Delaney Brendan, Ford Alex C, Forman David, Moayyedi Paul, Qume Michelle
Division of Health and Social Care Research, King's College London, 7th Floor Capital House, 42 Weston Street, London, UK, SE1 3QD.
Cochrane Database Syst Rev. 2009 Oct 7;2009(4):CD001961. doi: 10.1002/14651858.CD001961.pub3.
This review considers management strategies (combinations of initial investigation and empirical treatments) for dyspeptic patients. Dyspepsia was defined to include both epigastric pain and heartburn.
To determine the effectiveness, acceptability, and cost effectiveness of the following initial management strategies for patients presenting with dyspepsia (a) Initial pharmacological therapy (including endoscopy for treatment failures). (b) Early endoscopy. (c) Testing for Helicobacter pylori (H. pylori )and endoscope only those positive. (d) H. pylori eradication therapy with or without prior testing.
Trials were located through electronic searches and extensive contact with trialists.
All randomised controlled trials of dyspeptic patients presenting in primary care.
Data were collected on dyspeptic symptoms, quality of life and use of resources. An individual patient data meta-analysis of health economic data was conducted
Twenty-five papers reporting 27 comparisons were found. Trials comparing proton pump inhibitors (PPI) with antacids (three trials) and histamine H2-receptor antagonists (H2RAs) (three trials), early endoscopy with initial acid suppression (five trials), H. pylori test and endoscope versus usual management (three trials), H. pylori test and treat versus endoscopy (six trials), and test and treat versus acid suppression alone in H. pylori positive patients (four trials), were pooled. PPIs were significantly more effective than both H2RAs and antacids. Relative risks (RR) and 95% confidence intervals (CI) were; for PPI compared with antacid 0.72 (95% CI 0.64 to 0.80), PPI compared with H2RA 0.63 (95% CI 0.47 to 0.85). Results for other drug comparisons were either absent or inconclusive. Initial endoscopy was associated with a small reduction in the risk of recurrent dyspeptic symptoms compared with H. pylori test and treat (OR 0.75, 95% CI 0.58 to 0.96), but was not cost effective (mean additional cost of endoscopy US$401 (95% CI $328 to 474). Test and treat may be more effective than acid suppression alone (RR 0.59 95% CI 0.42 to 0.83).
AUTHORS' CONCLUSIONS: Proton pump inhibitor drugs (PPIs) are effective in the treatment of dyspepsia in these trials which may not adequately exclude patients with gastro-oesophageal reflux disease (GORD). The relative efficacy of histamine H2-receptor antagonists (H2RAs) and PPIs is uncertain. Early investigation by endoscopy or H. pylori testing may benefit some patients with dyspepsia but is not cost effective as part of an overall management strategy.
本综述探讨了消化不良患者的管理策略（初始检查与经验性治疗的组合）。消化不良的定义包括上腹部疼痛和烧心。
确定以下针对消化不良患者的初始管理策略的有效性、可接受性和成本效益：(a) 初始药物治疗（治疗失败时包括内镜检查）。(b) 早期内镜检查。(c) 检测幽门螺杆菌（Hp），仅对阳性患者进行内镜检查。(d) 无论是否进行过检测，均进行Hp根除治疗。
通过电子检索和与试验研究者广泛联系来查找试验。
所有在初级保健机构就诊的消化不良患者的随机对照试验。
收集消化不良症状、生活质量和资源使用的数据。对健康经济数据进行了个体患者数据荟萃分析。
共找到25篇报告27项比较的论文。对比较质子泵抑制剂（PPI）与抗酸剂（3项试验）、组胺H2受体拮抗剂（H2RA）（3项试验）、早期内镜检查与初始抑酸治疗（5项试验）、Hp检测和内镜检查与常规管理（3项试验）、Hp检测和治疗与内镜检查（6项试验）以及在Hp阳性患者中检测和治疗与单独抑酸治疗（4项试验）的试验进行了汇总分析。PPI比H2RA和抗酸剂均显著更有效。相对风险（RR）及95%置信区间（CI）为：PPI与抗酸剂比较为0.72（95%CI 0.64至0.80），PPI与H2RA比较为0.63（95%CI 0.47至0.85）。其他药物比较的结果要么缺失，要么无定论。与Hp检测和治疗相比，初始内镜检查可使复发性消化不良症状的风险略有降低（OR 0.75，95%CI 0.58至0.96），但不具有成本效益（内镜检查的平均额外成本为401美元（95%CI 328至474美元））。检测和治疗可能比单独抑酸治疗更有效（RR ＝ 0.59，95%CI 0.42至0.83）。
在这些可能未充分排除胃食管反流病（GORD）患者的试验中，质子泵抑制剂药物（PPI）对消化不良有效。组胺H2受体拮抗剂（H2RA）和PPI的相对疗效尚不确定。早期通过内镜检查或Hp检测进行评估可能使一些消化不良患者受益，但作为整体管理策略的一部分，其不具有成本效益。
