Abstract & Commentary
Synopsis: Eradication of H. pylori in a large outpatient general practice setting seemed to protect against the subsequent onset of gastroesophageal reflux disease (GERD), and there was evidence that eradication of H. pylori neither improved nor worsened pre-existing GERD symptoms.
Source: Harvey RF, et al. BMJ. 2004;328(7453):1417.
Harvey and colleagues studied 10,537 patients in 7 general practices were invited to participate in a study of Helicobacter pylori incidence and the effects of its eradication. In this study, 1634 patients positive for H. pylori were compared to 3268 randomly selected H. pylori-negative controls. H. pylori positive patients were randomized to either clarithromycin-ranitidine bismuth citrate eradication therapy or to placebo. H. pylori infection was associated with a slight excess of heartburn prevalence at baseline. Although successful eradication therapy neither increased nor decreased heartburn prevalence, patients with regurgitation symptoms at baseline developed less heartburn over a 2-year follow-up period.
Comment by Malcolm Robinson MD, FACP, FACG
Harvey et al comment that the results of this study may be consistent with effects of the hypersecretion associated with H. pylori infection of the antrum. However, H. pylori infection is not that simple. Although some strains of H. pylori do lead to hypersecretion and sometimes to duodenal ulcer disease, these strains are apparently vanishing in the Western world. Other variants of H. pylori can lead to gastric atrophy and to decreased gastric acid secretion. Moreover, many experts believe that eradication of H. pylori can produce an impaired response to the therapeutic effects of proton pump inhibitors. Harvey et al readily admit the absence of endoscopic or physiologic data in these patients, but they believed that these potential study flaws are balanced by the large numbers of participants in the study, the randomized design, and the avoidance of prolonged acid suppression in this population as part of the treatment paradigm. It seems to this reviewer that there remain more questions than answers in this area. Epidemiologic data strongly suggest a protective effect of H. pylori infection against GERD. There are a number of studies that have shown increased GERD prevalence after H. pylori eradication. Perhaps most importantly, there was no medical justification for the strategy undertaken in this study since eradication of H. pylori in normal individuals or GERD or dyspepsia cannot currently be justified by an evidence based medical data.
Dr. Robinson, Medical Director, Oklahoma Foundation for Digestive Research; Clinical Professor of Medicine, University of Oklahoma College of Medicine Oklahoma City, OK, is Associate Editor of Internal Medicine Alert.