Search

Gastroenterology, like many other disciplines, is expanding rapidly. In the past four years there have been exciting advances in screening, diagnosis, and therapy. This article describes some of the most clinically relevant developments. We selected the topics after discussion with colleagues and attending the British Society of Gastroenterology meeting, Birmingham 2002. We subjectively assessed the most important recent innovations and evaluated these in more depth by searching Medline and the Cochrane Controlled Trials Register. We also hand searched recent issues of Gastroenterology, Gut , and Gastrointestinal Endoscopy . ### Gastric cancer Gastric cancer is the second commonest cause of cancer mortality worldwide, causing around 660 000 deaths annually. In England and Wales it is the fifth commonest cause of cancer death, with an annual mortality of about 7000. A meta-analysis of nested case-control studies reported that patients infected with Helicobacter pylori were nearly six times more likely to develop distal gastric adenocarcinoma than uninfected controls.1 A recent randomised trial suggests that eradication of H pylori will improve gastric atrophy and intestinal metaplasia, which are thought to be premalignant changes.2 Studies have also identified subgroups of people infected with H pylori who may be at particular risk of developing gastric cancer.3 A randomised trial showed that H pylori screening and treatment might save money because of the reduced costs of treating dyspepsia.4 Oesophageal and proximal gastric adenocarcinoma have been increasing in recent years, and this parallels the fall in prevalence of H pylori infection. Some investigators have therefore suggested that H pylori infection protects against the development of cancers of the proximal stomach and oesophagus. This hypothesis is not supported by a meta-analysis of nested case-control trials,1 but the benefits and harms of population screening and treatment for H pylori can properly be evaluated only in a randomised controlled …

Objectives: To evaluate efficacy and cost effectiveness of Helicobacter pylori eradication treatment in patients with non-ulcer dyspepsia infected with H pylori. Design: Systematic review of randomised controlled trials comparing H pylori eradication with placebo or another drug treatment. Results were incorporated into a Markov model comparing health service costs and benefits of H pylori eradication with antacid treatment over one year. Data sources: Six electronic databases were searched for randomised controlled trials from January 1966 to May 2000. Experts in the field, pharmaceutical companies, and journals were contacted for information on any unpublished trials. Trial reports were reviewed according to predefined eligibility and quality criteria. Main outcome measures: Relative risk reduction for remaining dyspeptic symptoms (the same or worse) at 3-12 months. Cost per dyspepsia-free month estimated from Markov model based on estimated relative risk reduction. Results: Twelve trials were included in the systematic review, nine of which evaluated dyspepsia at 3-12 months in 2541 patients. H pylori eradication treatment was significantly superior to placebo in treating non-ulcer dyspepsia (relative risk reduction 9% (95% confidence interval 4% to 14%)), one case of dyspepsia being cured for every 15 people treated. H pylori eradication cost £56 per dyspepsia-free month during first year after treatment. Conclusion:H pylori eradication may be cost effective treatment for non-ulcer dyspepsia in infected patients but further evidence is needed on decision makers9 willingness to pay for relief of dyspepsia.

The possibility that peptic ulcer and gastric cancer could be an infectious disease would have been dismissed as ridiculous 30 years ago. We now realise that Helicobacter pylori infection is the major cause of both. As H pylori infection has been implicated in various upper gastrointestinal diseases, testing for the bacterium non-invasively and treating infected individuals (“test and treat”) has become widespread. The key question is in which group of patients is this approach appropriate? We searched MEDLINE, Clinical Evidence, the Cochrane central register of controlled trials, the Cochrane library, and http://clinicaltrials.gov to identify published and ongoing randomised controlled trials and systematic reviews that have assessed the effect of “test and treat” in patients with upper gastrointestinal diseases, including peptic ulcer disease, gastro-oesophageal reflux disease, functional dyspepsia, and uninvestigated dyspepsia, as well as in people in the community. ### Peptic ulcer disease H pylori is causally implicated in the pathogenesis of pyloric ulcer disease.1 A systematic review and meta-analysis of randomised controlled trials of eradication therapy versus placebo in H pylori positive disease showed that eradication therapy was cost effective compared with long term acid suppression and led to significantly lower rates of duodenal and gastric ulcer relapse, with numbers needed to treat (NNT) to prevent one ulcer relapse of 2 and 3 respectively.2 ### Gastro-oesophageal reflux disease A systematic review of observational studies showed that the prevalence of H pylori was significantly lower in people with gastro-oesphageal reflux disease than in healthy controls, suggesting that infection may be protective.3 This is biologically plausible because H pylori can induce an atrophic gastritis, which may reduce production of gastric acid. However, the association could also be the result of a confounding by socioeconomic status (reflux disease is more common in higher socioeconomic groups,4 whereas H pylori …

Potentially, but trials specifically designed to answer this question are needed The cardioprotective effects of aspirin are well established. A meta-analysis of individual subject data from primary prevention randomised controlled trials (RCTs) suggested that aspirin can reduce the relative risk of non-fatal myocardial infarction by about 20%.1 Overall, however, the risks of treatment (severe gastrointestinal and extracranial bleeding) were roughly the same as the benefits, so routine use of aspirin as a primary preventive strategy was not recommended. The meta-analysis did not evaluate any potential reduction of mortality from cancer, as has been suggested by observational data.2 Observational data are difficult to interpret, however, because associations may not be causal and may be the result of confounding or bias.3 Rothwell and colleagues have therefore conducted another meta-analysis of individual subject data from RCTs of aspirin versus no aspirin for prevention of vascular disease, but this time they evaluated mortality from cancer as the main outcome.4 They found a 21% (95% confidence interval 8% to 32%) reduction in the odds of death from cancer in people who took aspirin for almost six years, and the effect was strongest for gastrointestinal cancers. The authors …

EDITOR—Manes et al reported their trial of Helicobacter pylori test and treat v initial proton pump inhibitors.1 Their results in secondary care are encouraging in that eradication treatment for H pylori reduced the relapse of symptoms by 33% compared with a short course of treatment to suppress acid. However, we doubt whether their findings have any relevance …

Screening young dyspeptic patients for Helicobacter pylori and avoiding endoscopy in seronegative patients can reduce endoscopy workload by 30% without missing significant disease.1 Serological testing is commonly used to screen for H pylori but requires analysis in a central laboratory, which delays results. Cortecs Diagnostics has introduced the Helisal rapid whole blood test that claims to diagnose H pylori status within 10 minutes. This is the first near patient test to be available in the United Kingdom but its accuracy has not been independently evaluated. Our aims were to assess the accuracy of the rapid blood test against a “gold standard” and determine its effectiveness in screening young dyspeptic patients. One hundred and seventy seven patients undergoing routine endoscopy were invited to participate. Twenty patients taking antibiotics, bismuth salts, or non-steroidal anti-inflammatory drugs within a month or proton pump inhibitors …