Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Review: Successful Helicobacter pylori eradication prevents ulcer recurrence

ACP J Club. 1999 May-June;130:63. doi:10.7326/ACPJC-1999-130-3-063


Source Citation

Laine L, Hopkins RJ, Girardi LS. Has the impact of Helicobacter pylori therapy on ulcer recurrence in the United States been overstated?A meta-analysis of rigorously designed trials. Am J Gastroenterol. 1998 Sep;93:1409-15.


Abstract

Question

In North American patients with duodenal ulcers that are healed after Helicobacter pylori-eradication treatment, do ulcers recur less often in those without H. pylori infection than in those with persistent infection after treatment?

Data sources

Studies were identified by searching MEDLINE (from 1983) with the terms pylori or pyloridis, ulcer, treatment, eradication, recurrence, and double-blind; annual meeting abstracts; and bibliographies of relevant papers. Investigators and pharmaceutical manufacturers were also contacted.

Study selection

Published and unpublished studies were selected if they were randomized, double-blind trials of H. pylori-eradication treatment; used regularly scheduled endoscopy during ≥ 6 months of follow-up; and involved patients who did not use nonsteroidal anti-inflammatory drugs and who had duodenal ulcers that were healed after H. pylori-eradication treatment.

Data extraction

Reviewers independently extracted data on type of publication, medication type and dosage, and criteria for H. pylori care; they resolved disagreements by consensus. Missing data and updated results were obtained from and ambiguous data were clarified by trial investigators.

Main results

7 North American studies involving 989 patients met the inclusion criteria. 1 study was published in a peer-reviewed journal, 4 were published in 3 abstracts, and 2 were unpublished. 4 studies were placebo-controlled. All studies tested 2-week dual therapy for eradicating H. pylori (2 studies used omeprazole plus clarithromycin, 2 used ranitidine bismuth citrate [RBC] plus amoxicillin, 2 used RBC plus clarithromycin, and 1 used omeprazole plus amoxicillin). After treatment, 414 of 619 patients with healed ulcers tested positive for H. pylori (placebo [ n = 21], monotherapy [ n = 316], and dual therapy [ n = 77]). Ulcer recurrence was assessed at up to 24 weeks in 6 studies and 28 weeks in 1 study. Fewer patients without H. pylori infection had ulcer recurrence than did those with persistent H. pylori infection after treatment { P < 0.001}* (Table). 20% (unweighted rate) of H. pylori-negative patients had ulcer recurrence within 6 months.

Conclusions

In patients with healed duodenal ulcers after Helicobacter pylori-eradication treatment, patients without H. pylori infection have fewer ulcer recurrences than do those with persistent infection. H. pylori eradication does not preclude ulcer recurrence in H. pylori-negative patients.

Source of funding: Not stated.

For correspondence: Dr. L.A. Laine, GI Division, Department of Medicine, University of Southern California School of Medicine, 2025 Zonal Avenue, Los Angeles, CA 90033, USA. FAX 214-857-1571.

* P value calculated from data in article.


Table. Successful H. pylori eradication vs persistent infection after treatment†

Outcome at 24 to 28 weeks Weighted event rates RRR (95% CI) NNT (CI)
H. pylori-negative H. pylori-positive
Ulcer recurrence 18% 56% 63% (50 to 73) 3 (3 to 4)

†Abbreviations defined in Glossary; RRR, NNT, and CI calculated from data in article.


Commentary

Recognition of the importance of H. pylori in the pathogenesis of duodenal ulcer led to the expectation that eradication of the infection would cure the disease. Indeed, the initial studies done outside of the United States showed a recurrence rate as low as 2% at 6 months after successful treatment (1). This contrasts sharply to the 18% recurrence rate in this meta-analysis of U.S. studies. What accounts for the higher prevalence of H. pylori-negative duodenal ulcers?

The authors speculate that the differences may reflect variations in physiologic variables, such as acid secretion, but it seems unlikely that acid secretion in U.S. patients would differ substantially from that in patients in western Europe, where many of the earlier studies were done. Another explanation is the surreptitious use of nonsteroidal anti-inflammatory drugs in U.S. patients (2). The bottom line is that eradication of H. pylori is a very effective therapy for duodenal ulcer but, at least in the United States, does not produce a universal cure. Clinicians thus need to be aware that, despite successful eradication of H. pylori, a substantial proportion of patients with ulcer may continue to require long-term acid suppression medications to control symptoms or prevent recurrent hemorrhage.

Walter L. Peterson, MD
The University of Texas Southwestern Medical Center at DallasDallas, Texas, USA


References

1. Hentschel E, Brandstatter G, Dragosics B, et al. Effect of ranitidine and amoxicillin plus metronidazole on the eradication of Helicobacter pylori and the recurrence of duodenal ulcer. N Engl J Med. 1993;328: 308-12.

2. Lanas AI, Remacha B, Esteva F, Sainz R. Risk factors associated with refractory peptic ulcers. Gastroenterology. 1995;109:1124-33.