To date there is no convincing evidence that empiric eradication of H pylori in patients with NUD improves symptoms. One recent meta-analysis of randomized controlled trials revealed no improvement with H pylori eradication for the symptoms of NUD,29 while 2 others25,30 showed a modest but statistically significant benefit, with 1 patient cured for every 19 treated (number needed to treat = 19).
Prognosis
Without treatment, peptic ulcer disease can lead to serious complications such as gastrointestinal bleeding and cancer. Acid suppression achieves ulcer healing rates of approximately 90%, but is associated with a 10% recurrence rate even with long-term treatment.22 Successful eradication of H pylori in the absence of NSAID use cures ulcer disease in 95% of cases; the recurrence rate is 33% to 41% if eradication is not achieved.14 Reinfection is rare once eradication has been accomplished, with a rate of about 1% per year,31 though rates can be much higher in endemic areas.32 Persistent infection requires re-treatment, ideally with a regimen not previously used, in case of antimicrobial resistance. Persistent gastric ulcers can harbor malignancy and therefore, evaluation with endoscopy might be prudent. H pylori itself is associated with a 2- to 6-fold increase in risk of gastric cancer.33 Widespread screening or treatment to prevent cancer has not been recommended to date. A cost-benefit analysis suggests that the development and distribution of a vaccination for H pylori would be highly cost-effective,34 but such a vaccine is not available as yet.
The prognosis of NUD is more discouraging. NUD is a chronic relapsing and remitting disorder, and treatment responses difficult to measure. For example, one systematic review of the literature found 56% of patients experienced an improvement in symptom scores when given placebo (range 5% - 90%). As with other functional gastrointestinal disorders, underlying psychosocial and lifestyle factors may be involved and must be addressed. Further research is needed in this area, particularly in the primary care setting.
Each Applied Evidence review article considers a common presenting complaint or disease and summarizes the best available evidence for clinicians. The collected reviews are published online at www.jfponline.com. Explanations of the Levels of Evidence can be found at http://cebm.jr2.ox.ac.uk/docs/levels.html.
