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Rupal Shah
Dyspepsia and Helicobacter pylori
BMJ 2007; 334: 41-43 [Full text]
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[Read Rapid Response] Endoscopic mortality and refining the referral age limit
Shivaram Bhat, Anastasios Koulaouzidis, SpR in Gastroenterology, Warrington Hospital   (8 January 2007)
[Read Rapid Response] Mortality of Sedation for Upper GI Endoscopy
David N Hunter   (27 January 2007)
[Read Rapid Response] “Test, treat and confirm eradication”
Brian J Egan, Barbara M Ryan and Colm A O'Morain   (13 February 2007)

Endoscopic mortality and refining the referral age limit 8 January 2007
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Shivaram Bhat,
SpR in Gastroenterology
Warrington Hospital, WA5,
Anastasios Koulaouzidis, SpR in Gastroenterology, Warrington Hospital

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Re: Endoscopic mortality and refining the referral age limit

We read with interest the recent Masterclass in the clinical management of dyspepsia and found it a useful tool to help the non- specialist.(1) We would like to make a number of comments. Firstly, the quoted mortality (0.0005%) for upper GI endoscopy appears low. The recent British Society of Gastroenterology guidelines quote a mortality of 0.004%. (2) Although on paper this gives the illusion of a minor difference it is of significance for the valid consent of patients.

Secondly, current NICE guidelines recommend urgent referral of patients over the age of 55 that have persistent, unexplained recent onset dyspepsia.(2) We believe that out of the referral criteria this is the least likely to yield a diagnosis of upper GI malignancy.(3)

Initial concerns were raised regarding the increase in referral age to 55 years from the Maastricht II-2000 consensus recommended limit of 45. A number of studies have proved the safety of this threshold.(4,5) It may be possible to increase this age threshold to 60 years, in patients with dyspepsia without alarms symptoms. Evidence exists that a 'test and treat' policy for this subgroup may save more life years than initial endoscopy based management.(5)

The introduction of colorectal cancer screening and the ‘two week’ referral rule for patients with alarms symptoms certainly add a significant pressure on the gastroenterology service. It seems that without an expansion of the number of trained endoscopists, a review of the referral criteria may be necessary.

References:

1. Shah R. Dyspepsia and Helicobacter pylori BMJ 2007; 334: 41-43

2. British Society of Gastroenterology. Guidelines on Complications of Gastrointestinal Endoscopy. London: BSG, 2006. (Available from www.bsg.org.uk)

3. Said E, Koulaouzidis A, Nicolaides D, Clarkson D, Saeed AA. Predictive Value of Alarm Symptoms in Upper GI Cancer Diagnosis. The American Journal of Gastroenterology 2006;101 (s2):s499

4. Koulaouzidis A, Leontiadis GI, Eliades S, Azam F, Saeed A, Kadis S. Is the age limit of 55 years for endoscoping dyspeptic patients without alarm symptoms safe? Gut 2006;55 (supplement 2):a90

5. National Institute for Health and Clinical Excellence. Managing dyspepsia in adults in primary care. London: NICE, 2004 (available from www.nice.org.uk)

Competing interests: None declared
Mortality of Sedation for Upper GI Endoscopy 27 January 2007
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David N Hunter,
Consultant Anaesthetist
Royal Brompton Hospital SW3

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Re: Mortality of Sedation for Upper GI Endoscopy

The excellent masterclass on Dyspepsia & Helicobacter pylori, quotes a mortality from endoscopy of 0.0001–0.0005%. This is unreferenced, but others here have quoted the mortality of 0.004% displayed on the British Society of Gastroenterology website (1). This particular mortality figure comes from a survey conducted in the USA in 1974(2); it is therefore of dubious relevance to UK practice now.

Better data is available from a survey in two regions of England published in 1995 which included 30 day mortality following 13,036 diagnostic upper GI endoscopies. This study yielded a mortality rate of 1:2,000 (0.05%), and a morbidity rate of 1:200 (0.5%)(3). This high mortality rate prompted an editorial in the BMJ later that year calling for improved monitoring and sedation skills to reduce this figure (4).

I suggest, therefore, that the real risk to UK patients is likely to be far higher than that quoted in the Masterclass, and has major implications for informed consent for patients planning to undergo this procedure.

1. British Society of Gastroenterology. Guidelines on Complications of Gastrointestinal Endoscopy. London: BSG, 2006. (Available from www.bsg.org.uk)

2. Silvis SE, Nebel O, Rogers G, Sugawa C, Mandelstam P. Endoscopic complications. Results of the 1974 American Society for Gastrointestinal Endoscopy Survey. JAMA 1976;235:928.

3. Quine MA, Bell GD, McCloy RF,Charlton JE,Devlin HB,Hopkins A.Prospective audit of upper gastrointestinal endoscopy in two regions of England: safety,staffing and sedation methods. Gut 1995;36:462–467.

4. Charlton JE. Monitoring and supplemental oxygen during endoscopy. BMJ 1995;310:886-7.

Competing interests: None declared
“Test, treat and confirm eradication” 13 February 2007
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Brian J Egan,
Lecturer in Clinical Medicine
Adelaide and Meath Hospital Tallaght,Trinity College Dublin,Ireland,
Barbara M Ryan and Colm A O'Morain

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Re: “Test, treat and confirm eradication”

We read with great interest an excellent article by Rupal Shah which highlighted a number of practical issues and common pitfalls in the management of H pylori (1). However this article was strongly influenced by the NICE guidelines which unfortunately fail to consider a number of issues relating to H pylori infection (2).

Firstly empirical treatment with a proton pump inhibitor should only be considered in areas of low H pylori prevalence(<20%). An American study showed the most cost effective strategy in young patients without alarm symptoms was “Test & Treat” followed by six weeks proton pump inhibitor(PPI) therapy if required and progressing to endoscopic evaluation in those with persistent symptoms(3,4).

Shah also advocates a policy of test and treat without confirming successful eradication. A non-invasive follow up test to verify successful treatment was recommended by the most recently published European guidelines on H pylori management (4). The urea breath test was considered the follow up test of choice and this should be performed at least 4 weeks after treatment. This recommendation should be accepted in clinical practice for a number of reasons.

Approximately 10-15% of H pylori infected people develop complications and only cure of the infection may prevent these sequelae(5). H. pylori is a class 1 carcinogen(6) and plays a role in a number of gastrointestinal diseases including Gastric Cancer ,Peptic Ulcer Disease and Mucosa associated lymphoid tissue{MALT}Lymphoma.

Treatment failure of Helicobacter infection occurs for two main reasons; Patient non-compliance and Antibiotic resistance. Antibiotic resistance is an increasing problem (5). One large French study found that successful eradication rates were higher in patients with duodenal ulcer than in patients with non-ulcer dyspepsia(NUD). Clarithromycin resistance was more common in NUD and predicted eradication failure almost perfectly(7). A similar trend was noted in another trial(8). In non-ulcer dyspepsia(NUD), eradication of H pylori compares favourably with any other treatment available and reduces the risk of the long term complications of H pylori.

Initial empirical treatment with a PPI for dyspepsia can only be recommended in areas of low H. pylori prevalence. The complications of Helicobacter Pylori infection and increasing antimicrobial resistance especially in NUD patients underline the importance of confirmation of successful eradication of H pylori.

REFERENCES:

1. Shah R. Dyspepsia and Helicobacter pylori BMJ 2007; 334: 41-43

2. National Institute for Health and Clinical Excellence. Managing dyspepsia in adults in primary care. London: NICE, 2004 (updated 2005).

3. Spiegel BM, Vakil NB, Ofman JJ. Dyspepsia management in primary care: a decision analysis of competing strategies. Gastroenterology. 2002 May;122(5):1270-85.

4. Malfertheiner P, Megraud F, O'morain C, Bazzoli F, El-Omar E, Graham D, Hunt R, Rokkas T, Vakil N, Kuipers EJ. Current concepts in the management of Helicobacter pylori infection - The Maastricht III Consensus Report Gut, Jan 2007; doi:10.1136/gut.2006.101634

5. S Koletzko, F Richy, P Bontems, J Crone, N Kalach, M L Monteiro, F Gottrand, D Celinska-Cedro, E Roma-Giannikou, G Orderda, S Kolacek, P Urruzuno, M J Martínez-Gómez, T Casswall, M Ashorn, H Bodanszky, F Mégraud on behalf of the European Paediatric Task Force on Helicobacter pylori Prospective multicentre study on antibiotic resistance of Helicobacter pylori strains obtained from children living in Europe Gut, Dec 2006; 55: 1711 - 1716.

6. International Agency for Research in Cancer. Schistosomes,liver flukes and Helicobacter pylori.IARC Monogr Eval Carcinog Risks Hum 1994;61:177-240.

7. Broutet N, Tchamgoue S, Pereira E, Lamouliatte H, Salamon R, Megraud F.Risk factors for failure of Helicobacter pylori therapy--results of an individual data analysis of 2751 patients.Aliment Pharmacol Ther. 2003 Jan;17(1):99-109.

8..Xia B, Xia HH, Ma CW, Wong KW, Fung FM, Hui CK, Chan CK, Chan AO, Lai KC, Yuen MF, Wong BC.Trends in the prevalence of peptic ulcer disease and Helicobacter pylori infection in family physician-referred uninvestigated dyspeptic patients in Hong Kong.Aliment Pharmacol Ther. 2005 Aug 1;22(3):243-9.

Competing interests: Professor Colm A O'Morain is a member of the European Helicobacter Study Group(EHSG) who recently published the third Maastricht guidelines on the Management of Helicobacter Pylori