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Title: Test-And-Treat Strategy Preferred Approach In Treating Dyspepsia

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BMJ 2003; 326:1118-1120.
05/22/2003 07:03:00 PM
By Harvey McConnell

The test-and-treat strategy for patients with [Helicobacter pylori should be the preferred approach in treating dyspepsia, suggest Italian clinicians. In their study, it was also found that treatment with omeprazole is likely to mask an appreciable number of peptic ulcers and cases of oesophagitis, report Dr Gianpiero Manes and colleagues at the Department of Gastroenterology, Cardarelli Hospital, Naples. They note that no fully randomised trial, until now, has compared the efficacy of the test-and-treat strategy with that of empirical treatment with a proton pump inhibitor in a clinical setting as an initial management strategy for dyspeptic patients. The clinicians enrolled 219 outpatients, aged 18 and 45, with symptoms of dyspepsia and uninvestigated upper abdominal symptoms, but without alarming symptoms. A group of 109 patients were treated with omeprazole 20 mg (group A), and 110 patients with a urea breath test followed by an eradication treatment in case of H pylori infection on in uninfected patients, omeprazole alone (group B). Endoscopy was carried out among any patient who did not show signs of improvement, or who had a recurrence of symptoms. A total of 96 of 109 patients (88%) in group A, and 61 of 110 patients (55%) in group B, had endoscopy: 19 patients in group A and 32 in group B because of no improvement; another 77 patients in group A and 29 in group B because of recurrence of symptoms during follow-up. Endoscopic examination found peptic ulcers only among group A patients, and oesophagitis was more significant among patients in group B. About 80% of examinations were normal in both groups, but 9 duodenal scars occurred in group A. After discontinuation of treatment, symptoms recurred earlier in the patients who received eradication treatment than in those treated with proton pump inhibitor. The clinicians acknowledge that a main concern about empirical treatment of dyspepsia is the possibility of missing gastric cancer. No gastric cancer was diagnosed or missed in their study. They conclude: "The test-and-treat strategy was superior to empirical treatment with omeprazole in our study population, but this advantage might be less evident in populations with a lower prevalence of H pylori infection."

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