Does Helicobacter pylori cause dyspepsia?
ACP J Club. 1992 Sept-Oct;117:57. doi:10.7326/ACPJC-1992-117-2-057
Bernersen B, Johnsen R, Bostad L, et al. Is Helicobacter pylori the cause of dyspepsia? BMJ. 1992 May 16; 304:1276-9.
To determine whether Helicobacter pylori infection and dyspepsia occur in association.
Blinded, sex- and age-matched, case-control, population-based study.
A municipality in northern Norway.
A questionnaire designed to measure abdominal complaints, health, lifestyle, diet, and social conditions was sent to all adult residents ≥ 2 weeks duration or heartburn or acid regurgitation almost daily for ≥ 1 week. 89 people with dyspepsia were excluded because of a history of peptic ulcers, gall stones, kidney stones, or coronary heart disease. Controls were matched for sex and age within 10 years.
Assessment of risk factors
782 case and control participants were offered free endoscopies, and 619 (339 men) had an endoscopy (309 participants with dyspepsia and 310 control participants). All endoscopies were done by 1 person without knowledge of dyspepsia symptoms. Gastritis and peptic ulcer were identified by endoscopy and histologic examination of biopsy specimens from the duodenum, the corpus and antrum of the stomach, and from all lesions. To establish the presence of H. pylori, micro-aerobic cultures of the biopsy specimens were done on blood agar and on brain-heart infusion agar containing horse blood and were read after 3 to 10 days.
Main outcome measures
Prevalence of H. pylori, peptic ulcers, and gastritis.
48% of the participants with dyspepsia and 36% of the control participants were infected with H. pylori (P = 0.004 for the difference between the groups). There was a linear increasing trend in prevalence of H. pylori with age in both participants with dyspepsia (P = 0.04) and in those without dyspepsia (P = 0.003). The prevalence of H. pylori and histologically proven gastritis was 70% (CI, 65.5% to 85.3%) for participants with dyspepsia and 60% (CI, 52.7% to 67.7%) for participants without dyspepsia. For peptic ulcer the prevalence of H. pylori was 92% (CI, 61.5% to 99.8%) for participants with dyspepsia and 64% (CI, 9.4% to 99.2%) for those without dyspepsia.
Helicobacter pylori infection is common both in people with dyspepsia and those without. The infection is more common with increasing age and is strongly associated with histologic gastritis and peptic ulcer.
Source of funding: Not stated.
Address for article reprint: Dr. B. Bernersen, Institute of Clinical Medicine, University of Tromsø, N-9000 Tromsø, Norway.
It is generally accepted that H. pylori plays an important role in the pathogenesis of chronic gastritis and a possible contributory role in the causation of peptic ulcers (1) and that the prevalence of H. pylori infection increases with age, especially among low socioeconomic groups (2). The study by Bernersen and colleagues supports these beliefs by showing that the relation between the prevalence of H. pylori and the presence or absence of nonulcer dyspepsia appears to be less important than between H. pylori and chronic gastritis, peptic ulcers, and older age.
Nonulcer dyspepsia is a poorly defined entity and objective parameters for its diagnosis are lacking. The high prevalence of H. pylori in the population, however, especially among the older asymptomatic participants, means that the relation between dyspepsia and H. pylori infection is weak at best.
The authors of the study excluded patients with peptic ulcers and other conditions known to be associated with H. pylori from the case patient group (the group with dyspepsia). This step, in combination with the high prevalence of abnormal antral gastric mucosa in the asymptomatic controls, may account for the rather small difference in the prevalence of H. pylori between persons with and without dyspepsia. Until a clear association between H. pylori and nonulcer dyspepsia can be shown, clinicians are unlikely to consider eradication of H. pylori as a reasonable approach to the treatment of nonulcer dyspepsia.
Nirmal S. Mann, MD, DSc
Texas A & M University Temple, Texas