Eradicating H pyloriBMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7453.1388 (Published 10 June 2004) Cite this as: BMJ 2004;328:1388
- Brendan Delaney, professor of primary care (, )
- Paul Moayyedi, Richard Hunt-AstraZeneca professor of gastroenterology
- Department of Primary Care and General Practice, University of Birmingham, Birmingham B15 2TT
- Department of Medicine, McMaster University, Hamilton, ON, Canada L8N 3Z5
Does not increase symptoms of gastro-oesophageal reflux disease
Does eradication of Helicobacter pylori lead to an increase in symptoms of gastro-oesophageal reflux disease? We need to know this because the benefits of eradicating H pylori relative to acid suppression alone are small in non-ulcer dyspepsia and uninvestigated dyspepsia.1 2 The absolute benefits are 6-7%, and even a small increase in gastro-oesophageal reflux disease would be likely to make eradicating H pylori in these patients of dubious benefit. New guidelines for the management of dyspepsia in Scotland and forthcoming guidelines in England and Wales recommend eradicating H pylori in both non-ulcer dyspepsia and uninvestigated dyspepsia.3 4 In addition, advocates of population screening for and treating H pylori to prevent distal gastric cancer need to ensure that the risk-benefit ratio is favourable.
The trial reported by Harvey et al in this issue does not find an increase in reflux symptoms in those randomised to eradication therapy (p 1417).5 A previous community based trial in the United Kingdom also evaluated the efficacy of H pylori eradication versus placebo as part of a population “screen and treat” strategy.6 The trial reported by Harvey has the advantage of studying a wider age range and has a better response rate than this previous trial, although the prevalence of H pylori was lower. A Danish study randomised subjects from the general population to an H pylori screen and treat programme or to no intervention.7 These three trials show that eradicating H pylori did not cause an increase in heartburn or acid regurgitation in the total of 2956 people positive for H pylori who were randomised to receive antibiotics. This is consistent with a randomised controlled trial of H pylori eradication in infected healthy blood donors, which did not find a statistically significant impact on reflux symptoms.8
The disadvantage of these community based trials5 6 7 is that endoscopy was not performed, so the impact of eradicating H pylori in various types of upper gastrointestinal disease cannot be established. But the data are consistent with randomised controlled trials in patients having an endoscopic investigation. Eradicating H pylori does not cause an increase in gastrooesophageal reflux disease in patients with peptic ulcer disease and non-ulcer dyspepsia, and no overall worsening of symptoms occurred in patients who already had reflux disease.9–12 w1 w2 The influence of more pathogenic strains of H pylori, such as cytotoxin associated gene A positive strains, has not been well evaluated in randomised controlled trials, and eradication may exacerbate reflux disease in the rare patient with reversible achlorhydria induced by the infection.w3 w4
Overwhelming evidence now shows that eradicating H pylori has little or no impact on gastrooesophageal reflux disease in the general population. This is in contrast to a meta-analysis of observational studies that showed a negative association between H pylori infection and gastro-oesophageal reflux disease.w5 But association is not causation: improved nutrition and increased adult height may act as confounders, as these individuals will have increased acid output and may be more prone to gastrooesophageal reflux and less likely to acquire H pylori.w6
The trial by Harvey et al is indirect evidence that using “test and treat” in patients with dyspepsia in primary care will not lead to an increase in symptoms of gastro-oesophageal reflux disease.5 Other evidence to support the effectiveness of the strategy comes from randomised controlled trials comparing H pylori eradication versus placebo in H pylori positive patients.3 Whether small benefits in the order of 7% are worthwhile depends on both the persistence of effects of the treatment and its cost effectiveness. On the basis of good data for up to two years of follow up, H pylori eradication is likely to provide more lasting benefit than acid suppression alone.1 Direct evidence of cost effectiveness is awaited from an ongoing randomised controlled trial funded by the Medical Research Council that is comparing H pylori “test and treat” with acid suppression in the initial management of dyspepsia in more than 200 general practices in the United Kingdom.
Primary carep 1417
Additional references w1-w6 are on bmj.com
Competing interests The authors have received speaker's honorariums from the following manufacturers of proton pump inhibitors: AstraZeneca, Eisai, Takeda, Wyeth. PM's chair is partly endowed by AstraZeneca.