Common-sense management of Helicobacter pylori-associated gastroduodenal disease. Personal views

We have tried to present a rational approach to the medical treatment of peptic ulcer disease and nonulcer dyspepsia in the era of H. pylori. We are aware that the natural history of peptic ulcer disease is still debated. Some clinicians believe that peptic ulcer disease may "burn out" over a 10- to 15-year period, and in light of this, the emphasis toward a nonsurgical "cure" for peptic ulcer disease may seem misguided. Yet, all factors must be taken into account. Current medical therapy has demonstrated inadequacies. H. pylori is unequivocally (in our view) associated with peptic ulcer disease. Anti-H. pylori therapy has proven efficacy in the long-term prevention of peptic ulcer recurrence. Despite our enthusiasm for treatment of H. pylori in select circumstances, we encourage further controlled clinical trials to better delineate the role of H. pylori in the natural history and treatment of peptic ulcers. The association between H. pylori and nonulcer dyspepsia is tenuous at best. Treatment directed at eradicating H. pylori in nonulcer dyspepsia does not impress us favorably. We are intrigued by preliminary data that, despite a lack of improvement in the short term, H. pylori eradication in nonulcer dyspepsia patients may reduce symptoms over the long term. Unfortunately, this study suffers methodologic difficulties. If other studies were to confirm these findings, this would provide a cogent reason for us to reassess our views on the treatment of H. pylori in nonulcer dyspepsia. At present, the costs, benefits, and risks of anti-H. pylori therapy in nonulcer dyspepsia are not sufficient to warrant its use outside of therapeutic trials.