MRCGP Update - H pylori testing in dyspepsia

Current situation

 - Managing dyspepsia costs the NHS around £1.1 billion each year.

- There is currently inadequate evidence to guide whether full-dose treatment with a proton pump inhibitor for one month or H pylori 'test and treat' should be offered first.

- There is currently plenty of debate regarding which is the best investigation to diagnose H pylori.

What is the evidence?

- In one study, 500 patients with simple dyspepsia were randomised to testing for H pylori, followed by eradication, if positive, or prompt endoscopy.

Patients in both groups recorded the same number of days with and without dyspepsia during the follow-up period. The 'test and eradicate' strategy resulted in less use of medication and fewer repeat endoscopies (Gut 2004; 59: 1,041).

- Another study compared the efficacy of 'test and treat' with that of an empirical trial of omeprazole for young patients with dyspepsia (BMJ 2003; 326: 1,118).

The results showed that eradication treatment allowed the resolution of symptoms in a large number of dyspeptic patients and reduced endoscopic workload.

'Test and treat' is marginally less effective than management based on endoscopy but is still cost-effective (Scand J Gastroenterol 2004; 39: 913-8).

- A recent study has shown that H pylori eradication following a screening programme offers long-term relief from symptoms, but with an increase in cost (BMJ 2006; 332: 199).

- Conversely, population screening and treatment of H pylori has been shown to result in significant savings in dyspepsia-related healthcare costs.

Ten years after a 'search and eradicate' programme was introduced in Leeds, the costs for dyspepsia treatment were £65 per patients per year less for people who underwent H pylori eradication compared to those given placebo (Gastroenterology 2005; 129: 1,910-17).

- Serology is the main non-invasive test used in the UK but is notably less sensitive.

Half of all positive serology tests will be false positives (BMJ 2006: 332: 187).

- The stool antigen test is almost as sensitive and specific as the urea breath test.

However, it is considerably cheaper. It is also more acceptable to patients (J Med Microbiol 2004; 53: 1).

Primary care implications

- Doctors are best advised to inform patients that a stool or breath sample is extremely accurate (BMJ 2005; 330: 106-7).


- The NICE guidelines on dyspepsia were published in August 2004.

- National Guideline Research and Development Unit. Dyspepsia: managing dyspepsia in adults in primary care.

USEFUL WEBSITES - for all the latest NICE guidelines.


- Patients with dyspepsia should be tested for H pylori.

- 'Test and treat' appears to be the best management.

- Screening for H pylori is effective.

- Stool antigen test may be the most preferable test in the future.

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