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A 43-year-old man is evaluated for a 1-year history of upper epigastric discomfort that occurs once every other month and lasts for 2 to 3 weeks without progression in severity. He describes the discomfort as a gnawing, mild pain that waxes and wanes and is associated with mild nausea and, occasionally, bloating. His history is negative for changes in stool patterns, NSAID use, weight loss, or tobacco use. He drinks alcohol occasionally and has no risk factors for alcohol misuse.
The physical examination is unremarkable, including rectal examination, complete blood count, and fecal occult blood testing.
Which of the following is the most cost-effective initial step in the management of this patient?
A Helicobacter pylori infection testing and treatment
B Upper endoscopy
C Empiric H. pylori eradication therapy
D Double-contrast barium meal
E Proton-pump inhibitor
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A- breath test and triple antibiotics
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~ Correct Answer .................... A
This patient has nonspecific dyspepsia, of which there are a limited number of causes and for which the clinical history does not accurately distinguish between organic and functional (or nonulcer) dyspepsia. In patients without alarm symptoms suggestive of serious disease (age of onset >50 years, anemia, weight loss, and positive fecal occult blood testing results), one decision analysis concluded that a œtest-and-treat approach using urea breath testing (UBT) (or serum Helicobacter pylori antibody testing if UBT is not available) followed by H. pylori eradication in patients with positive results, was the most cost-effective strategy to produce a symptomatic cure compared with initial endoscopy, double-contrast barium, empirical eradication therapy, or empirical antisecretory therapy.
This analysis was sensitive to the efficacy of eradication therapies for H. pylori infection in patients with nonulcer dyspepsia. A meta-analysis of the effect of eradicating H. pylori in patients with nonulcer dyspepsia showed a small effect (9% relative risk reduction) on persistent symptoms.
Endoscopy would be an appropriate initial strategy for patients with warning signs of a more serious underlying condition but is too costly as an initial step for use in all patients with dyspepsia.
Double-contrast barium imaging does not facilitate evaluation for H. pylori, which is responsible for many cases of dyspepsia for which a cure is available.
Although empiric acid suppression, particularly with a proton pump inhibitor (PPI), would lead to symptomatic improvement in this patient, lifelong therapy would be required in many patients who might otherwise be cured with a simpler, short-term H. pylori eradication regimen.
An empirical trial of acid suppression with a PPI for 4 to 8 weeks may be an initial option in situations in which the prevalence of H. pylori infection is low (
