[Should we take into account Helicobacter pylori infection in a patient with dyspeptic symptoms?]

Dyspepsia is a common disorder that presents many clinical dilemmas in patient management despite progress accomplished in the treatment of acid related diseases with proton pomp inhibitors (PPI) and of ulcer disease with eradication of Helicobacter pylori (Hp) infection. Traditionally, uninvestigated patients presenting with dyspeptic symptoms are subjected to prompt endoscopy. This policy is still required in patients older than 45 years or with risk factors of esophageal and gastric cancer. The present review of the literature suggests that in younger patients with no alarming features, a strategy taking into account Hp infection is safe and cost-effective. The best policy consists in an Hp breath test followed by eradication in Hp+ patients. In Hp- patients, empirical treatment with PPI seems the most efficient strategy. In both cases, endoscopy is required when symptoms persist or rapidly recur. In France, where endoscopy is cheap and its accessibly optimal, prompt endoscopy could still be preferable. In absence of well-conducted controlled studies in our country, it is thus not possible to formally recommend the test-and-treat strategy in the management of uninvestigated dyspepsia. In patients with functional dyspepsia (no lesions detected by endoscopy), review of the literature suggests that the therapeutic benefit of eradicating Hp is, if it exists, of little value. Should we eradicate Hp systematically or only in patients mostly concerned by such benefit (ulcer-like and refractory dyspepsia)? The answer will come from the place of eradication of Hp in the general population for prevention of some gastric cancers.