Helicobacter Pylori Testing Research Articles

Prevalence of Helicobacter pylori in the adolescent oral cavity

Helicobacter pylori (HP) infection usually occurs in childhood. While there are various studies on the prevalence of HP in dental plaque, ours is the first to analyze its prevalence during orthodontic therapy and its interaction with competitive bacteria in adolescents. The prevalence of HP was examined before and during the first 12weeks of orthodontic therapy with fixed appliances in 11patients with a mean age of 12.7years. A total of 93plaque samples were analyzed using PCR. The data acquired at every consultation were the following: PCR analysis of dental plaque and (13)C urea breath tests for HP, quantitative analyses of saliva for Lactobacilli and Streptococcus mutans, the interproximal plaque index (API), and sulcus bleeding index (SBI). The prevalence of HP in plaque was 82% before orthodontic therapy, dropping to 54% during therapy (t test, p≤0.05). In contrast to HP's prevalence, the Lactobacilli count rose (p≤0.05). The number of Streptococcus mutans bacteria in saliva decreased during orthodontic therapy (p≤0.05). The prevalence of HP in dental plaque amounted to 82%. Orthodontic treatment did not reduce its prevalence. The prevalence of Lactobacilli was inversely proportional to that of HP.

Gastrointestinal events during treatment with nonsteroidal anti-inflammatory drugs (according to the data of the CONDOR study)

The paper presents the results of a randomized double-blind study of the impact of therapy with celecoxib and a combination of diclofenac and omeprazole in patients with osteoarthrosis and rheumatoid arthritis on a risk for developing gastrointestinal diseases. The study was conducted at health care facilities in 196 centers of 32 countries and covered 18-to-60-year-old patients who belonged to an increased gastrointestinal risk group and had a history of gastroduodenal ulcers and a negative Helicobacter pylori test at screening. The included patients were randomized by a computer program in a 1: 1 ratio to treatment groups receiving celecoxib in a dose of 200 mg twice daily or sustained-release diclofenac 75 mg twice daily + omeprazole 20 mg once daily. The primary efficacy criterion was assessed as the development of clinically relevant changes in the upper or lower gastrointestinal tract (GIT). 4484 patients were randomized to treatment groups (2238 took celecoxib; 2246 received diclofenac + omeprazole). Twenty (0.9%) patients who took celecoxib and 81 (3.8%) who used diclofenac + omeprazole achieved the primary assessment criterion (p<0.0001). One hundred and fourteen (6%) patients who received celecoxib and 167 (8%) who took diclofenac + omeprazole were withdrawn from the study prematurely because of adverse reactions in the GIT (p = 0.0006). The risk of clinically relevant GIT changes was lower in the patients treated with celecoxib, that is a selective cyclooxygenase 2 (COX-2) inhibitor, than in the patients who received diclofenac, a nonselective COX inhibitor, and omeprazole, the proton pump inhibitor. The findings should contribute to the revision of approaches to reducing the gastrointestinal risk in nonsteroidal anti-inflammatory drugs treatment.

Conventional Narrow-Band Imaging Has Good Correlation with Histopathological Severity of Helicobacter pylori Gastritis

Narrow-band imaging (NBI) is an optical image enhancement technique that enhances the vessels and patterns of gastric mucosal surface. Here we aim to test the diagnostic role of conventional NBI (C-NBI) in identifying Helicobacter pylori (HP) infection, severity of gastritis, and gastric atrophy. Initially, the endoscopic records of 300 patients were retrospectively searched for specific C-NBI gastric mucosal patterns, where five different C-NBI mucosal patterns were identified. In a second step, 20 patients with different C-NBI mucosal patterns were subjected to gastric mucosal biopsy for HP testing and histopathological assessment. Five different histopathological grades of HP gastritis, in terms of grade of gastric atrophy, intestinal metaplasia, infiltration by inflammatory cells, and density of HP infection, were recognized among the different C-NBI mucosal patterns. C-NBI seems to be a promising method for HP infection identification and gastric cancer risk stratification of patients.

Gastric mucosa-associated lymphoid tissue lymphoma complicated with hemophagocytic syndrome in an elderly woman

Dear Editor, Hemophagocytic syndrome (HPS) has been described in association with a variety of lymphomas, most commonly Tor NK-cell-type tumors [1]. More rarely, HPS occurs in association with aggressive B-cell tumors, including diffuse large B-cell lymphoma and intravascular large B-cell lymphoma [2, 3]. Although these lymphoma-associated forms of HPS generally show a poor prognosis [1], appropriate therapy for the underlying lymphoma can lead to the resolution of this condition [2]. Here, we report an elderly patient with mucosa-associated lymphoid tissue (MALT) lymphoma of the stomach, who developed HPS during the course of the disease. An 80-year-old woman, who had been treated for cognitive disorder in a psychiatric clinic, presented with upper abdominal discomfort. Endoscopy of the upper gastrointestinal tract revealed multiple mucosal lesions from the lower body to the antrum of the stomach, including superficial erosions/ulcers and “gastritis-like” erythema (Fig. 1a). A biopsy demonstrated mucosal infiltrates of small lymphoid cells showing a monocytoid appearance associated with lymphoepithelial lesions, being compatible with gastric MALT lymphoma (Fig. 1b). Tests for Helicobacter pylori were positive. Triple therapy comprising lansoprazole, amoxicillin, and clarithromycin was initiated; however, the patient soon discontinued treatment due to the development of an allergic skin rash. As the patient’s symptoms persisted, she was finally admitted to our hospital 4 months after the initial presentation. On examination, she was febrile and icteric, and the abdomen showed hepatosplenomegaly. There was no superficial lymphadenopathy. The blood counts were: hemoglobin, 11.5 g/dl; white blood cell count, 2,500/μl with 86% neutrophils; and platelet count, 117×10/μl. The blood chemistry values included: total bilirubin, 9.2 mg/dl; asparate aminotransferase, 1,446 IU/l; alanine aminotransferase, 387 IU/l; alkaline phosphatase, 1,439 IU/l; lactate dehydrogenase, 1,851 IU/l; and γ-glutamyl transpeptidase, 143 IU/l. The level of triglyceride was 294 mg/dl, fibrinogen—83 mg/dl, fibrinogen/fibrin degradation product—15.5 μg/ml, ferritin—2,929 ng/ml, and soluble interleukin-2 receptor was as high as 17,388 U/ml. A computed tomographic scan and ultrasonography of the abdomen revealed hepatosplenomegaly and wall thickening of the gall bladder (Fig. 1c); the latter finding suggested portal cellular infiltration [4]. Bone marrow specimens obtained from the iliac crest revealed hypocellular marrow with increased numbers of macrophages ingesting blood cells (Fig. 1d); no lymphoma cells were apparent on microscopic examination or flow cytometric analysis. A diagnosis of gastric MALT lymphoma complicated with HPS was made. The patient was treated with chemotherapy consisting of vincristine, cyclophosphamide, prednisolone, and doxorubicin, in combination with rituximab. HPS responded well to the treatment; H. Ohno (*) Department of Hematology, Takeda General Hospital, 28-1, Mori-minami-cho, Ishida, Fushimi-ku, Kyoto 601-1495, Japan e-mail: hitoshi-ono@fm2.seikyou.ne.jp

Analysis of the grade of esophagitis, chromendoscopical and histological findings of esophagus in patients with gastroesophageal reflux disease before and after the therapy

The symptoms of gastroesophageal reflux disease (GERD) are among the most common complaints for which patients are indicated for visiting gastroenterologist. It occurs as a result of the effect made by gastric reflux contents that moves into the esophagus. The prevalence of all forms of GERD is 40%. The aim of this study was to analyze the grade of esophagitis, chromendoscopical and histological findings of esophagus in patients with GERD before and after the therapy. A prospective study included 90 patients with symptoms of GERD, divided into 2 groups depending on whether they had endoscopic signs of gastroezophageal reflux (group ERD), or not (group NERD). All the patients had esophagogastroduodenoscopy, chromoendoscopy staining, test for Helicobacter pylori and histological findings of the esophagus. In the patients with Helicobacter pylori infection eradication therapy was done. Esophagitis-B level was present in most of the patients. Among the groups, roughly the same number responded to positive findings on chromoendoscopy. After the therapy, chromoendoscopy was significantly negative in both groups of the patients comparing to chromoendoscopy before the therapy (p = 0.00001). Multiplication and elongation of papilla, basal cell hyperplasia, vascular dilatation, increasing of mitotic activity and the presence of polymorphonuclear leukocyte cells were statistically more frequent histological findings in the group ERB compared to the group NERB. After the therapy, the patients in both groups had statistically less histological findings of appropriate esophageal parameters. Chromoendoscopy combined with the standard endoscopy increases the sensitivity and specificity for reflux disease. Histology in the reflux disease is associated with endoscopic and clinical findings so that the localization of taking biopsies and histological criteria of pathohistological changes must be clearly defined. Multiplication and elongation of papilla, basal cell hyperplasia and the presence of polymorphonuclear leukocytes are the most relevant criteria in the diagnosis NERD.

Accuracy of Diagnostic Tests for Helicobacter pylori: A Reappraisal

Accuracy of Diagnostic Tests for Helicobacter pylori: A Reappraisal

A study of duodenal intraepithelial lymphocytic population and its relation to coeliac disease in a cohort of patients in the Nile delta of Egypt

Background and study aims Coeliac disease is the permanent intolerance to dietary gluten, the major protein component of wheat. Recent epidemiological studies have provided evidence showing that this disorder is common in various parts of the world. The counting and the immunoprofile of intraepithelial lymphocytes of the small bowel have been proposed as methods to measure mucosal infiltration in gluten-sensitive patients. The aim of the present study was to quantify and define the immunohistochemical profile of intraepithelial lymphocytes in the duodenal mucosa of patients suffering non-ulcer dyspepsia, and compare them with known cases of coeliac disease. Patients and methods Archival paraffin wax embedded duodenal sections from 50 endoscopic biopsies were stained using CD3, CD4, and CD8 antibodies. Sections were obtained from 24 patients with confirmed coeliac disease, 20 patients with non-ulcer dyspepsia, and 6 patients with functional dyspepsia as control. Patients with non-ulcer dyspepsia were on gluten containing diets. The number of intraepithelial lymphocytes was quantified in five different villi by counting the number of lymphocytes/100 epithelial cells in each villus, and calculating the mean. Endomysial antibodies and testing for Helicobacter pylori were done in all cases. Results A positive correlation was observed between the degree of villous atrophy and CD3, CD4, and CD8+ intraepithelial lymphocytes. A positive correlation was also observed with the lamina propria lymphoid aggregates. H. pylori infection had a positive correlation with the degree of lymphoid aggregation in the lamina propria. Conclusion Although the difference between potential coeliac disease and non-coeliac controls was significant, these lesions overlapped considerably. Clinicians as well as pathologists should increase the index of suspicion of coeliac disease. The frequent occurrence of duodenal intraepithelial lymphocyte expansions in other diseases may justify the use of immunohistochemical examination of duodenal biopsy specimens from patients suffering from dyspepsia.

WITHDRAWN: Initial management strategies for dyspepsia.

This review considers management strategies (combinations of initial investigation and empirical treatments) for dyspeptic patients. Dyspepsia was defined to include both epigastric pain and heartburn. To determine the effectiveness, acceptability, and cost effectiveness of the following initial management strategies for patients presenting with dyspepsia (a) Initial pharmacological therapy (including endoscopy for treatment failures). (b) Early endoscopy. (c) Testing for Helicobacter pylori (H. pylori )and endoscope only those positive. (d) H. pylori eradication therapy with or without prior testing. Trials were located through electronic searches and extensive contact with trialists. All randomised controlled trials of dyspeptic patients presenting in primary care. Data were collected on dyspeptic symptoms, quality of life and use of resources. An individual patient data meta-analysis of health economic data was conducted Twenty-five papers reporting 27 comparisons were found. Trials comparing proton pump inhibitors (PPI) with antacids (three trials) and histamine H2-receptor antagonists (H2RAs) (three trials), early endoscopy with initial acid suppression (five trials), H. pylori test and endoscope versus usual management (three trials), H. pylori test and treat versus endoscopy (six trials), and test and treat versus acid suppression alone in H. pylori positive patients (four trials), were pooled. PPIs were significantly more effective than both H2RAs and antacids. Relative risks (RR) and 95% confidence intervals (CI) were; for PPI compared with antacid 0.72 (95% CI 0.64 to 0.80), PPI compared with H2RA 0.63 (95% CI 0.47 to 0.85). Results for other drug comparisons were either absent or inconclusive. Initial endoscopy was associated with a small reduction in the risk of recurrent dyspeptic symptoms compared with H. pylori test and treat (OR 0.75, 95% CI 0.58 to 0.96), but was not cost effective (mean additional cost of endoscopy US$401 (95% CI $328 to 474). Test and treat may be more effective than acid suppression alone (RR 0.59 95% CI 0.42 to 0.83). Proton pump inhibitor drugs (PPIs) are effective in the treatment of dyspepsia in these trials which may not adequately exclude patients with gastro-oesophageal reflux disease (GORD). The relative efficacy of histamine H2-receptor antagonists (H2RAs) and PPIs is uncertain. Early investigation by endoscopy or H. pylori testing may benefit some patients with dyspepsia but is not cost effective as part of an overall management strategy.

Long Term Proton Pump Inhibitor Therapy and its Association with Fundic Gastric Polyps

Purpose: Proton pump inhibitors (PPI) have been effectively used to treat acid peptic disease for a few decades now. Recent studies have associated long term PPI use with osteoporosis, increased incidence of Clostridium difficile colitis, Vitamin B12 deficiency and more recently with development of Fundic Gastric Polyps (FGPs). The association of PPIs with FGPs continues to be controversial and poorly understood. The purpose of this study was to present in detail a series of three cases that developed FGPs with long term PPI therapy and had complete resolution after discontinuation of the PPI. Methods: In this longitudinal study, three patients (average 57 years; range 52 to 66 years) with documented Gastroesophageal Reflux Disease (GERD) with long term PPI therapy (average 9 years; range 6 to 13 years) were included. Each patient had well documented endoscopy with mucosal biopsies prior to PPI therapy, during and following discontinuation of PPI therapy. Helicobacter pylori testing was performed on the mucosal biopsies using standard techniques. Results: No polyps were observed in the body of the stomach in all three cases prior to PPI therapy. After long term PPI therapy (6 to 12 years), a follow-up endoscopy performed to evaluate persistent GERD symptoms revealed presence of multiple sessile polyps. At this point of time, association of FGPs with PPI use was considered and therefore PPI therapy was discontinued. Repeat endoscopies 1 to 2 years after discontinuation of PPI therapy revealed near complete disappearance of these FGPs in all three cases. All three cases were negative for Helicobacter pylori infection. Conclusion: These observations suggest that long term use of PPI therapy in a select group of patients may be associated with development of numerous fundic polyps in the stomach. This phenomenon seems to be reversible with discontinuation of PPI therapy.

Helicobacter pylori Testing in Patients with Funcional Dyspepsia: What Factors Dictate the Practice?

Purpose: Both functional dyspepsia (FD) and peptic ulcer disease (PUD) are associated with Helicobacter pylori (Hp) colonization. While Hp eradication is beneficial in patients with PUD, the same approach does not always reduce symptoms in FD patients. Despite this uncertainty, Rome III guidelines for FD recommend obtaining gastric biopsies for Hp testing in FD patients undergoing esophagogastroduodenoscopy (EGD). The extent to which this practice is performed is unknown. Methods: We evaluated the practice of obtaining gastric biopsies during EGD in dyspeptic patients with no endoscopic pathology (FD), compared this to patients with endoscopically confirmed PUD, and assessed the predictors of obtaining biopsies. All EGDs performed for evaluation of dyspepsia in adults at an urban hospital during the previous 29 months were identified and reviewed. Demographic and clinical information was extracted along with endoscopic and pathologic findings. Hp colonization was confirmed by histology. Results: A total of 1010 patients (618 women, mean age 50) underwent EGD. FD was diagnosed in 853 (84.5%) while 35 (3.5%) had PUD. The percentage of FD patients who had gastric biopsies taken did not differ significantly from patients with PUD (86.5% vs. 94.3%; p=0.37). Amongst those in which biopsies were obtained, the prevalence of Hp was 45.4% in FD compared to 60.6% in PUD patients (p=0.23). Within the FD cohort, there were significant ethnic differences in biopsy frequencies: Asians 91.7%, Hispanics 86.1%, African Americans 78.6%, and Caucasians 77.6%; p=0.016. FD patients born outside the U.S. were more likely to have biopsies taken than those born in the U.S. (87.2% vs. 65.7%; p=0.01). FD patients in whom gastropathy was noted endoscopically were more likely to have biopsies taken than those without gastropathy (95.7% vs. 63.4%; p<0.001). Neither patient age (p=0.08), gender (p=0.10), language (p=0.35), history of prior gastric surgery (p=0.34), history of prior Hp testing (p=0.39), nor the level of experience of the endoscopist (p=0.14) was predictive of whether or not biopsies would be obtained in the setting of FD. In multivariate logistic regression analysis controlling for age, gender, and ethnicity, both non-U.S. birth (OR 5.7 CI 1.7-18.8; p=0.005) and endoscopic gastropathy (OR 16.5 CI 8.4-32.5; p<0.001) remained significant predictors of obtaining biopsies. Conclusion: While the majority of patients with FD undergoing EGD had gastric biopsies taken, several factors were predictive of this practice including non-U.S. country of birth and the presence of endoscopic gastropathy. Further evaluation of the endoscopic assessment of FD patients may help provide important practice quality improvement measures.

Asymptomatic free intraperitoneal gas with duodenal stenosis.

A 30-year-old man was referred to our hospital in October 2006 for asymptomatic free air in the peritoneal cavity found on a plain chest X-ray on a routine health examination. Esophagogastroduodenoscopy (EGD) revealed an ulcer scar and deformity of the duodenal bulb, a healing-phase ulcer in the anterior wall of the upper gastric corpus, gradeB esophagitis (Los Angeles grading system), and a sliding hiatal hernia. A test for Helicobacter pylori was negative. Upon obtaining an informed consent (asymptomatic perforation), laparoscopic selective proximal vagotomy, Toupet fundoplication, and small skin incision Finney pyloroplasty were performed. Intraoperatively, extensive adhesions of the greater omentum to the duodenal bulb were found, which were suspected to engulf the cryptic perforation. The patient's postoperative course has been uneventful and, at present, recurrence of the ulcer has not been observed. The presented case is rare considering the absence of surgical history, lack of symptoms, and incidental finding of the intraperitoneal free air during a health examination.

Managing dyspepsia

The prevalence of dyspepsia in the general population is as high as 40%, and its management represents a considerable financial burden to the health care system. Causes of dyspepsia amenable to medical therapy include peptic ulcer and functional dyspepsia, and testing for Helicobacter pylori and treating positive individuals is beneficial in both conditions. Individuals presenting for the first time with uninvestigated dyspepsia, age greater than 50 years, or alarm features require upper gastrointestinal (GI) endoscopy to exclude gastroesophageal malignancy. Upper GI endoscopy for younger individuals without alarm features is not cost-effective compared with the "test and treat" approach. Test and treat and empirical acid-suppression using a proton pump inhibitor (PPI) have similar costs and effects. Recent evidence suggests that empirical acid suppression commencing with antacids is as effective as PPI. Screening and treatment of H. pylori in PPI users and the community may reduce the costs of managing dyspepsia.

Non-invasive Testing for Helicobacter pylori in Patients Hospitalized with Peptic Ulcer Hemorrhage: A Cost-Effectiveness Analysis

Guidelines recommend routine invasive screening for Helicobacter pylori in patients with peptic ulcer hemorrhage (PUH). However, compliance with screening remains suboptimal. The aim of this study was to determine if a simplified approach based on noninvasive screening is cost effective in PUH. In the base case, post-endoscopy urea breath test (UBT) dominated the invasive testing with 34 fewer hemorrhages and cost savings of $406,600 in a cohort of 10,000 patients. When compliance with invasive testing decreases to 60%, post-endoscopy UBT leads to 109 fewer hemorrhages and cost savings of $1,089,600. The invasive strategy becomes the preferred choice if the sensitivity of UBT reduces to <75%, such as in patients taking proton-pump inhibitors (PPI) before hospitalization. Post-endoscopy UBT is cost effective in PPI-naïve patients presenting with PUH. This strategy, once prospectively validated, can prove to be a preferred approach in institutions where compliance with invasive testing is suboptimal.

Helicobacter pylori related dyspepsia: prevalence and treatment outcomes at University Kebangsaan Malaysia-Primary Care Centre

BackgroundOptimum management of dyspepsia in primary care is a debatable subject. Testing for Helicobacter pylori (HP) has been recommended in primary care as this strategy will cure most underlying peptic ulcer disease and prevent future gastro duodenal disease.MethodsA total of 98 patients completed Modified Glasgow Dyspepsia Severity Score Questionnaire (MGDSSQ) at initial presentation before undergoing the 13Carbon Urea Breath Test (UBT) for HP. Those with positive UBT received Eradication Therapy with oral Omeprazole 20 mg twice daily, Clarithromycin 500 mg daily and Amoxycillin 500 mg twice daily for one week followed by Omeprazole to be completed for another 4 to 6 weeks. Those with negative UBT received empirical treatment with oral Omeprazole 20 mg twice daily for 4 to 6 weeks. Patients were assessed again using the MGDSSQ at the completion of treatment and one month after stopping treatment.ResultsThe prevalence of dyspepsia at Universiti Kebangsaan Malaysia-Primary Care Centre was 1.12% (124/11037), out of which 23.5% (23/98) was due to HP. Post treatment assessment in both HP (95.7%, 22/23) and non HP-related dyspepsia (86.7%, 65/75) groups showed complete or almost complete resolution of dyspepsia. Only about 4.3% (1/23) in the HP related dyspepsia and 13.3% (10/75) in the non HP group required endoscopy.ConclusionThe prevalence of dyspepsia due to HP in this primary care centre was 23.5%. Detection of HP related dyspepsia yielded good treatment outcomes (95.7%).

Helicobacter pylori test and treat versus proton pump inhibitor in initial management of dyspepsia in primary care: multicentre randomised controlled trial (MRC-CUBE trial)

Helicobacter pylori test and treat versus proton pump inhibitor in initial management of dyspepsia in primary care: multicentre randomised controlled trial (MRC-CUBE trial)

Helicobacter pylori test and treat versus proton pump inhibitor in initial management of dyspepsia in primary care: multicentre randomised controlled trial (MRC-CUBE trial)

Helicobacter pylori test and treat versus proton pump inhibitor in initial management of dyspepsia in primary care: multicentre randomised controlled trial (MRC-CUBE trial)

Accuracy of Diagnostic Tests for Helicobacter pylori: A Reappraisal

Accuracy of Diagnostic Tests for Helicobacter pylori: A Reappraisal

Risk Factors Involved in Patients with Bleeding Peptic Ulcers: A Case–Control Study

Our objectives were to (1) identify the risk factors involved in patients with peptic ulcer disease and determine if they predict bleeding in these patients, (2) determine the association between these risk factors, and (3) analyze the cost effectiveness of various tests for Helicobacter pylori (H. pylori). Two-hundred and thirty patients were included in our study between January 2004 and June 2005 (128 bleeding peptic ulcer disease patients constituted the cases, 102 nonbleeding ulcer patients constituted the controls). H. pylori infection was assessed by urease test and biopsy from gastric antrum. There was no statistically significant difference between these groups regarding sex, age, or location of ulcer. Nonsteroidal anti-inflammatory drug (NSAID) use was higher in the case group (P < 0.001), and the rate of H. pylori infection was lower in these patients (P < 0.05). There was no interaction between NSAID use and H. pylori infection in predicting bleeding ulcer risk (P = 0.08). Sensitivity and specificity for urease test in detecting H. pylori was 75% and 99.7%, respectively. So a positive urease test does not need confirmation with biopsy, which is cost effective.

The management of common gastrointestinal disorders in general practice: A survey by the European Society for Primary Care Gastroenterology (ESPCG) in six European countries

Background Gastrointestinal (GI) disorders account for 10% of all consultations in primary care. Little is known about the management of GI disorders by general practitioners (GP) across different European countries. Aim and methods We undertook a postal survey of randomly selected samples of GPs in six European countries (UK, Holland, Spain, Greece, Poland, Czech Republic) to determine patterns of diagnosis, management and service use in GI disorders. Results We received 939 responses, response rate 32%. Over 80% of GPs were aware of at least three national guidelines for gastrointestinal disease. The availability of open access endoscopy ranged from 28% (Poland) to over 80% (Holland, Czech and UK). For uninvestigated dyspepsia the preferred first line management was proton pump inhibitor therapy (33–82%), Helicobacter pylori test and treat (19–47%), early endoscopy (5–32%), specialist referral (2–21%). Regarding irritable bowel syndrome, 23% of respondents were familiar with one or more diagnostic criteria, but between 7% (Netherlands) and 32% (Poland) would ask for a specialist opinion before making the diagnosis. Conclusion The wide variation between GPs both between and within countries partly reflects variations in health care systems but also differing levels of knowledge and awareness, factors which are relevant to educational and research policy.

Orientação inicial da dispepsia ao nível dos cuidados de saúde primários. Revisão sistemática

Introduction: The initial management of dyspepsia on a primary health level is controversial. It is estimated that 4 out of 10 adults present per year a new or a first episode of dyspepsia, and 1 out of 10 visits his/her doctor. Many patients that perform an upper digestive endoscopy (UDE) do not report significant findings. The aim of this work is to determine, based on scientific evidence, which primary health strategies present the best trade-off cost-effectiveness for the initial management of patient with dyspepsia. Methodology: A systematic review was conducted on several sources: MEDLINE®, The Cochrane Library, Bandolier, Medscape®, TRIP database, DARE, EBM Resources and Preventive Services, of papers published between 1985 and May 2005. Randomized Clinical Trials (RCT) that benchmark different initial strategies were performed. Five RCTs were included for a comparison of «initial UDE» versus «empirical treatment», four RCTs for a comparison of «test for Helicobacter pylori (H. pylori) and its eradication («test and treat»)» versus « pharmacology intervention», and four RCTs for trading-off «»test and treat» strategy» versus «UDE». Three meta-analyses (one still to be published), and eight guidelines and one review based on scientific evidences were reviewed. Results: Five RCTs (n = 1473) that compared the initial UDE to the empirical treatment demonstrate a non-significant reduction of recurrence risk of dyspeptic symptoms. In four RCTs (n = 1863), the initial UDE strategy showed a small clinical benefit, but statistically significant, when compared to the «test and treat» strategy; nevertheless, the incurred costs were higher. In four RCTs (n = 1056) where the «test and treat» strategy was benchmarked against the empirical treatment, the clinical benefit was proved to be statistically significant, without cost differences. In addition, guidelines based on scientific evidences of various societies were reviewed and compared, along with recommendation forces. Discussion/Conclusion: The initial management of «Helicobacter pylori (H. pylori) and its eradication » test presents a best trade-off cost-effectiveness than that of strategies that involve UDE or initial prescription; on the other hand, the empirical treatment was more advantageous on the «cost-effectiveness» relationship that the initial UDE. The latter is not recommended as a first line of approach to patients with dyspepsia without alarm symptoms. A decision making algorithm, enriched with recommendation levels, is presented.