Before the 1980s, the prevailing belief was that ulcers were caused by stress, spicy foods, and other noninfectious factors. By 1994, however, approximately 90% of primary care physicians and gastroenterologists were aware of the etiologic association between H. pylori and PUD.
The differential diagnosis for H. pylori-associated dyspepsia includes PUD, gastroesophageal reflux disease (GERD), nonulcer dyspepsia, biliary tract disease, pancreatitis, and cancer. Once the likelihood of biliary tract disease, pancreatitis, and cancer is judged to be low, based on history and the age of the patient (cancer is rare in patients under the age of 50) and the use of NSAIDs has been stopped or ruled out, consideration of H. pylori-associated ulcer disease is necessary. If the patient apparently has a history suggestive of ulcer disease on history-taking and physical examination, testing for H. pylori infection is appropriate. No laboratory test, however, can reliably distinguish between PUD and other causes of dyspepsia, and some patients have more than one disease concurrently (i.e., PUD and GERD). Unless the patient has classic heartburn (suggesting GERD), there are no findings on history-taking or physical examination that reliably distinguish PUD from GERD.
Alarm symptoms and signs that raise the suspicion of upper GI carcinoma and indicate the need for upper GI endoscopy include: dysphagia, GI bleeding, new-onset symptoms after the age of 50 years, unexplained anemia or weight loss, and severe vomiting.
H. pylori status should be established in symptomatic patients younger than 50 years of age who are otherwise healthy and have no warning signs or symptoms that suggest the need for endoscopy. If the test result is positive, an anti-H. pylori treatment regimen should be initiated; if the test result is negative and symptoms persist, further evaluation may be required.
Peptic ulcer disease and GERD may coexist in the same patient, although the two diseases are not causally related. Empiric treatment for GERD with an H2-receptor antagonist or proton pump inhibitor is acceptable. In contrast, a prerequisite to treatment for H. pylori infection is a positive result on diagnostic testing (i.e.,HpSA ® ) for the organism. Without confirmation of H. pylori activity, antibiotics should not be given.