INDICATIONS FOR TREATMENT OF HELICOBACTER-PYLORI INFECTION - A SYSTEMATIC OVERVIEW

Objective: To determine (a) the advantages and disadvantages of treatm ent options for the eradication of Helicobacter pylori and (b) whether eradication of H. pylori is indicated in patients with duodenal ulcer ; nonulcer dyspepsia and gastric cancer. Data sources: A MEDLINE searc h for articles published in English between January 1983 and December 1992 with the use of MeSH terms Helicobacter pylori (called Campylobac ter pylori before 1990) and duodenal ulcer, gastric cancer, dyspepsia and clinical trial. Six journals and Current Contents were searched ma nually for pertinent articles published in that time frame. Study sele ction: For duodenal ulcer the search was limited to studies involving adults, studies of H. pylori eradication and randomized clinical trial s comparing anti-H. pylori therapy with conventional ulcer treatment. For nonulcer dyspepsia with H. pylori infection the search was limited to placebo-controlled randomized clinical trials. Data extraction: Th e quality of each study was rated independently on a four-point scale by each author. For the studies of duodenal ulcer the outcome measures assessed were acute ulcer healing and time required for healing, H. p ylori eradication and ulcer relapse. For the studies of nonulcer dyspe psia with H. pylori infection the authors assessed H. pylori eradicati on, the, symptoms used as outcome measures and whether validated outco me measures had been used. Data synthesis: Eight trials involving duod enal ulcer met our inclusion criteria: five were considered high quali ty, two were of reasonable quality, and one was weak. Six trials invol ving nonulcer dyspepsia met the criteria, but all were rated as weak: Among treatment options triple therapy with a bismuth compound, metron idazole and either amoxicillin or tetracycline achieved the highest er adication rates (73% to 94%). Results concerning treatment indications for duodenal ulcer were consistent among all of the studies: when ant i-H. pylori therapy was added to conventional ulcer treatment acute ul cers healed more rapidly. Ulcer relapse rates were dramatically reduce d after H. pylori eradication. All of the studies involving nonulcer d yspepsia assessed clearance rather than eradication of H. pylori. No s tudy used validated outcome measures. A consistent decrease in symptom severity was no more prevalent in patients in whom the organism had b een cleared than in those taking a placebo. Of the studies concerning gastric cancer none investigated the effect of eradication of H. pylor i on subsequent risk of gastric cancer. Conclusions: There is sufficie nt evidence to support the use of anti-H. pylori therapy in patients w ith duodenal ulcers who have H. pylori infection, triple therapy achie ving the best results. There is no current evidence to support such th erapy for nonulcer dyspepsia in patients with H. pylori infection. Muc h more attention must be paid to the design of nonulcer dyspepsia stud ies. Also, studies are needed to determine whether H. pylori eradicati on in patients with gastritis will prevent gastric cancer.