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Does Helicobacter pylori really cause duodenal ulcers? No

BMJ 2009; 339 doi: (Published 14 August 2009) Cite this as: BMJ 2009;339:b2788
  1. Michael Hobsley, emeritus professor of surgery1,
  2. Frank I Tovey, honorary senior research associate1,
  3. Karna Dev Bardhan, consultant physician and gastroenterologist 2,
  4. John Holton, reader in clinical microbiology3
  1. 1University College London Medical School, London N20 8AS
  2. 2Rotherham General Hospital, Rotherham
  3. 3Windeyer Institute for Medical Sciences, University College London
  1. Correspondence to: M Hobsley m.hobsley{at}

    The link between duodenal ulcer and Helicobacter pylori has revolutionised treatment. Alexander Ford and Nicholas Talley (doi:10.1136/bmj.b2784) argue that the association is causal, but Michael Hobsley and colleagues believe acid secretion is the key

    Helicobacter pylori and duodenal ulcer are linked. However, association does not prove causation. An association between A and B may mean that A causes B, B causes A, or both B and A are caused by another factor.

    Without detracting from the Nobel prize winning investigation that first drew attention to the role of H pylori, we think that H pylori infection does not cause duodenal ulcer but prevents healing of an ulcer produced by hypersecretion of gastric acid. Acid diminishing treatment reduces the principal barrier against gastric H pylori infection and so the patient becomes infected.

    No link with prevalence

    If H pylori were the primary cause, we would not see regional variation in the prevalence of duodenal ulcer within areas of high prevalence, particularly developing countries.1 2 3 4 5 This does not refer to Holcombe’s “African enigma,”6 the alleged finding that duodenal ulcer was uncommon in …

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