Getting rid of H-pylori bacteria... Does it make sense for dyspepsia?

More than a decade ago, scientists established that the bac-terium H. pylori—not stress—is responsible for most cases of ulcers in the stomach and the adjoining segment of the small intestine (duodenum). But you can have H. pylori living inside your gut and not have an ulcer. In fact, about a third of Americans are infected with this bacterium.

What dyspepsia feels like

Many infected individuals who don’t have an ulcer nonetheless suffer stomach symptoms that can be described as “ulcer-like.” These people may experience a gnawing or burning sensation or a feeling of fullness and bloating. They may also have some nausea. These abdominal symptoms, called dyspepsia, may be due to such problems as stomach inflammation (gastritis), acid reflux, long-term use of non-steroidal anti-inflammatorydrugs(NSAIDs),or,rarely,cancer.Often symptoms are simply the result of stomach muscle spasms or oversensitivity (called functional dyspepsia).

Test-and-treat?

The question for doctors is how to proceed when they aren’t sure what’s behind dyspepsia. The answer isn’t always clear-cut. But many take a “test-and-treat” approach toward H. pylori.

The main exceptions to this strategy are people who are older than 45 (or 55, depending on the guidelines followed) or who have symptoms that suggest a more serious underlying condition, such as cancer. (So-called “alarm” symptoms include difficulty swallowing, major unexplained weight loss, an abdominal mass, prolonged vomiting, jaundice, or rectal bleeding.) For these individuals, endoscopy is called for—an examination of the stomach lining with a lighted tube inserted through the mouth and down the throat. In addition, some experts argue that test-and-treat isn’t appropriate for individuals whose dyspepsia is associated with long-term use of NSAIDs.

How test-and-treat works

In the test-and-treat approach, people with dyspepsia symptoms are first tested for H. pylori using a non-invasive method. A urea breath test may be done or a person’s stool tested for a molecule (an antigen) that identifies the bacterium. In the breath test, a person drinks a urea solution.

If the person has an H. pylori infection, the bacteria break down the urea (a carbon compound)—a process evident when carbon is detected in the the person’s breath. (One drawback of these two methods is that their sensitivity is reduced unless dyspepsia medications are stopped 1 to 4 weeks before the test is administered.) If the test result is positive for H. pylori, the next step is antibiotic treatment to wipe out the infection. Previously, this therapy was given for 10 to 14 days. Newer studies suggest that a shorter course of treatment (up to 7 days) may be just as effective, knocking out H. pylori in as many as 95% of cases. The shorter regimen has the advantage of fewer side effects, better compliance with the schedule for taking antibiotics, and decreased cost. The longer course is still recommended for children, though.

Both long-and short-course treatments rely on a combination of antibiotics to kill the bacteria, an acid blocker to reduce stomach acid, and a medication to protect the stomach lining (e.g., Pepto-Bismol or Kaopectate). If the infection proves resistant to a standard regimen, additional antibiotics may be used.

Even when the original treatment successfully eliminates H. pylori, the infection may return. Women and younger people tend to have higher recurrence rates than others, as do people with lingering gastritis and those who had high readings on a urea breath test. Depending on the person’s symptoms and the risk for complications linked with infection, doctors typically treat recurrence with an alternative eradication regimen.

How beneficial?

When it comes to bleeding ulcers, eliminating H. pylori with medication, and taking medication to reduce stomach acid, will further lower the risks of bleeding again and ulcer recurrence. On the other hand, studies show that with dyspepsia that is not related to an ulcer, symptom relief with these medications is likely to be modest, if it occurs at all. Nonetheless, some argue, getting rid of H. pylori may be warranted to help reduce the possibility that H. pylori infection could progress to ulcers or stomach cancer.

From American Family Physician and the American Journal of Gastroenterology