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Abstract & Commentary
Synopsis: H pylori eradication is frequently and inappropriately used in uninvestigated dyspepsia.
Source: O’Connor HJ. Aliment Pharmacol Ther. 2002;16(3): 487-496.
Despite the wide dissemination of information regarding the pathogenetic role of H pylori in peptic ulcer, actual management of ulcer disease continues to involve both neglect as well as use of ineffective eradication regimens. Although there are few data to support such behavior, physicians are extremely aggressive in eradicating H pylori in GERD patients and in those with dyspepsia.
Many have said that the discovery of H pylori infection was one of the most important medical advances of the 20th century, followed by the observation that eradication of H pylori could effectively cure ulcer disease. This article reviews the biomedical literature available to December 2000. Many physician surveys confirmed that both primary care physicians and gastroenterologists understood the H pylori ulcer relationship. Nevertheless, by 1998, less than half of US family physicians and only 64% of Italian primary care doctors routinely used H pylori eradication therapy for duodenal ulcer. Despite far less belief in the relationship of gastric ulcer and H pylori, most physicians (including gastroenterologists) used eradication therapy similarly in these disparate illnesses. Although less than 10% of physicians believed that H pylori had any causative role in dyspepsia, as many as two thirds of international physicians reported use of H pylori eradication in uninvestigated dyspeptic patients. Although European doctors were less likely to treat GERD patients for H pylori than surveyed American physicians, use of H pylori eradication in this inappropriate setting remained common on both sides of the Atlantic. Great variations were described in the choice of treatment regimens for H pylori eradication. One study discovered 66 different eradication regimens, and only 52% of these were deemed to be potentially efficacious. In an interesting large survey in the United Kingdom, patients who received an H pylori eradication regimen were documented to have subsequently received antisecretory therapy in 53% of cases in the subsequent year. Other studies elsewhere have led to similar findings.
Comment by Malcolm Robinson MD, FACP, FACG
It seems clear that the wide dissemination of information regarding H pylori and the development of many national guidelines for its management, physicians seem confused regarding appropriate care for patients with gastrointestinal disorders coupled with H pylori infection. Far more aggressive educational efforts must be undertaken to rectify these international misperceptions and resulting therapeutic misadventures.
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.