Randomised trial of endoscopy with testing for Helicobacter pylori compared with non-invasive H pylori testing alone in the management of dyspepsiaBMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7344.999 (Published 27 April 2002) Cite this as: BMJ 2002;324:999
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
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.
Consultant Paediatric Gastroenterologist
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-
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
Competing interests: No competing interests
-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
Competing interests: No competing interests