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Role of Endoscopy in the Management of Dyspepsia
- Andrew Batey, Alexis Ayonote (29 April 2002)
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Patient selection for H.pylori Test&Treat
- Cesare Tosetti (6 May 2002)
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Non invasive Helicobacter pylori testing for children with dyspeptic recurrent abdominal pain.
- Ieuan H Davies, Huw G Jenkins, Consultant Paediatric Gastroenterologist (25 June 2002)
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Andrew Batey, Gastroenterology Fellow University of Wisconsin Hospital, Madison, WI , 53792, USA, Alexis Ayonote
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-The study by K. E. McColl et al, again confirms the non-invasive initial approach to patients with dyspepsia. The two most common predisposing factors for peptic ulcer disease, the use of Non-steroidal anti-inflammatory drugs and the presence of Helicobacter Pylori infection should be screened for in patients presenting with dyspepsia. -The prevalence of H. pylori infection in correlation with peptic ulcer disease in dyspeptic patients is significant enough to emphasize the need to test and treat the infection. The wide availability of non-ivasive tests for H. pylori makes this easily attenable. Even for patients starting long-term NSAID treatment, screening and treatment for H. pylori infection appear to reduce the risk of peptic ulceration (1). -In as much as endoscopy is increasingly becoming available its initial utilization in the investigation of patients with dyspepsia appears to be expensive and an over-kill. This study is therefore re-assuring about the non-invasive initial approach. -The problem and perhaps a recurring theme the study failed to address is the role of endoscopy in those subset of patients with negative H. pylori test and those with persistent symptoms after eradication of H. pylori. It is our opinion that at least one time endoscopy is inidicated in these sub -sets. Although, uncomfortable and more expensive, endoscopy remains a useful tool in the evaluation if not re-assurance of the absence of "cancer" in these sub-group of patients. 1. Chan F, To K, Wu J, Yung M, Leung W, Kwok T, et al. Eradication of Helicobacter pylori and risk of peptic ulcers in patients starting long- term treatment with non-steroidal anti-inflammatory drugs: a randomised trial. Lancet 2002;359:9-13 |
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Cesare Tosetti, General Practice 40046 Porretta Terme (BO) Italy
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Sir, the paper of McColl et al. (1) provides additional data about the safety of Test&Treat strategy, but the conclusions about the effectiveness should be limited to the population selected for the study, rather than to the management of upper gastrointestinal symptoms. The study has been carried out in patients referred for endoscopic investigation of upper gastrointestinal tract and therefore selected by general practitioners for suspected lesions of the gastro-oesophageal mucosa, so that predominant heartburn or epigastric painful symptoms were recorded in 83% of patients. The potential benefit of Test&Treat when restricted to patients suspected of peptic ulcer disease has been suggested in economic analysis (2). The paper of McColl et al. demonstrates that this strategy is safe and effective as management based on prompt endoscopy when applied in a selected population with a prevalence of ulcer disease of about 21% (29 gastro/duodenal ulcers out of 135 H.pylori positive patients with predominant painful symptoms). Data obtained in selected populations suspected of peptic ulcer disease can not be generalised to the management of dyspepsia that includes patients with different symptom presentations and potential pathophysiological mechanisms other than peptic disease (3, 4). 1.McColl KEL, Murray LS, Gillen D, Walker A, Wirz A, Fletcher J, et al. Randomised trial of endoscopy with testing for Helicobacter pylori compared with non-invasive H pylori testing alone in the management of dyspepsia. BMJ 2002;324:999-1007. 2.Bozzani A, Sturkenboom M, Ravasio R, Nicolosi A. Diagnostic work-up and management of young patients with ulcer-like dyspepsia. A cost- minimisation study. Eur J Gen Pract 2001;7:148-53. 3.Talley NJ, Stanghellini V, Heading RC, Koch KL, Malagelada JR, Tytgat GNJ. Functional gastroduodenal disorders. Gut 1999;45(Suppl II):1137-42. 4.Hession PT, Malagelada JR. Review article: the initial management of uninvestigated dyspepsia in younger patients – the value of symptom- guided strategies should be reconsidered. Aliment Pharmacol Ther 2000;14:379-88. Cesare Tosetti, MD General Practitioner and Gastroenterologist Porretta Terme (Bologna), Italy tosetti@libero.it |
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Ieuan H Davies, SpR Paediatric Gastroenterology Department of Paediatric Gastroenterology, University Hospital of Wales, Cardiff, CF14 4XW, Huw G Jenkins, Consultant Paediatric Gastroenterologist
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In their recent paper McColl et al(1) conclude that non invasive testing for Helicobacter pylori infection is as effective and safe as endoscopy in the management of adults with uncomplicated upper GI symptoms. They argue that two benefits of such a policy are low cost and less distress for the patient. Paediatric Gastroenterologists are faced with a similar dilemma when investigating children with recurrent abdominal pain. As with the adult population, no definitive link has been demonstrated between Helicobacter pylori gastritis and symptoms and to date there have been no large placebo controlled trials of eradication therapy in symptomatic children with Helicobacter pylori infection. The current management of Helicobacter pylori infection in UK children is based on the European Consensus Statement(2). This recommends that non-invasive tests should not be used to investigate whether or not symptomatic children have Helicobacter pylori infection. It is stated that endoscopy is the preferred method of investigation in children with upper digestive symptoms suggestive of organic disease after exclusion of other causes with non-invasive methods. Upper GI endoscopy in children is usually limited to tertiary centers. It is an invasive procedure that requires intravenous sedation or a general anaesthetic in children under the age of 8 years. Because of these problems it is likely that the interval between initial presentation with symptoms to definitive diagnosis following endoscopy can be many months or even years. Both the 13C-Urea breath test(3)and the more recently introduced stool antigen tests(4)are effective and validated for the diagnosis of Helicobacter pylori infection in children. The authors feel that it safe and not against current evidence to investigate children with uncomplicated dyspeptic pain using these non invasive tests without the need for endoscopy. We would advocate a test and treat policy for uncomplicated cases and would reserve endoscopy for those children who remain symptomatic or where another diagnosis is suggested. This could lead to the quick and effective treatment of both children with ulcer disease and the sub population of children that have symptomatic Helicobacter pylori gastritis. It also has the potential to reduce the risk of future ulcer disease or stomach malignancies in those infected with Helicobacter pylori. Ieuan Davies Huw Jenkins References 1. McColl KEL, Murray LS, Gillen D et al. Randomised trial of endoscopy with testing for Helicobacter pylori compared with non-invasive H pylori testing alone in the management of dyspepsia. BMJ. 2002:324:999- 1002. 2. Drumm B, Koletzko S, Oderda G (European Paediatric Task Force on Helicobacter pylori). Helicobacter pylori infection in children: a consensus statement. J Ped Gastroenetrol Nutr 2000;30:207-213. 3. Cadranel S, Corvaglia L, Bontems P, Deprez C et al. Detection of Helicobacter pylori infection in children with a standardized and simplified 13C-Urea breath test. J Ped Gastroenterol Nutr 1998;27:275-80 4. Ni Y, Lin J, Huang S et al. Accurate diagnosis of Helicobacter pylori infection by stool antigen test and 6 other currently available tests in children. Pediatrics 2000;136:823-27 |
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