Empiric treatment based on Helicobacter pylori serology cannot substitute for early endoscopy in the management of dyspeptic rural black Africans.

BACKGROUND

Evidence that chronic gastric Helicobacter pylori (HP) infection is an aetiological factor in dyspepsia, peptic ulcer disease, gastric carcinoma and lymphoma has led to the suggestion that all serologically positive dyspeptic patients should be treated empirically with antibiotics to eradicate the infection, without endoscopic diagnosis. The following study was performed to determine whether such a policy would prove to be of benefit in rural Africa, where endoscopic facilities are lacking and infection rates high.

METHODS

Four district clinics were visited and 97 consecutive patients with persistent upper gastro-intestinal symptoms studied. After history-taking and physical examination, a blood sample was taken for HP serology (IgG anti-HP EIA) and endoscopy was performed.

RESULTS

In comparison with similar studies in westernised countries HP was considerably more common (80%), and similar to that reported for the background population (83-86%), but peptic ulceration (17%) and gastric cancer (1%) were not. HP status and antibody levels failed to predict the presence of serious disease; patients with 'alarm' signs (78%), cancer (78%) and peptic ulcers (81%) had similar seropositivity rates to patients with non-ulcer dyspepsia (81%). Interestingly, many patients with distal oesophagitis were seronegative (40%). Haemoglobin concentrations and nutritional status were similar in HP-positive and negative patients. On the basis of published decision analysis strategies, empiric treatment of HP-positive patients with uncomplicated dyspepsia could be expected to produce symptomatic relief in 50% of cases, but would have delayed the diagnosis of 3 cases of cancer if patients over the age of 45 were included.

CONCLUSION

The lack of association between HP serology and upper gastro-intestinal disease indicates that serological investigation cannot substitute for endoscopy in the management of black Africans with dyspepsia, and that empiric anti-HP therapy cannot be justified.