Empiric treatment based on Helicobacter pylori serology cannot substitute for early endoscopy in the management of dyspeptic rural black Africans

Background. Evidence that chronic gastric Helicobacter pylori (HP) infectio n is an aetiological factor in dyspepsia, peptic ulcer disease, gastric car cinoma and lymphoma has led to the suggestion that all serologically positi ve dyspeptic patients should be treated;empirically with antibiotics to era dicate the infection, without endoscopic diagnosis. The following study was performed to determine whether such a policy would prove to be of benefit in rural Africa, where endoscopic facilities are lacking and infection rate s high. Methods. Four district clinics were visited and 97 consecutive patients wit h:persistent upper gastro-intestinal symptoms studied. After history-taking and physical examination, a blood sample was taken for HP serology (IgG an ti-HP EIA) and endoscopy was performed. Results. in comparison with similar:studies in westernised countries HP was : considerably more common (80%), and similar to that reported for the back ground population (83 86%), but peptic ulceration (17%) and gastric cancer (1%) were not. HP status and antibody levels failed to predict the presence of serious disease; patients with 'alarm' signs (78%), cancer (78%) anti p eptic ulcers (81%) had similar seropositivity rates to patients with non-ul cer dyspepsia (81%). Interestingly, many patients with distal oesophagitis were seronegative (40%). Haemoglobin concentrations and nutritional status were similar in HP-positive and negative patients. On the basis of publishe d decision analysis strategies, empiric treatment of HP-positive patients w ith uncomplicated dyspepsia could be expected to produce symptomatic relief in 50% of: cases, but would have delayed the diagnosis of 3 cases of cance r if patients over the age of 45 were included. Conclusion. The lack of association between HP serology and upper gastro-in testinal disease indicates that serological investigation cannot substitute for endoscopy in the management of black Africans with dyspepsia, and that empiric anti-HP therapy cannot be justified.