Testing for Helicobacter pylori in dyspeptic patients suspected of peptic ulcer disease in primary care: Cross sectional study

Objectives: To develop an easily applicable diagnostic scoring method to determine the presence of peptic ulcers in dyspeptic patients in a primary care setting; to evaluate whether Helicobacter pylori testing adds value to history taking. Design: Cross sectional study. Setting: General practitioners' offices in the Utrecht area of the Netherlands. Participants: 565 patients consulting a general practitioner about dyspeptic symptoms of at least two weeks' duration. Main outcome measures: The presence or absence of peptic ulcer; independent predictors of the presence of peptic ulcer as obtained from history taking and the added value of H pylori testing were quantified by using multivariate logistic regression analyses. Results: A history of peptic ulcer, pain on an empty stomach, and smoking were strong and independent diagnostic determinants of peptic ulcer disease, with odds ratios of 5.5 (95% confidence interval 2.6 to 11.8), 2.8 (1.0 to 4.0), and 2.0 (1.4 to 6.0) respectively. The area under the receiver operating characteristic curve (ROC area) of these determinants together was 0.71. Adding the H pylori test increased the ROC area only to 0.75. However, in a group of patients at high risk, identified by means of a simple scoring rule based on history taking, the predictive value for the presence of peptic ulcer increased from 16% to 26% after a positive H pylori test. Conclusions: In the total group of dyspeptic patients in primary care, H pylori testing has no value in addition to history taking for diagnosing peptic ulcer disease. In a subgroup of patients at high risk of having peptic ulcer disease, however, it might be useful to test for and treat H pylori infections. In primary care, predicting the presence of peptic ulcer disease in dyspeptic patients on the basis of history taking is difficult Infection with Helicobacter pylori is associated with peptic ulcer disease Many non-invasive H pylori tests are available, but the value they add to history taking is not known Three simple questions from history taking can distinguish between patients at high and low risk of peptic ulcer disease In uninvestigated patients with dyspepsia in primary care, H pylori testing adds nothing to optimal history taking in the diagnosis of peptic ulcer disease In patients at high risk of peptic ulcer disease it is useful to test for and treat H pylori infection.