Helicobacter pylori and the management of gastro-oesophageal reflux disease
This thesis is centred on the current controversy and possible links between H. pylori and GORD and whether the infection should be eradicated in those requiring long PPIs. The thesis combines three methodologies: systematic reviews to ascertain current knowledge, qualitative research to ascertain the perceptions of GPs regarding this link, and, a cross sectional survey of patients on long term PPIs, including an evaluation of their H. pylori status. The field work was done in Northern England. The findings were:1) Patients with oesophagitis or reflux were less likely to have H. pylori infection. 2) The eradication of H. pylori in patients with duodenal ulcer did not influence the presence or absence of oesophagitis afterwards. The view that eradication provokes oesophagitis was not substantiated. 3) The effect of H. pylori eradication in patients with reflux oesophagitis,without peptic ulcer, was uncertain. 4) GPs held diverse views to justify variations in PPI prescribing. They did not consider a link between H. pylori and GORD and rarely prescribed eradication therapy to such patients. 5) 1. 73% of the population was on long term PPIs, rates varying six fold between practices. Reflux disease was associated with a third of this prescribing. 111 6) Over 66% of patients on long term PPIs had had an upper Gl investigation. However, practices varied widely in their use of endoscopy (33%-82%).7) Virtually all patients on long term PPIs still had ongoing symptoms. 31% were positive for H. pylori and in them, reflux symptoms and quality of life measures were better than those who tested negative. Conclusions A potential link between H. pylori and GORD did not impinge upon decision making in general practice. Current knowledge does not substantiate the view that H. pylori eradication provokes reflux oesophagitis but there are insufficient data about the effect of eradication in patients treated solely for reflux. The widespread variations in PPI prescribing and investigation rates could not be correlated with epidemiological or practice characteristics but it was ascertained that the rate of long term PPI usage was three times than previously determined. Virtually all patients had ongoing symptoms despite PPI use and reflux symptoms and QoL measures were worse in those patients who tested negative. This research does not definitively answer the question whether H. pylori should be eradicated in patients on long term PPIs. However,should this be considered necessary, the size of this task is quantified. Future research centred on therapy in this category of patients is required for a definitive answer.