Ivan Jovanovic, Tomica Milosavljevic, Milenko Ugljesic, Dragan Popovic, Miodrag Krstic, Predrag Dugalic, Srdjan Djuranovic, Milan Spuran, Nada Kovacevic, Marjan Micev and Mirko Bulajic

Institute of Digestive Diseases, Clinical Center of Serbia, Belgrade

Address correspondence to:

Dr Ivan Jovanovic

Institute of digestive diseases- Clinical Center of Serbia

6 Koste Todorovic street

11 000 Belgrade, Yugoslavia

Tel: (+381) 11 361 47 44;Fax: (+361) 11 361 54 32; (+361) 18 96 53

E-mail: [email protected]

Abstract

It has been remarkably difficult to confirm or to reject an association between Helicobacter pylori induced gastritis and symptoms of dyspepsia. Even more difficult is to define symptom pattern specific to the Helicobacter pylori infection. 

The aim of our study was to investigate whether symptom cluster (reflux-like, ulcer-like and dysmotility-like) can be useful in describing Helicobacter positive and negative functionaldyspepsia.

We prospectively investigated, using questionnaire, 64 consecutive dyspeptic patients (41 Helicobacter pylori positive and 23 Helicobacter pylori negative) for the symptoms of dyspepsia. According to the symptom clusters, patients were divided into the following subgroups: ulcer-like, reflux-like, dismotility-like and non-specific dyspepsia.

In the Helicobacter positive group of patients, ulcer-like symptoms were more frequent, but there was no significant difference observed comparing to the other three groups. In the Helicobacter pylori negative group of patients, dismotility like symptoms were more frequent, but this was also not of the significant value.

In the conclusion, we must say that symptom clusters are not helpful in diagnosis either Helicobacter pylori positive or Helicobacter pylori negative functional dyspepsia.

Key words: Helicobacter pylori, dyspepsia, dyspepsia subgroups, and symptom cluster

Introduction

Relationship between Helicobacter pylori positive gastritis and symptoms of dyspepsia still remains controversial. Moreover, it is questionable, whether, if Helicobacter pylori causes dyspeptic complains, there is specific pattern of symptoms. 

There has been some suggestions that Helicobater pylori positive dyspeptic patients resemble more often patients suffering from ulcer disease (ulcer like dyspepsia) than other disorders (dysmotility and reflux like dyspepsia) (1-4). Variations in definitions of dyspepsia, lack of validation in the scoring system, unclear end-points, short follow up make interpretation of the available data difficult (5). 

Trend in investigating dyspepsia is to exclude reflux like dyspepsia since in most cases gastroesophageal reflux diseases could be diagnosed either during endoscopy examination or using 24 hours pH-metry (6). 

It would be extremely useful if, in clinical practice, dyspeptic patients could be divided into simple subgroups as a base for certain management. This would not only be helpful in diagnosis dyspepsia, but also would affect endoscopy load and cost-and –effectiveness of different treatment régime. 

The aim of our study was to investigate whether symptom cluster (reflux-like, ulcer-like and dismotility-like) can be useful in describing Helicobacter positive and negative functionaldyspepsia. 

Material and methods

We prospectively investigated, using questionnaire, 64 consecutive patients for the dyspeptic complains (table 1). Patients demographic data are given in table 2. Duration of the symptoms was taken into account (>6 months). According to the symptom present, patients were divided into the following dyspepsia subgroups (table 3).

All patients underwent upper GI endoscopy. Exclusion criteria were the presence of any macroscopic abnormality in the esophagus, stomach or duodenum and a history of prior peptic ulcer disease. 

Antral and corpus biopsy specimens were studied for the presence of Helicobacter pylori in the terms of histology and rapid ureasa test. 

Forty one (64%) patient were Helicobacter pylori positive and twenty-three (36%) were Helicobacter pylori negative.

Results

In the Helicobacter positive (HP+) patients only 5 (12.2%) had pure reflux-like dyspepsia, 17 (41.5%) had pure ulcer-like dyspepsia and 10 (24.4%) suffered from pure dismotility-like dyspepsia. 

In the Helicobacter negative (HP-) group of patients 1 (4.3%) patient had symptoms mimicking gastroesophageal reflux disease, 4 (17.4%) had symptoms of ulcer disease and 13 (56.5%) had dismotility-like dyspepsia complains (Table 3).

Testing within the Helicobacter pylori positive group of dyspeptic patients, show no significant differences between different symptom patterns (Table 4).

Similar results were evident in Helicobacter pylori negative group of patients (Table 5). 

Discussion

Many investigators have studied dyspeptic patients and healthy controls with or without evidence of Helicobacter pylori infection, in attempt to identify specific Helicobacter pylori related symptoms. In most cases this was an unrewarded attempt, since symptom clusters did not show any discriminate value (7-9). When identified, the putative Helicobacter related symptoms differed greatly between the studies (Table 6).

A major problem is that dyspepsia is not disease entity. The term dyspepsia encompasses a variety of symptoms and symptom clusters that could reflect diversity of potential underlying diseases. Symptoms of dyspepsia can be non-specific or misleading. Wide spectrum of very well defined conditions can be presented with symptoms of dyspepsia. Furthermore, symptoms are often modified by the patient expectation, prior life situation, and ethnic background, taken medications and sometimes, doctors themselves. The subjectivity of the different origin could be overcome by use of objective symptom scales (3). 

According to our results, there is no pathognomonic group of symptoms related to the Helicobacter pylori positive dyspeptic patients, even though, they frequently resemble patients suffering from peptic ulcer disease. 

On the contrary, dysmotility like symptoms occur more often within Helicobacter pylori negative group of patients, suggesting specific pathophysiological mechanism underlying, but this is also not of the significant value. It has been assumed for the very long time that motility disorder can be detected in at least group of dyspeptic patients (14-18). Since symptoms like nausea, early satiety, postprandial bloating and belching could originate form intestinal motility disorder this population should be the target for further functional investigation.

Conclusion

It is not possible to identify patients suffering from Helicobacter infection on the basis of symptom clusters. 

More often they are presented as patient suffering from ulcer disease, but this is not of significant value.

It can be argued that this is not of importance anymore since Helicobacter pylori is a known pathogen and a recognized carcinogen. Based on these arguments eradication of Helicobacter pylori in positive dyspeptic patients seems to be inevitable regardless of whether or not complaints are due to the infection.

Table 1. Dyspepsia subgroups

Table 2. Demographic characteristics of dyspeptic patients

 

	HP +	HP-	Total
Patients	41	23	64
Sex (M:F)	25:16	8:15	33:31
Age (years + SD)	50.3 + 14.48	39.0 + 17.84	46.2 + 16.55
Smokers	15 (36.6%)	5 (21.7%)	20 (31.3%)
Alcohol drinkers	9 (23.1%)	3 (14.3%)	12 (20%)

Table 3. Distribution of dyspepsia subgroups in H.pylori positive and negative patients

 

	HP+		HP-		Total
	N0	%	N0	%	N0	%
Dismotility like dyspepsia (DLD)	10	24.4	13	56.5	23	35.9
Ulcer-like dyspepsia (ULD)	17	41.5	4	17.4	21	32.8
Reflux-like dyspepsia (RLD)	5	12.2	1	4.3	6	9.4
Non-specific	9	22.0	5	21.7	14	21.9
Total	41	100.0	23	100.0	64	100.0

Table 4. Symptom cluster associated with Helicobacter pylori infection

 

	HP+
	True value	Expected value	c2	P
Dismotility like dyspepsia (DLD)	10	10
Ulcer like dyspepsia (ULD)	17	11	3.01	P>0.05
Reflux like dyspepsia (RLD)	5	10
Non specific	9	10
Total	41	41

Table 5. Symptom cluster in Helicobacter pylori negative patients

Table 6. Symptoms associated with Helicobacter pylori infection in published studies

 

Reference	Number of patient	Helicobacter pylori associated symptoms
Marshall (10)	65	“burping”
Rokkas (11)	55	bloating
Tucci (12)	45	Epigastric pain, burning
Sobala (7)	186	-
Goh (8)	71	-
Deltenre (13)	200	Ulcer-like symptoms

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