BMJ  2005;330 (14 May), doi:10.1136/bmj.330.7500.0-e

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Test and eradicate is best for dyspepsia after six years

Question What is the best strategy for managing dyspepsia in the primary care setting?

Synopsis Although testing for Helicobacter pylori infection and treating patients who are positive has become a recommended approach to managing dyspepsia, many patients and doctors still opt for immediate endoscopy. In this Danish study, the authors identified 500 patients presenting to their primary care physician with epigastric pain with or without heartburn, regurgitation, nausea, vomiting, or bloating. Those recently treated with a proton pump inhibitor (PPI) or an H₂ receptor antagonist were excluded, as were those with any red flags (unintended weight loss, suspicion of upper gastrointestinal bleeding, anaemia, or jaundice). Patients were then randomised (allocation concealed) to undergo either H pylori testing with a breath test followed by eradication with a PPI, amoxicillin, and metronidazole for seven days, or prompt upper endoscopy. Patients in the test and eradicate group who were H pylori negative with reflux symptoms were given a PPI; those without reflux symptoms were simply reassured that they had functional dyspepsia. Those in the test and eradicate group who were H pylori negative and taking non-steroidal anti-inflammatory drugs underwent endoscopy. Patients in the prompt endoscopy group were treated according to the endoscopic findings in a manner consistent with usual practice, including the use of PPIs and/or the eradication of H pylori, as indicated. Similar percentages of patients in the test and eradicate and prompt endoscopy groups returned questionnaires (70.4% v 74.8%). Patients were followed up for a median of 6.7 years. Data regarding resource use were available for about 90% of the patients in each group (in effect, all of the patients still in the country). The results were fascinating: There was no difference between groups regarding any of the clinical outcomes, such as gastrointestinal symptoms, psychological well being, and a variety of individual symptoms. However, the test and eradicate group underwent fewer endoscopies (0.88 v 1.5; P < 0.001), used fewer daily doses of PPIs and H₂ receptor antagonists (271 v 373; P = 0.03), and had a similar number of outpatient visits and hospital days for gastrointestinal problems. Prompt endoscopy seemed to "medicalise" dyspepsia and lead to greater use of resources, but it made no difference in clinical outcomes.

Bottom line Prompt endoscopy for patients with dyspepsia who do not have any alarm symptoms increases costs, use of drugs, and procedures but does not improve outcomes. Testing for H pylori and treating if positive should remain the standard of care for these patients in the primary care setting.

Level of evidence 1b- (see www.infopoems.com/levels.html). Individual randomised controlled trials (with a wide confidence interval).

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Lassen AT, Hallas J, Schaffalitzky de Muckadell OB. Helicobacter pylori test and eradicate versus prompt endoscopy for management of dyspeptic patients: 6.7 year follow-up of a randomised trial. Gut 2004;53: 1758-63[Abstract/Free Full Text].

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^* Patient-Oriented Evidence that Matters. See editorial ( BMJ 2002;325: 983[Free Full Text])

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