Occasional viewpoint Search and treat strategy to eliminate Helicobacter pylori associated ulcer disease

Peptic ulcer disease is a serious disorder aVecting many people and carrying substantial morbidity and even mortality as a result of bleeding or perforation. 2 The discovery of Helicobacter pylori as its main aetiological factor is a major breakthrough in gastroenterology. We can cure patients that before were suVering from a chronic recurrent ailment. After curing the infection, H pylori associated ulcers do not recur, nor do ulcer complications. Quality of life improves, use of medication diminishes or stops, and the number of doctor visits, hospital admissions, and absenteeism from work decreases. Curing the infection may even increase life expectancy. Hence treating H pylori infection in ulcer patients is associated not only with improved health but also with significant economic benefits. It was demonstrated that the use of acid suppressants decreases significantly in ulcer patients whereas it usually does not decrease in those with non-ulcer dyspepsia. Some have claimed that reflux symptoms and/or reflux oesophagitis may develop in successfully treated patients. Whether this is a true development of a new disease or merely the unmasking of an already present but occult diathesis is controversial. 9 This possible disadvantage does not outweigh the benefits of curing the infection in this specific ulcer patient group. The major clinical discoveries regarding this infection are well known to general practitioners, internists, gastroenterologists, and microbiologists. Unfortunately, implementation of this new knowledge to the level of actually treating the right patients remains problematic. In general it is hard to change physician behaviour. Many ulcer patients even today are still being treated with chronic or on demand acid suppressants, a therapy now considered obsolete. 12 Vreeburg et al showed that only a minority of patients admitted with an upper gastrointestinal bleed in the Amsterdam area was tested for the presence of H pylori, and few were actually oVered appropriate treatment. Similar disturbing data were published from the USA 14–16 and the UK. But even if the right patients are treated, surveys have shown that many diVerent inappropriate and ineVective treatments are being used. Better outcomes therefore also depend on a more general agreement on how to treat H pylori. We have recently proposed a logical approach to H pylori therapy which combines a regimen based on clarithromycin and one based on metronidazole which, if used consecutively, would come close to the desired 100% cure. Almost 20 years after the discovery of H pylori it is sad to realise that we have failed in treating all patients with chronic (duodenal) ulcer disease. One wonders why. In some countries, organisational problems in the deliverance of proven interventions within the healthcare system have obstructed its appropriate use. Another reason may be that too much attention was given to the role of H pylori infection in non-ulcer dyspepsia. In retrospect, it would have been more sensible to first treat peptic ulcer disease completely and to move forward to other indications only after appropriate studies had shown these indications to be cost eVective targets for treatment. The confusion caused by the controversy in eradication studies of functional dyspepsia has drawn the attention of the medical community away from the only real and proven benefit of Helicobacter therapy. Because we have not been able to eliminate ulcer disease, health authorities and insurance companies have become interested in interventions that may help to reach this goal. They also want to address the rapidly increasing and sometimes inappropriate use of long term acid suppression. 22 In this paper we wish to explore what can be done to eliminate ulcer disease. Success depends on the ability to target the treatment to the appropriate population. An asymptomatic subject with H pylori infection is unlikely to benefit whereas a patient with proven ulcer disease is very likely to benefit from treatment. Studies have shown that the likelihood of finding an ulcer is slightly higher in patients with ulcer-like dyspepsia compared with patients with dysmotility or reflux-like dyspepsia. 24 If in a target population the pretest likelihood for ulcer disease is higher, the treatment is more likely to be cost eVective (fig 1). The essentials of disease management in ulcer disease have been described previously. Here we will focus on ways to implement H pylori therapy for the only group of patients that really needs it: those with proven ulcer disease. Treating other larger groups of subjects only defer us from reaching that goal. The purpose is to search for ulcer patients systematically and treat them. We call this “search and treat” strategy. We will discuss some of the options and results of pilot projects testing such programmes.