample size is introduced by the studies' a priori power calculations. The results suggest that the funnel plot itself is inappropriate for heterogeneous meta-analyses. Selection modelling is an alternative method warranting further study. It performed better than trim and fill in our simulations, although its frequency of convergence varied, depending on the simulation parameters.

A randomized comparison of quadruple and triple therapies for Helicobacter pylori eradication: The QUADRATE Study

BACKGROUND & AIMS

Direct comparisons of bismuth and proton pump inhibitor (PPI)-based triple and quadruple therapies for Helicobacter pylori eradication are lacking. To address this, a randomized study was conducted.

METHODS

Infected dyspeptic patients received pantoprazole 40 mg, amoxicillin 1000 mg, and clarithromycin 500 mg, all twice daily, for 7 days (PAC7); or pantoprazole 40 mg twice daily, bismuth subcitrate 108 mg, and tetracycline 500 mg, both 4 times daily, and metronidazole 200 mg 3 times daily and 400 mg at night for 7 days (PBTM7); bismuth subcitrate 108 mg and tetracycline 500 mg, both 4 times daily, and metronidazole 200 mg 3 times daily and 400 mg at night for 14 days (BTM14). Outcome was assessed with (13)C-urea breath test.

RESULTS

Eradication rates (intention to treat [n = 405]/per protocol [n = 320]) were similar for PAC7 (78%/82%) and PBTM7 (82%/88%); the latter significantly superior to BTM14 (69%/74%; P < 0.01). Pretreatment metronidazole resistance (MR) was 53% and clarithromycin resistance was 8%. Eradication rates for primary metronidazole sensitive/resistant isolates were 74%/87% with PAC7 and 80%/81% for PBTM7, compared with 76%/55% (P < 0.02) for BTM14. Noncompliance was greater with BTM14 (15%; P < 0.001) than PAC7 (3%) or PBTM7 (6%). Moderate-severe adverse events were more common with BTM14 (45%; P < 0.001), than PAC7 (23%) or PBTM7 (25%) with more discontinuations (9%, 2%, 3%, respectively).

CONCLUSIONS

One-week PPI triple therapy is well tolerated and effective. The addition of PPI to bismuth triple therapy allows reduction of treatment duration with improved efficacy and tolerability, despite a high rate of MR. Quadruple therapy appears to overcome pretreatment MR in most cases. Two-week bismuth triple therapy is significantly inferior to quadruple therapy and less well tolerated than both 1-week therapies.

Helicobacter pylori and nonmalignant disease

Helicobacter pylori eradication has become the recognized standard and widely adopted therapy to cure peptic ulcer disease. Other H. pylori associated conditions with potential benefit from eradication therapy are still subject to clinical investigations. The current state of evidence for these indications is summarized in this article. For NSAID associated peptic ulcer disease the current evidence needs to be grouped in three subsets of clinical conditions: a) H. pylori eradication for prevention of ulcers before starting NSAIDs therapy is advisable; b) eradication during PPI treatment for NSAID associated active ulcer shows no advantage on healing; and c) eradication alone is not sufficient for secondary prevention of ulcer complications induced by NSAID, however it appears to protect from further episodes of aspirin induced bleeding. In nonulcer dyspepsia the latest Cochrane collaboration review supports a small benefit in favour of H. pylori eradication. New insight in the relationship of H. pylori with GERD is provided from clinical trials which show that H. pylori eradication does not influence the clinical course of patients with reflux esophagitis. Finally important new data are presented regarding the management of dyspepsia at the primary care level with the confirmation that the H. pylori 'test and treat' strategy in the appropriate setting is more cost-effective than endoscopy.

Dyspepsia: challenges in diagnosis and selection of treatment

BACKGROUND

Despite considerable study, the pathophysiology of dyspepsia remains obscure. This and other factors have impeded development of precise and effective treatment strategies.

OBJECTIVE

This paper provides a brief review of the clinical syndrome of dyspepsia and its pathophysiology, symptoms, diagnosis, and treatment.

METHODS

To identify articles for inclusion in this review, a search of MEDLINE was conducted using the key word dyspepsia. Because the literature on this topic is voluminous and duplicative, the search was limited primarily to literature from the last decade and to articles concerning dyspepsia in adults.

RESULTS

The symptoms of dyspepsia, which may include epigastric pain, heartburn. bloating, and early satiety, defy diagnosis in as many as 50% of patients, even after endoscopy and other appropriate studies. In the other half of patients, such causative disorders as gastroesophageal reflux disease (GERD), peptic ulcer disease, cholecystitis, pancreatitis, and gastric cancer may be diagnosed. Despite controversy regarding the selection of therapy, empiric treatment is common for apparent idiopathic dyspepsia. Histamine2-receptor antagonists, proton pump inhibitors (PPIs), promotility agents, and coating agents have all been used as empiric therapy for dyspeptic symptoms. With empiric treatment, subsequent management is directed by the therapeutic response. In the absence of a definitive diagnosis, treatment is usually selected on the basis of the type and severity of symptoms, a thorough history and physical examination, and factors such as age and the presence of Helicobacter pylori infection. Five PPIs are currently available--lansoprazole, omeprazole, rabeprazole, pantoprazole, and esomeprazole--all with established efficacy in GERD and other acid-mediated disorders. The PPIs can be expected to be useful in certain patients with dyspepsia, and may be prescribed for patients who are found to re- spond to potent antisecretory therapy. Patients' concern about their symptoms, practical considerations, and restrictions imposed by managed care organizations may all affect the choice between empiric therapy and early endoscopy in patients with dyspepsia.

CONCLUSIONS

Despite the variety of therapeutic options available for the symptoms of dyspepsia, the many presentations of this condition and the uncertainty of the response to the currently available therapeutic options continue to pose a substantial clinical challenge.