Letter to the Editor
February 2022
The Less Expensive Test to Diagnose Helicobacter Pylori Eradication
By
Rinaldo Pellicano
Affiliations
- Unit of Gastroenterology, Molinette-SGAS Hospital, Turin, Italy
doi: 10.29271/jcpsp.2022.02.266
Sir,
I have read with great interest the original article by Butt et al., who reported that in patients with non-malignant gastroduodenal lesions, concomitant therapy permitted a higher Helicobacter pylori (H. pylori) eradication than triple therapy, based on esomeprazole, amoxicillin, and chlarithromycin. The outcome was assessed by histology. The authors explained that this diagnostic strategy should be less expensive than urea breath test (UBT) or fecal antigen test in free endoscopic services dedicated to poor patients.1
Regarding the later point, I have a comment. The methods used to diagnose H. pylori infection, before or after antibiotic treatment, are defined as invasive or non-invasive. The former is based on endoscopy with biopsy sampling.2 When endoscopy is not mandatory, UBT should be the best choice, with high cost-effectiveness, if performed in facilities with high burden of tests.3 When this is not possible, the fecal antigen test could be the most appropriate alternative option.4 Recently, it has been reported that in Greece, the cost of UBT is 30.36 Euros, versus 104.76 of endoscopy plus biopsy.5 Hence, it should be of great interest to know on which data is based the consideration that endoscopy is less expensive in the above reported service.1
Conflict of Interest:
The author declared no conflict of interest
AUTHOR’S CONTRIBUTION:
RP: Conception and drafting.
References
- Butt AMK, Sarwar S, Nadeem MA. Concomitant therapy versus triple therapy: Efficacy in H.pylori eradication and predictors of treatment failure. J Coll Physicians Surg Pak 2021; 31(02): 128-31. doi: 10.29271/jcpsp.2021.02.128.
- Pellicano R, Ribaldone DG, Fagoonee S, Astegiano M, Saracco GM, Mégraud F. A 2016 panorama of Helicobacter pylori infection: key messages for clinicians. Panminerva Med 2016; 58(4):304-17.
- Marinoni C, Ribaldone DG, Rosso C, Astegiano M, Caviglia GP. Diagnosis of helicobacter pylori infection: A look into molecular aspects of urea breath test. Minerva Biotecnologica 2019; 31(3):100-7. doi:10.23736/S1120- 4826.19.02555-2.
- Malfertheiner P, Megraud F, O'Morain CA, Gisbert JP, Kuipers EJ, Axon AT, et al. European helicobacter and microbiota study group and consensus panel. Management of Helicobacter pylori infection: The maastricht v/florence consensus report. Gut 2017; 66(1):6-30.doi: 10.1136/ gutjnl-2016-312288.
- Liatsos C, Papaefthymiou A, Kyriakos N, Giakoumis M, Kountouras J, Galanopoulos M, et al. Evaluation of the direct economic cost per eradication treatment regimen against Helicobacter pylori infection in Greece: Do national health policy-makers need to care? Medicina 2020; 56(3):133. doi: 10.3390/medicina56030133.
Authors Reply Section
By
Shahid Sarwar
Affiliations
- Dr. Shahid Sarwar, Department of Medicine, Services Institute of Medical Sciences, Lahore, Pakistan
AUTHOR’S REPLY
Sir,
I thank you for highlighting an important issue related to testing for H. Pylori eradication. We agree that H. pylori needs to be tested with non-invasive methods like stool for H. pylori antigen or urea breath test (UBT), when there is no clinical indication for performing upper gastrointestinal endoscopy like weight loss, new-onset symptoms at age above 60 years, presence of malena or failure to respond to treatment.1
Apart from efficacy of investigations, these recommendations are also based on data related to demographic features of population, cost-effectiveness and availability of these tests, which can vary in different countries depending on available resources and their public health system; therefor, prompting flexibility. Cut-off limit of age for performing endoscopy in patients with dyspepsia, which is 60 years in western guidelines, is as low as 40 years in Asian population.2 Morever, in resource-constrained country, like Pakistan, not every test is available in public sector hospitals at subsidised rates. However, these tests are available in private laboratories, but at much higher cost.
Endoscopic services, being life-saving intervention, are available in every tertiary care hospital at minimal charges. It costs less than $10 (PKR 1,600 ̶ 1,650) in public sector hospitals with free pathology reporting service, while both stool for H. pylori antigen and UBTs are not available in majority of public sector hospitals; and it costs more than $50 (PKR 8,000 ̶ 8,250) each at few private laboratories where these tests are performed. Therefore, decision to use endoscopic biopsy for H. pylori testing is based on availability of test and is meant to ensure cost-effectiveness. Moreover, endospic biopsy continues to be the gold standard test for H. Pylori testing.
REFERENCES
- Moayyedi PM, Lacy BE, Andrews CN, Enns RA, Howden CW, Vakil N. ACG and CAG Clinical Guideline: Management of Dyspepsia. Am J of Gastroenterol 2017; 112(7):988-1013. doi: 10.1038/ajg.2017.154.
- Oh JH, Kwon JG, Jung HK, Tae CH, Song KH, Kang JS, et al. Clinical Practice Guidelines for Functional Dyspepsia in Korea. J Neurogastroenterol Motil 2020; 26(1):29-50. https://doi.org/10.5056/jnm19209.