Commentary

Patients with dyspeptic symptoms should be managed with 2 goals in mind: early detection of malignant disease and cost-effective relief of symptoms. Patients <55 years of age without “alarm features” (eg, weight loss, dysphagia, and anaemia) are at very low risk of malignancy and do not require endoscopic investigation. The question of management then turns on the relative costs and effectiveness of endoscopy, noninvasive tests, and eradication of H pylori and empiric acid suppression.¹

The trials by McColl and Chiba and their colleagues provide important information for physicians managing patients presenting with uninvestigated dyspepsia. The study by McColl et al adds to 2 previous studies^2–3 that confirm the cost effectiveness of a secondary care based H pylori test and treat service compared with endoscopy based management. All 3 trials of test and treat compared with endoscopy based management showed equivalent effectiveness, but costs were reduced because fewer patients had endoscopy. The trial by McColl et al showed a rate of endoscopy in the year of follow up in the test and treat group of only 8%, whereas Heaney² and Lassen³ showed rates nearer 30%. Patients positive for H pylori in both groups of the trial by McColl et al received eradication treatment. Thus, any differences caused by the eradication treatment itself were abolished. The trial can therefore be considered to address the question, “Is the cost of endoscopy warranted by the effect on symptoms, quality of life, and patient satisfaction of having the investigation?” The answer is “no”.

The trial by Chiba et al (CADET-Hp) takes the McColl et al trial 2 steps further. Firstly, patient recruitment and the intervention took place in a primary care setting. Secondly, test and treat was compared with acid suppression alone. In contrast to the trial by McColl et al, CADET-Hp was designed to examine the effect of eradication treatment on dyspeptic symptoms, and found a substantial improvement in the proportion of patients with dyspeptic symptoms at the end of the trial. However, the difference in costs was small and not statistically significant.

The reason for the difference in effects and costs between CADET-Hp and McColl et al lies in the use of eradication treatment for H pylori. In CADET-Hp the control group patients did not receive eradication treatment and were therefore at risk of recurrent peptic ulcers that had healed initially with omeprazole

Furthermore, patients with nonulcer dyspepsia may also benefit from H pylori eradication. A Cochrane review of 9 placebo controlled trials of H pylori eradication treatment in patients without peptic ulcers or oesophagitis at endoscopy found a number needed to treat of 15.⁴

The CADET-Hp trial does not show conclusively that H pylori test and treat is more cost effective in primary care than omeprazole alone, because it was only done in H pylori–positive patients. The cost effectiveness of this strategy needs to be tested by randomising patients with dyspepsia, both positive and negative for H pylori, before noninvasive testing for H pylori, to determine the effect of the management strategy on the whole group. It does, however, lend more support to the eradication of H pylori in all patients known to be infected.