Consensus guidelines: agreement and debate surrounding the optimal management of Helicobacter pylori infection

Helicobacter pylori is a recognized cause of a variety of gastroduodenal pathology. The high prevalence of both H pylori infection and related diseases within the community warrants its consideration as a public health care issue. The availability of reliable and safe noninvasive diagnostic techniques coupled with the development of effective and tolerable treatments has enabled primary health care personnel to manage this infection actively. The role of the primary care physician in the future management of H pylori infection is thus of central importance. The wealth of evidence produced by over 15 years of research into H pylori has expanded the list of disease associations and treatment benefits as well as elucidated the pathophysiological mechanisms involved. As a result, there has been a growing need to harmonize this information with clinical practice and to provide direction for the appropriate management by both specialists and general practitioners. Several national guidelines have been produced. The areas relating to H pylori infection that they considered and their recommendations vary. In 1994, the National Institutes of Health produced globally accepted recommendations for the management of H pylori-related peptic ulceration. The broader role of H pylori as a gastroduodenal pathogen and a public health care issue was not addressed. Recently, European and Canadian consensus guidelines have been published that identified overall management issues, including the role of primary and specialist care, and considered the appropriateness of employing eradication therapy for the spectrum of conditions in which H pylori has a direct or indirect association based on the available information. These guidelines, while in agreement regarding many issues, differ considerably in their recommendations for primary health care and regarding central issues such as the management of dyspepsia and gastric cancer. Some variations may reflect differing health care structures as well as the prevalence of both infection and associated diseases. However, the interpretation of evidence produced by recent research contributes to their conflicting statements.