There are conflicting studies regarding the role of eradicating Helicobacter pylori in patients with functional dyspepsia. This study described the Helicobacter Eradication Relief of Dyspeptic Symptoms (HEROES) trial as designed to provide a large, randomized, double-blind, placebo-controlled clinical trial to study the effects of H pylori eradiation on the symptomatic responses and quality-of-life of community and primary care patients with functional dyspepsia. Human patients were assigned to receive omeprazole, amoxicillin trihydrate, and clarithromycin or omeprazole plus a placebo for 10 days. Patients returned for follow-up visits after treatments. Upper GI tract endoscopies were performed, and biopsy specimens were taken from the stomach, antrum, and insicura angularis. One biopsy sample from each geographic location was used for a urease test and others were examined histologically. The primary endpoint was the proportion of patients with at least a 50% decrease in the dyspeptic symptoms at 12 months compared with their baseline score. A statistically significant benefit was seen in symptomatic improvement among H pylori–positive functional patients with dyspepsia treated with omeprazole and antibiotics when compared with those treated with omeprazole and placebo antibiotics. No predictors of treatment success were found, which is consistent with the findings of a systemic review reporting little heterogeneity between studies. One important finding was that the long-term benefit lasted at least a year after a 1-to 2-week course of antibiotics. This approach would be cost-effective in patients who are positive for H pylori infection with functional dyspepsia. Eradication of H pylori may reduce inflammation, but the main culprit may be a different unidentified organism. While there is strong evidence that eradicating H pylori is effective in some patients with functional dyspepsia, the challenge is to establish the mechanism underlying this effect.
I have commented previously on articles that provide new knowledge or challenges with regard to H pylori. The organism and its many nuances continue to fascinate me, possibly because I was probably infected as a child and unknowingly lived with it for many years. It was only after the discovery of the organism by Dr. Barry Marshall and the subsequent development of diagnostic tests that I made the connection between my symptoms and possible infection. As a veterinary gastroenterologist, I knew more about this disease than my general practitioner and after educating him I was tested, diagnosed, treated, and cured. In this article, Mazzoleni and colleagues address the putative association between H pylori and functional dyspepsia. This is a relationship that comes as no surprise, but what is more fascinating is the speculation by Moayyedi in the accompanying commentary that the efficacy of antibiotics in H pylori infection may be because we are treating other organisms than H pylori and that this may be the reason for their efficacy in functional dyspepsia. At times like these I am reminded of one of my favorite quotations by the philosopher physician Charcot: “Disease is very old, and nothing about it has changed. It is we who change as we learn to recognize what was formerly imperceptible.” As we move into the new frontiers of One Medicine and more sophisticated diagnostic techniques, this thought becomes ever more relevant.—Colin F. Burrows, BVetMed, PhD, Hon FRCVS, DACVIM
Helicobacter pylori eradication in functional dyspepsia. Mazzoleni LE, Sander GB, Francesconi CFdeM, et al. ARCH INTERNMED 171:1929-1936, 2011.
Helicobacter pylori eradication in functional dyspepsia. What are we treating? Invited commentary. Moayyedi P. ARCH INTERNMED 171:1936-1937, 2011.