Correspondence

Treatment of Helicobacter pylori Infection

N Engl J Med 1996; 335:1843-1844December 12, 1996

Article

To the Editor:

I enjoyed seeing the excellent photomicrograph of Helicobacter pylori provided by Genta and Graham in Images in Clinical Medicine (July 25 issue).1 They describe a 35-year-old man with a duodenal ulcer who received triple therapy with omeprazole, clarithromycin, and metronidazole for two weeks. Why did the patient undergo endoscopy eight weeks later, as well as a urea breath test? Documentation of the eradication of H. pylori is not currently warranted in clinical practice.2 The best evidence of a cure is the absence of recurrent symptoms of an ulcer. I suspect that the patient was enrolled in a therapeutic study. If this was the case, it should have been mentioned.

Klaus E. Mönkemüller, M.D.
University of Alabama at Birmingham, Birmingham, AL 35294

2 References

1. 1

   Genta RM, Graham DY. Helicobacter pylori in a gastric pit. N Engl J Med 1996;335:250-250
   Full Text | Web of Science | Medline

2. 2

   Walsh JH, Peterson WL. The treatment of Helicobacter pylori infection in the management of peptic ulcer disease. N Engl J Med 1995;333:984-991
   Full Text | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: The gastric-biopsy specimen was from a patient who participated in a study designed to compare the reliability of the urea breath test with that of the histologic examination for the detection of H. pylori infection. We did not mention this in the description of our photomicrograph because we view the Images in Clinical Medicine section as a vehicle for illustrating particularly attractive visual aspects of medicine rather than as a forum for the dissemination of diagnostic or therapeutic opinions.

We take exception to Dr. Mönkemüller's statement, “The best evidence of a cure [of H. pylori infection] is the absence of recurrent symptoms of an ulcer.” Although this strategy may be the cheapest one, it may not be the best. Patients with ulcers in whom a combined regimen consisting of an antibiotic and a proton-pump inhibitor has failed to eradicate H. pylori may still have prolonged relief of symptoms, and the ulcer may then recur with a classic presentation or, in some patients, with a catastrophic event, such as an upper gastrointestinal hemorrhage. The possibility of such consequences should be a factor in the equation used to assess the cost effectiveness of a procedure or a test.

We do not believe that post-treatment upper endoscopic examinations or urea breath tests are needed in all patients, but using a reliable and relatively inexpensive noninvasive test such as the urea breath test may be better than letting treatment failures announce themselves catastrophically.

Robert M. Genta, M.D.
David Y. Graham, M.D.
Veterans Affairs Medical Center, Houston, TX 77030