Why is it necessary to detect and eradicate Helicobacter pylori before diagnosing functional dyspepsia?

It is only for reference by medical professionals.
Pay attention to the role of Helicobacter pylori eradication in the management of functional dyspepsia.

Functional dyspepsia (FD) is a common functional gastrointestinal disease [1], with a high incidence, with a prevalence of 10% to 30% in the population, accounting for about 40% of visits to digestive tract diseases.
%[2].

Although FD is very common, its etiology and pathogenesis have not been fully elucidated.
Among them, the status of Helicobacter pylori (Hp) infection in the pathogenic factors of FD is still unclear.

However, the 2005 American Gastroenterology Association's dyspepsia management evaluation report pointed out: Overall, the established efficacy (compared with placebo treatment) in FD treatment is the eradication of Hp and acid suppression treatment [3].

 Therefore, people cannot help but wonder, why should Hp eradication treatment be recommended for FD patients under the premise of uncertainty about the correlation between Hp and FD? To answer this question, we must first understand the changes in the basic concepts of dyspepsia, so as to help correctly understand the application of Hp eradication in the treatment of dyspepsia.

 In the early years, according to the Rome III criteria for functional gastrointestinal diseases released in 2006 [4], dyspepsia refers to a group of symptoms manifested as pain or burning in the upper abdomen, fullness of the upper abdomen after a meal, and early satiety.

Indigestion can be divided into uninvestigated indigestion and indigestion that has been investigated.

The dyspepsia that has been investigated is divided into organic dyspepsia, including: peptic ulcer, gastroesophageal reflux disease, upper gastrointestinal tumor, biliary tract disease, pancreatic disease, food or drug intolerance and FD.

It should be noted that the FD referred to here is a broad concept, which does not exclude chronic gastritis and Hp infection (Figure 1).

 Figure 1: Classification of past dyspepsia 1 Why can FD not rule out chronic gastritis? Chronic gastritis emphasizes the histological changes of the gastric mucosa, and most patients (75%-85%) have no symptoms of dyspepsia [5]; while FD emphasizes the symptoms of dyspepsia, and some patients may not have chronic gastritis.

 2Why didn't Hp infection be ruled out in the early diagnosis of FD? Most people with Hp infection have no symptoms of dyspepsia, and those without Hp infection can also have symptoms of dyspepsia.
Therefore, the causal relationship between Hp infection and dyspepsia is questionable, and it is impossible to judge FD based on the presence or absence of dyspeptic symptoms.
Whether the patient has Hp infection.

 In 2015, the Kyoto Global Consensus on Helicobacter Pylori Gastritis[6] proposed the concept of upper gastrointestinal endoscopy to clarify Hp-related dyspepsia.

The consensus points out that after eradication treatment, if the patient's symptoms improve and continue to relieve for 6 to 12 months, it is considered to be Hp-related dyspepsia; if the patient's symptoms do not improve, it is called FD.

If the patient's symptoms are improved in a short time after eradication treatment, but the symptoms recur within 6 months, it is also called FD.

 In this way, the original broad classification of FD should be changed accordingly, and Hp-related dyspepsia should be classified as organic dyspepsia.

 3Why do we need to detect and eradicate Hp before diagnosing FD? Our consensus recommendation [3], before making a reliable diagnosis of FD, Hp-related dyspepsia must be ruled out.

To implement this strategy, the clinician first needs to detect whether the patient has Hp infection, and those who are positive are treated for eradication; the patients whose symptoms are significantly improved after Hp eradication and long-term (>6 months) remission are attributed to Hp-related digestion Bad, these patients no longer belong to FD.

Therefore, for clinicians to make a clear diagnosis of FD, Hp must be detected and eradicated.

 4Hp "detection and treatment", a cost-effective treatment strategy for dyspepsia For patients with Hp-positive dyspepsia, eradication treatment is the most economical and effective method, because one treatment can achieve long-term results.

The Rome IV standard for functional gastrointestinal disease also accepts the above viewpoints [7].

The Kyoto consensus recommends eradication of Hp as the first-line treatment for dyspepsia, because this strategy is not only relatively effective, but also can prevent peptic ulcer and gastric cancer and reduce the source of infection.

 However, in my country in the 1990s, the standard triple scheme Hp eradication rate was as high as 90% or more [8], but even if the bismuth-containing quadruple program is now applied, the eradication rate fluctuates between 70% and 85%.
It is difficult to achieve a satisfactory effect of more than 85% [9]; in contrast to my country, the eradication rate of Hp in Japan has gradually increased from 78.
5% in 2015 to 90.
1% in 2018 [10].

 Therefore, the current Hp eradication treatment still has unmet clinical needs.

A good eradication program should achieve the goal of eradication rate >90% [11], among which adequate acid suppression treatment is essential for the eradication of Hp.

Studies have shown that the activity of Hp is affected by the pH value in the stomach.
When the pH is 4-6, Hp can survive but cannot reproduce; and when the pH is 6-8, Hp is in a reproductive state, only at this time.
, Antibiotics can eradicate it.

Another study also showed that when the 24-hour median pH>6 [12-14], most patients can be successfully eradicated, regardless of whether Hp is sensitive to clarithromycin.

 The current PPI is difficult to achieve the best acid suppression effect [15-16], which is one of the reasons that affect the Hp eradication rate in my country.

Therefore, the application of drugs that can better meet the ideal acid suppression standards in the future will have a significant effect on improving the efficacy of antibacterial drugs and increasing the eradication rate of Hp.

It can greatly reduce the burden of chronic gastritis, gastric cancer and other related diseases caused by Hp infection, which is of great significance for both the individual patients and the society.

 Recommendations in the past: A review: 6 clinical issues related to Helicobacter pylori eradication, screening and eradication of H.
pylori to prevent gastric cancer, the global consensus interpretation is here! For important recommendations, see the references here: [1] Editor-in-Chief Fan Xiaoming.
"Acid-Related Diseases".
Fudan University Press, Shanghai.
2011.
[2] Wang Ying.
Research on the correlation between functional dyspepsia and Helicobacter pylori infection[J].
Chinese Journal of Nosocomial Infection.
2011; 21(13): 2748-2749.
[3] Helicobacter pylori and peptic ulcer group of the Digestive Diseases Branch of the Chinese Medical Association, et al.
The fifth national consensus report on the management of Helicobacter pylori infection [J].
Chinese Journal of Digestion.
2017; 37(6): 364-378.
[4]Drossman DA.
The functional gastrointestinal disorders and the Rome III process[J].
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Helicobacter pylori infection, chronic gastritis and functional dyspepsia[J].
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[6]Sugano K, Tack J, Kuipers EJ, et al.
Kyoto global consensus report on Helicobactor pylori gastritis [J].
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[7]StanghelliniV, ChanFK, HaslerWL, et al.
Gastroduodenal disorders [J].
Gastroenterology, 2016,150 (6):1380-1392.
[8]Liu Wenzhong, Xiao Shudong.
Efforts to improve the eradication rate of Helicobacter pylori[J].
Chinese Journal of Internal Medicine, 2009, 048(008):620-622.
[9]Zhang Jianzhong.
Helicobacter pylori in China The status of low eradication rate of bacteria in treatment and countermeasures[J].
Journal of Gastroenterology and Hepatology, 2017, 26(6): 637-639.
[10]Mori H, et al.