Letters

Comparison groups were not clear in study

In their analysis of screening for H pylori in dyspeptic patients in the community, it is not clear what strategies they were comparing. They state that all patients who were serologically positive for H pylori underwent endoscopy to determine whether they had peptic ulcer disease followed presumably by eradication treatment if an ulcer was identified. What was the comparative strategy? Was it patients who were serologically positive for H pylori and then empirically treated with eradication treatment without previous endoscopy? Or was it patients who were empirically treated with cimetidine without previous serological testing for H pylori? Regardless of the comparative group, the outcome of patients who are negative for H pylori in serological tests or those who are positive for H pylori in such tests but do not have an ulcer on endoscopy should have been considered, although it is unclear if this was done. These subgroups of patients are important because they represent the majority of patients and could account for a significant number of follow up office visits, repeat endoscopies, and loss of days from work.

The three strategies for managing dyspepsia in the community are (a) serological testing for H pylori followed either by endoscopy if H pylori positive or by antimicrobial treatment without endoscopy, (b) empirical treatment with antisecretory drugs, and (c) empirical treatment with antisecretory drugs and antibiotic agents to eradicate H pylori. Decision analysis studies from the United States have suggested that there is little difference in the cost effectiveness between these strategies.^{2 3} Compared with an invasive strategy of immediate endoscopy, a prospective randomised study comparing immediate endoscopy with empirical H2 receptor antagonists in dyspepsia has shown that in the long term endoscopy is more cost effective.⁴ However, decision analyses of immediate endoscopy compared with non-invasive strategies give conflicting findings.^{2 3}

Prospective studies to compare the different management strategies of dyspepsia in the community are clearly warranted. At present, any of the above strategies can be justified based on decision analyses.

TONY C THAM Visiting gastroenterology fellow

DAVID R LICHTENSTEIN Instructor in medicine

Endoscopy Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA

Tony C K Tham, David R Lichtenstein 

1. Briggs AH, Sculpher MJ, Logan RPH, Aldous J, Ramsay ME, Baron JH. Cost effectiveness of screening for and eradication of Helicobacter pylori in management of dyspeptic patients under 45 years of age. BMJ 1996;312:1321-5. (25 May.) (Correction: 29 June, p 1647.) [Abstract/Free Full Text]
2. Silverstein MD, Petterson T, Talley NJ. Initial endoscopy or empirical therapy with or without testing for Helicobacter pylori for dyspepsia: a decision analysis. Gastroenterology 1996;110:72-83. [Medline]
3. Fendrick AM, Chernew ME, Hirth RA, Bloom BS. Alternative management strategies for patients with suspected peptic ulcer disease. Ann Intern Med 1995;123:260-8. [Abstract/Free Full Text]
4. Bytzer P, Hansen JM, Schaffalitzky de Muckadell OB. Empirical H(sub 2)-blocker therapy or prompt endoscopy in management of dyspepsia. Lancet 1994;343:811-6. [Medline]