Helicobacter pylori test-and-eradicate versus prompt endoscopy for management of dyspeptic patients: a randomised trial

Background Strategies based on screening for Helicobacter pylori to manage dyspeptic patients in primary care have been proposed, but the clinical consequences are unclear. We did a randomised trial to assess the efficacy and safety of a test-and-eradicate strategy compared with prompt endoscopy in the management of patients with dyspepsia. Methods 500 patients presenting in primary care with dyspepsia (≥2 weeks of epigastric pain, no alarm symptoms) were assigned H pylori testing plus eradication therapy or endoscopy. Symptoms, quality of life, patientsʹ satisfaction, and use of resources were recorded during 1 year of follow-up. Findings 250 patients were assigned test-and-eradicate, and 250 prompt endoscopy. The median age was 45 years and 28% were H pylori infected. 1 year follow-up was completed by 447 patients. We found no differences in symptoms between the two groups (median registered days without dyspeptic symptoms=0·63 [IQR 0·27–0·81] in the test-and-eradicate group vs 0·67 [0·36–0·86] in the prompt endoscopy group; mean difference 0·04 [95% Cl-0·01–0·10], p=0·12). Nor did we find any difference in quality of life or numbers of sick-leave days, visits to general practitioners, or hospital admissions. In the test-and-eradicate group, 27 (12%) of the patients were dissatisfied with management, compared with eight (4%) in the endoscopy group (p=0·013). After 1 year, the use of endoscopies in the test-and-eradicate group was 0·40 times (95% Cl 0·31–0·51) the use in the endoscopy group, the use of H pylori tests increased by a factor of 8·1 (5·7–13·1), the use of eradication treatments increased by a factor of 1·5 (0·9–2·7), and the use of proton-pump inhibitors was 0·89 (0·59–1·33) times the use in the endoscopy group. 43 (91% [80–98%]) of 47 peptic-ulcer patients would have been identified by endoscopy or treated by eradication therapy. Interpretation A H pylori test-and-eradicate strategy is as efficient and safe as prompt endoscopy for management of dyspeptic patients in primary care, although fewer patients are satisfied with their treatment.