Helicobacter pylori: criminal or innocent bystander?

Most patients with peptic ulcer disease are infected with Helicobacter pylori. However, the infection may not be always causative for the disease. The prevalence of H. pylori infection is about 50% in general. Therefore, half of the patients with peptic ulcer could be infected with this microorganism just by chance. In such cases, H. pylori may do nothing for the ulcer, although it causes chronic active gastritis. This could be the reason for the existence of both H. pylori-positive nonrecurring ulcers and ulcers that recur even after cure of H. pylori infection. H. pylori-positive non-recurring ulcers should be included in non-H. pylori ulcer disease in addition to H. pylori-negative ulcers. NSAIDs are the major cause of H. pylori-negative ulcers, especially H. pylori-negative gastric ulcers. However, more than 10% of ulcers recurred even after cure of H. pylori infection in nonusers of NSAIDs in a 7-year follow-up study. In the same study, 46% of ulcers did not recur in patients in whom eradication of H. pylori failed. There are few (<5%) H. pylori-negative ulcers; about 10% of ulcers recur after cure of H. pylori infection, and about 40% of H. pylori-positive ulcers do not recur. These are all non-H. pylori ulcers, and they represent 30% of all ulcers, which is the general prevalence rate for nonulcer subjects. Therefore, H. pylori may be an innocent bystander in approximately one third of all ulcer patients.