Dyspepsia, characterized by pain or discomfort centered in the upper abdomen, is common. The diagnosis of nonulcer dyspepsia, also called functional or idiopathic dyspepsia, is made when no structural or biochemical explanation for symptoms can be found. This disorder has minimal morbidity and mortality but is often chronic and has a negative effect on quality of life. The role of Helicobacter pylori infection in nonulcer dyspepsia is uncertain, which makes treatment decisions difficult. Laine and associates performed a systematic review of randomized controlled trials of H. pylori eradication therapy in patients with nonulcer dyspepsia to determine if H. pylori therapy is significantly better than control therapy.
Only studies that used accepted H. pylori treatments and included a control group treated in a manner that was ineffective against H. pylori were included. Seven trials provided information on the proportion of patients who had successful eradication of H. pylori at least one month after completion of therapy. Although data aggregation problems were noted, the difference in the decrease in dyspepsia scores for H. pylori therapy compared to control therapy was minimal. In the groups that received H. pylori eradication treatment, no significant benefit was found in patients whose infection was cured compared with those whose infection persisted.
The authors conclude that most cases of nonulcer dyspepsia are caused by some mechanism other than H. pylori infection. It remains reasonable to treat patients who have dyspepsia and positive nonendoscopic testing for H. pylori with no alarm symptoms (i.e., weight loss or bleeding). This strategy can decrease the total cost of dyspepsia management and probably benefits the minority of patients who have true ulcer disease. However, when the diagnosis of nonulcer dyspepsia is established by endoscopy, H. pylori therapy is not likely to benefit these patients.
editor's note: Management of nonulcer dyspepsia is a common problem. A Cochrane review dated January 2000 on “Initial Management Strategies for Dyspepsia” reviewed trials of a variety of management strategies in patients with dyspepsia. Proton pump inhibitors (PPIs) were found to be significantly more effective than both H2 receptor antagonists and antacids, but the studies may not have excluded patients with gastroesophageal reflux disease. The conclusion was that the relative efficacy of H2 receptor antagonists and PPIs remains uncertain in the management of nonulcer dyspepsia and requires further study. Results for other drugs were not available or were inconclusive. In a separate Cochrane review, dated September 2000, on “Eradication of Helicobacter pylori for Nonulcer Dyspepsia,” H. pylori eradication therapy was shown to have a small but statistically significant effect in H. pylori–positive nonulcer dyspepsia. It is unclear whether this conclusion holds only for endoscopically confirmed nonulcer dyspepsia or for all presumed cases of the disease. The potential difference from the conclusion of the article presented above indicates that further review and study are needed. The common ground is the potential value of eradicating H. pylori in patients with nonulcer dyspepsia without endoscopy as a cost-effective management strategy and one that will help with the minority of cases in which actual ulcer disease is present.—r.s.