Current issues of ACP Journal Club are published in Annals of Internal Medicine


Etiology

Helicobacter pylori infection was not associated with nonulcer dyspepsia

ACP J Club. 1999 Jan-Feb;130:19. doi:10.7326/ACPJC-1999-130-1-019


Source Citation

Nandurkar S, Talley NJ, Xia H, et al. Dyspepsia in the community is linked to smoking and aspirin use but not to Helicobacter pylori infection. Arch Intern Med. 1998 Jul 13;158:1427-33.


Abstract

Questions

Is Helicobacter pylori infection associated with nonulcer dyspepsia? What are the risk factors for nonulcer dyspepsia and H. pylori infection?

Design

Community-based study.

Setting

Blood bank of a major teaching hospital in western Sydney, New South Wales, Australia.

Participants

592 consecutive adults who volunteered to donate blood (age range 18 to 65 y).

Assessment of risk factors

Helicobacter pylori optical density values were measured using the donated blood, and H. pylori infection was defined as an optical density value ≥ 0.9. Other risk factors evaluated were alcohol, coffee, aspirin, and nonsteroidal anti-inflammatory drug (NSAID) use; smoking; age; sex; education level; net family income; marital status; blood group status; and Rh factor.

Main outcome measures

Self-reported frequency and severity (dyspepsia impact score) of dyspepsia symptoms.

Main results

65 participants (11%) had nonulcer dyspepsia, and 87 (14.7%) had H.pylori infection. 29 participants (4.9%) had a history of peptic ulcer disease and were excluded from further analysis. No difference existed for the prevalence of H. pylori infection between participants who had and those who did not have dyspepsia (15.4% vs 14.6%; OR 1.0, CI 0.5 to 2.2, P = 0.9). Among the participants who had dyspepsia, no difference existed for the mean dyspepsia impact scores between those who had and those who did not have H. pylori infection (4.7 vs 5.4; OR 0.8, CI 0.6 to 1.1, P = 0.2). Among the participants who had H. pylori infection, no difference existed for the median H. pylori optical density values between those who had and those who did not have dyspepsia (P = 0.30). Multivariate analysis showed that nonulcer dyspepsia was associated with aspirin use (OR 2.2, CI 1.3 to 3.8, P = 0.003) and smoking (OR 2.2, CI 1.3 to 3.7, P = 0.005) but not alcohol, coffee, or NSAID use; age; sex; education level; net family income; marital status; blood group status; or Rh factor. Helicobacter pylori infection was associated with increasing age (OR 1.8/decade, CI 1.5 to 2.3, P < 0.001), male sex (OR 2.1, CI 1.3 to 3.4, P = 0.001), and lower net family income (OR 1.7, CI 1.1 to 2.9, P = 0.02).

Conclusions

Helicobacter pylori infection was not associated with nonulcer dyspepsia, but aspirin use and smoking were. Increasing age, male sex, and lower net family income were associated with Helicobacter pylori infection.

Source of funding: None stated.

For correspondence: Professor N.J. Talley, Department of Medicine, University of Sydney, Nepean Hospital, Penrith, New South Wales 2751, Australia. FAX 011-61-2-9351-6645.


Commentary

Dyspepsia is a common symptom, and its investigation and treatment results in substantial costs to health care systems in developed countries. The underlying causes of dyspepsia include peptic ulcer disease, gastroesophageal reflux disease (GERD), and gastric malignancy. However, most patients have negative investigations and are labelled as having nonulcer, or functional, dyspepsia. Although H. pylori is now recognized as the cause of most peptic ulcers, results from trials of H. pylori eradication in patients with nonulcer dyspepsia conflict (1).

Nonulcer dyspepsia is a diagnosis of exclusion that can only be made with any degree of confidence after gastroscopy. Definitions of the condition have shifted to exclude patients with predominant reflux symptoms in addition to those with esophagitis (2). This study by Nandurkar and colleagues recruited participants from a community setting. It excluded those with a history of peptic ulcer disease from analysis but not those with a history of GERD. The study population is likely to include many patients who would meet the definition of nonulcer dyspepsia as well as those with undetected peptic ulcer or GERD. Although it is possible that a tighter case definition would produce different results, this study represents patients who might be treated on clinical grounds as having nonulcer dyspepsia.

The importance of lifestyle factors and aspirin use in nonulcer dyspepsia is highlighted. Clinicians who choose to eradicate H. pylori in patients with nonulcer or uninvestigated dyspepsia should not raise false expectations or neglect lifestyle issues. Although final results of trials of H. pylori eradication in nonulcer dyspepsia are awaited, it is clear that dyspepsia is a complex problem of which H. pylori infection is only a part.

Brendan C. Delaney, MD
University of Birmingham Medical SchoolEdgbaston, Birmingham, UK


References

1. Veldhuyzen van Zanten SJ, Cleary C, Talley NH, et al. Drug treatment of functional dyspepsia: a systematic analysis of trial methodology with recommendations for design of future trials. Am J Gastroenterol. 1996;91:660-73.

2. Talley NJ, Colin-Jones D, Koch KL, et al. Functional dyspepsia: a classification with guidelines for diagnosis and management. Gastroenterology International. 1991;4:145-60.