Helicobacter pylori“test-and-treat” strategy is not suitable for the management of patients with uninvestigated dyspepsia in Shanghai

Abstract

H. pylori "test-and-treat" and "test-and-endoscopy" strategies are both not suitable for the management of patients with uninvestigated dyspepsia in Shanghai. For most Shanghai dyspeptic patients, prompt endoscopy should be recommended as the first-line initial management option.

Alarm features and age for predicting upper gastrointestinal malignancy in Chinese patients with dyspepsia with high background prevalence of Helicobacter pylori infection and upper gastrointestinal malignancy: an endoscopic database review of 102 665 patients from 1996 to 2006

“…In addition, recent Asian studies cast doubt on the safety of the ‘test and treat’ strategy for the management of young patients with dyspepsia without alarm symptoms. Sung et al detected 17.4% upper GI malignancies in these low-risk patients,10 while Li et al 11 found, among 202 Chinese patients with GI malignancies, that only 108 (53.5%) presented with alarm features. However, it should be noted that although we detected many young patients with upper GI malignancy by endoscopy, the proportion of patients with cancer among the whole ≤35 years patient group was 0.6% (128/22 011), which suggested that endoscopy, though very cheap in China, may not be the most cost-effective method and other non-invasive, inexpensive screening tools are still needed.…”

“…During the 10 year period investigated, only 2462 patients (2.4% of the whole population) had their H pylori status recorded, and we were not able to investigate the effectiveness of the H pylori ‘test and treat’ strategy. However, because the prevalence of H pylori infection in Shanghai was as high as 66.4% in the general population,18 we suppose that if the C-13-urea breath test had been used, the majority (∼60%) of the included patients would have been diagnosed as H pylori positive, and it is suggested that in areas with a high prevalence of H pylori , the ‘test and treat’ strategy was unlikely to be beneficial 7 11. (4) There were 118 patients who were excluded from the final analysis due to incomplete information, comprising 75 patients with unclear indications for OGDs and the other 43 patients without documented information of age.…”

“…However, studies from areas with a high background prevalence of gastric cancer demonstrated that 0.4–5% of gastric cancers would have been missed if endoscopy had not been offered9 10; another study from Shanghai also suggested both H pylori ‘test and treat’ and ‘test and endoscopy’ strategies are not suitable for the management of patients with uninvestigated dyspepsia 11. Nonetheless, because dyspepsia is so prevalent in the general population, it is impossible to recommend prompt endoscopy for all patients with dyspepsia; therefore, efforts have been made to minimise unnecessary endoscopy by restricting its use to those above a certain age, generally 45–55 years old, or to those who present with alarm features.…”

Rationale in diagnosis and screening of atrophic gastritis with stomach-specific plasma biomarkers

“…This strategy has been criticized in several studies, in particular, from Asia [96,97,98,99]. In these investigations, the H. pylori assay alone is not considered reliable enough to exclude the cancer risk in populations in which the stomach cancer (and H. pylori gastritis or AG) is frequent also among subjects below the age of 45.…”

Cost-effectiveness of and satisfaction with a Helicobacter pylori "test and treat" strategy compared with prompt endoscopy in young Asians with dyspepsia

“…This finding has led many to conclude that a non-invasive approach alone in these populations would risk missing treatable gastric malignancy in a proportion of young adults. Furthermore, one of the studies from Shanghai, China, demonstrated that almost 30% of young adults with gastric cancer were H pylori negative, leading the authors to advocate “prompt endoscopy” for most of their patients 6. However, Asia remains a geographically vast and diverse region, and similar studies on dyspeptics from Southern China have shown that the mean age of patients with gastric cancer at presentation was 54 years 8…”