Presumptive Diagnosis of Peptic Ulcer Disease Often Incorrect

Laurie Barclay, MD

May 30, 2003

May 30, 2003 -- Many patients with presumptive diagnoses of peptic ulcer disease (PUD) who are receiving chronic acid suppression have neither PUD nor Helicobacter pylori (HP) infection, according to the results of an open-label, randomized trial published in the May 26 issue of the Archives of Internal Medicine. The Study of Management and Costs of H pylori Infection (STOMACH) also suggests that a protocol of testing and treating neither reduces symptoms nor saves costs in a large managed care population.

"Guidelines recommend testing and treatment for patients with a history of PUD, assuming that PUD has been documented and that successful HP eradication would eliminate the need for further therapy and medical utilization," write James E. Allison, MD, from the Kaiser Permanente Medical Care Program in Oakland, California, and colleagues. "Most patients receiving long-term acid suppression therapy for physician-diagnosed PUD in community practice settings are likely to have HP-negative, uninvestigated dyspepsia."

Of 650 patients receiving long-term acid suppression therapy for physician-diagnosed PUD, 321 were randomized to test-and-treat (T & T) for HP, and 329 to usual care. Radiography or endoscopy confirmed PUD in only 17% of subjects, and only 38% of the T & T group tested positive for HP.

At 12 months, patients in the T & T group were less likely to report ulcerlike dyspepsia or use of acid-reducing medication, but during the first 12 months, they had higher total acid-peptic-related costs than did the usual care group. During the second half of the 12-month follow-up, however, 75% of the T & T group used acid-suppressing medication.

"Routine testing and treating for HP will not reduce acid-peptic-related costs and have only a modest (though statistically significant) effect in reducing clinical symptoms and use of acid-reducing medications," the authors write. "PUD must be documented by radiography or endoscopy before adopting a strategy of routine testing for and treating of HP infection in patients similar to those in our study. Otherwise, expectations of dramatic symptom reduction and cost savings in these patients as a group may be unfounded."

AstraZeneca supported this study through a grant. Otherwise, the authors report no relevant financial interest in this article.

Arch Intern Med. 2003;163:1165-1171

Reviewed by Gary D. Vogin, MD