Implications for treatment: pH, Helicobacter pylori or alternative approaches?

There are three well-accepted management strategies for patients with non-investigated dyspepsia. These are the early endoscopy for all, empiric antisecretory therapy, or the Helicobacter pylori test and treat strategy, with benefits and limitations to each of these methods. Although early endoscopy provides a precise diagnosis that guides treatment, its widespread use is limited by its cost (at least in countries such as the USA), availability, and risk for complications that is largely related to the need for conscious sedation. Therefore, it is generally reserved for those patients with onset of dyspepsia symptom after aged 45–50 years, those of all ages with concurrent alarm symptoms, and those who fail to respond to H. pylori test and treat strategies or empiric antisecretory therapy. The test and treat strategy has the advantage of not requiring endoscopy, being less costly than endoscopy, and offers the potential for curative treatment in those found to be infected with H. pylori. Its clinical utility is probably greatest in younger patients without alarm symptoms in geographic regions where H. pylori prevalence remains robust but gastric cancer prevalence is low. The contribution of H. pylori infection to dyspeptic symptoms appears to vary based upon geographic and demographic factors. A recent update of the Cochrane systematic review of H. pylori eradication therapy in patients with functional dyspepsia found a small but significant benefit associated with cure of the infection: 37% mean response rate in the active treatment group compared with 29% in those treated with placebo or a short course of PPI therapy. Empiric antisecretory therapy is a widely used, costeffective, safe management strategy in those with dyspepsia. In a recent publication, two double-blind, randomized, placebo-controlled trials involving 921 patients with functional dyspepsia found that treatment with a proton-pump inhibitor (PPI; lansoprazole 15 mg or 30 mg once daily for 8 weeks) produced significantly (P < 0.001) greater mean reductions in the percentage of days with upper abdominal discomfort and, as illustrated in Figure 1, significantly greater number of patients with complete symptom resolution compared with placebo-treated patients. The finding of PPIs being superior to placebo in relieving symptoms is similar to that of a recently updated Cochrane meta-analysis of pharmacological interventions for functional dyspepsia. The major disadvantage to this strategy is that it may, on rare occasions, mask serious disease and postpone timely investigation or subject patients with a curable disease (i.e. H. pylori-related ulcer disease) to long-term pharmacological therapy. A recent study reported that response to PPI treatment in functional dyspepsia was most reliable in patients with dyspepsia of short-duration (few days of heartburn during the first week and a history of symptoms for <3 months); low scores for bloating, epigastric pain and diarrhoea; and in young patients with dyspepsia and no alarm symptoms.