Although Hp eradication will not necessary alleviate the symptoms of FD, most patients with Hp have chronic gastritis, which is an indication for eradication therapy in Japan.

The main reason for eradication of H. pylori in dyspeptic patients is not to improve symptoms, but to block possible evolution towards gastric cancer. Therefore, the assioma is: every time Hp is found, it should be cured.

I would like to thank all colleagues who participate in the discussion. 

The problem is that a patient seeks us as physicians for her/his symptoms. We all know that the main problem is that the symptoms as known till now is functional in its nature and has no significant association with H pylori.

With eradicating H pylori are we treating the patient and helping her/him in alleviating the symptoms or are we going to do a good thing for the patient irrelevant from the symptoms?!

If a good H pylori is a dead one, then national screening and eradication of the organism should be recommended.

As a patient with a problem I think that it is better focus on the complaint and the reason of the visit!

I do not treat my patients since eradication of H pylori does not help/alleviate symptoms. 60% of functional dyspepsia in my region would be having H pylori infection, and without robust data supporting its eradication, it would be wrong to advise treatment to eradicate the infection. 

Yes!

First, even though the infection is asymptomatic in more than 50% of individuals, you do not know a priori whether symptoms will disappear or not.

Second, it has been shown that symptoms are mostly linked to CagA positive H. pylori infection (Noyan et al. Cytotoxin associated gene A-positive Helicobacter pylori strains in dyspeptic pregnant women. Obstetric and Gynecol October 15, 2004Volume 116, Issue 2, Pages 186–189. DOI: http://dx.doi.org/10.1016/j.ejogrb.2004.02.028; Loeffeld et al. Scand J Gastroentrol, 36:4, 351). So, I would advice to test patients for antibodies to CagA and treat those who are positive.

Third, even if symptoms do not disappear after eradication, tha patients reduce the risk of peptic ulceration and gastric cancer. Not to talk of the extradigestive diseases triggered or worsened by this infection.

No doubt, that Helicobacter pylori is potentially harmful. However, no clearcut relation is demonstrated with the symptoms of functional dyspepsia. The clinical improvement observed in some patients can be related with the antibiotic treatment of small intestinal bacterial overgrowth, frequent in irritable bowel syndrome.

In addition, to argument: "every time Hp is found, it should be cured", it means, about 40-50% of healthy population,  we should answer the following questions:

1. Number of patiens necessary to treat to prevent one gastric cancer

2. Frequency of antibiotic resistance, necessity of repeated second (and third) line treatment.

3. Frequency of adverse effects of antibiotics

4. Importance of Helicobacter pylori treatment in the development of antibiotic resistance of different bacteria.

There is no doubt that this is an infection, and as such, it should be treated. In the end, we treat pharyngitis caused by Streptococcus pyogenes and cystitis by Escherichia coli and these diseases are not as dangerous as chronic gastritis by H. pylori.

If I said to the patients "If I do not treat you, you have 20% of probability of developing peptic ulcer and 1%-3% of developing gastric cancer, but I decided not to treat you because, if I do not have success, the bacteria could become resistant to antibiotics", do you think the patient  will be resigned to not seek treatment?

Patients have the right to know their condition and the risks they run. The final decision is their.

I am agree, once Helicobacter is detected, it is difficult not to treat it. I am also agree that the patients have to know the risks and benefits and the final decision must be made together with them.

But there is a big difference between the examples cited by Dr. Figura and Helicobacter infection, and it is just the original question of Iradj Maleki: Streptococcus pyogenes and E. coli produces the disease and the patient's symptom, while Helicobacter "only" increases the probability to develop the disease (ulcer or cancer) during the patient's life. Thus, treatment of Streptococcus and E. coli resolves the disease and the complaints while even successful eradication of Helicobacter pylori only reduces a statistical probability. Thus, the patient's age and comorbidities are also important.

I can not tell my patients "If I do not treat you, you have 20% of probability of developing peptic ulcer and 1%-3% of developing gastric cancer, but I decided not to treat you because, if I do not have success, the bacteria could become resistant to antibiotics",

If I do so, I would be lying, because this is not true for Indians. As treating physicians, we are not for "House keeping"; treating all the bugs detected.

The matter should be considered in proper context. In countries with high incidence of gastric cancer (like Japan) it is worth eradicating even if the symptom is of functional dyspepsia but in countries like India where incidence of reinfection, antibiotic resistance and cost of therapy is high about 60-70% people harbor H.pylori without high incidence of gastric cancer, I would be hesitant to treat just for symptom of  functional dyspepsia without investigation.

This is the most sensible response I've read.

However, if the patient wants to be treated (and in the end, after reading on this subject in the internet and have been updated by the doctor about risks of infection, he will choose the antibiotic treatment) thedoctor can not refuse to treat him.

A factor which is not taken into account is the patient's wishe.

Dear Gautam, you are absolutely right.

Dr.Figura, Of course the patient's wish stands foremost after full explanation of the pros and cons.

very interesting challenge on this issue.

It is clear for all of us that H pylori is a carcinogen and has a role in the development of gastric cancer. But the question is the size of this risk. I have not seen an evidence showing the incidence of 1-3% of gastric cancer in Hp infected individuals yet! It would be a great pleasure from Natale to send me the reference for that. Considering this and the prevalence of 50% of Hp infection in the world's population, one should state that 2-3% of the world population will dye of gastric cancer which is not correct.

I should also mention on the difference between H pylori colonization in the stomach and of the Streptococcus in the setting of pharyngitis (a disease). Our GI tract is harbor of a lot worst micro-organisms from mouth to anus. We do not try to eradicate them unles they are aggressive and cause diseases.

We know microbiota as a novel organ of the body doing a lot of useful activities in the body. Elimination of microbes from our environment is neither possible nor recommended. There are issues combining of H pylori eradication and some allergic diseases and eosinophilic esophagitis.

In the setting of functional dyspepsia I do recommend to focus on the patient and his/her symptoms with explanation of its benign nature of the disease (like IBS), rather than making his/her anxiety double with the Hp story.

There are almost 10e6 new cases of gastric carcinoma (GC) every year. If we consider 40 years the number of years in which someone can develop GC, the total number of GC cases are 4 x 10e7 . If we admit that

a)      GC only develops in CagA positive H. pylori infected people,

b)      that the whole number of infected persons are 50% ca. of the world population (that is formed by 6 x 10e9 people), that is 3 x 10e9,

c)      that individuals that harbor CagA positive strains are approx. 50% of those who are infected, i.e. 1.5 x 10e9,

then, the prevalence of GC will be 3.7%. Thus, the ratios of infected persons who develop GC, that is 1%-3%, is optimistic. In reality, the number of GC cases is higher.

I am including some references on this subject and some publications, including one of my group, in which we dealt with the observation that not all H. pylori strains and patients are alike.

 Nomura A, Stemmermann GN, Chyou PH, Kato I, Perez GI, Blaser MJ. Helicobacter pylori infection and gastric carcinoma among Japanese Americans in Hawaii. N Engl J Med. 1991;325:1132–6.

 Parsonnet J, Friedman GD, Vandersteen DP, Chang Y, Vogelman JH, Orentreich N, et al. Helicobacter pylori and the risk of gastric carcinoma. N Engl J Med. 1991;325:1127–31.

 Uemura N, Okamoto S, Yamamoto S, Matsumura N, Yamaguchi S, Yamakido M, et al. Helicobacter pylori infection and the development of gastric cancer. N Engl J Med. 2001;345:784–9.

The data on the association of helicobacter pylori and gastric cancer is real. But the issue that I am talking about is the association of helicobacter pylori (Hp) and functional dyspepsia!

Regarding the best evidence available in this regard, about 90% of patients suffering from functional dyspepsia will not get any benefit in their symptoms after eradication of Hp. As a clinician what will we do after eradication trial of Hp and persistence of the symptoms? Telling them that I have eradicated the microbe is not sufficient for the patient with the persistent symptoms!

It seems like you check the cholesterol level for the patient with FD and then treating it if it is high. But the problem of patient persists after lowering the cholesterol!

Looking at just one aspect of the problem without paying attention to other aspects seems not wise.

Trying to eradicate Hp in these patients has other consequences too that should be elucidated further. 

If anyone recommends Hp eradication for FD patients, logically he/she should recommend for national/ international Hp screening and eradication too!

When approaching dyspepsia, HP testing should be performed (in this case HP testing is indicated, certainly not in mass screening). If the infection is detected, we MUST propose an eradication treatment to the patient, but the clinician MUST underline pros (prevention of gastric cancer) and cons (it is possible that the eradication may not improve symptoms). Only if the patient is aware of all possibilities, he can choose wisely to accept or not the treatment. As prof. Figura underlined, eradication of HP is always necessary, but the wish of the patients and a correct dialogue with the doctor is very important.

Dear Giuseppe:

Test and treat Hp in approach to dyspepsia is recommended as an option in populations with Hp prevalence of more than 20% and not in populations under 10% and all the data and studies rely on economic benefit for this approach (Management of Helicobacter pylori infection—the Maastricht V/Florence Consensus Report).

The problem is that the cost of antibiotic use and tests and endoscopy differs in different countries and even the ratio of prices / cost for procedures differs in many countries. So the guidelines based on economic base should be performed locally for these areas. This is why we doubt the results in out region (As Dr Shivaram Prasad Singh also commented before).

But one issue should be clearly defined in approaching functional dyspepsia; regarding the above mentioned reference, in the management of FD, eradication of Hp will cause a symptom improvement in about 10% of patients, meaning that 90% will not get any benefit. So this should be clearly described for the patients as getting no improvement in symptoms is the rule not a possibility!

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