Dr Mark Cottrill weighs up the revised recommendations from the European Helicobacter Pylori Study Group


In 1996, the European Helicobacter Pylori Study Group met in Maastricht to formulate guidelines to facilitate the management of H. pylori in clinical practice. Based on the best available scientific evidence and expertise, recommendations for the testing and treatment of H. pylori in different conditions were made.1

In the past 4 years, significant progress has been made in the understanding of the infection. In September 2000 a second meeting was held to update the management guidelines.2

As in the original guidelines, the recommendations of who to treat were made on three levels (strongly recommended, advisable and uncertain) based on evidence at five levels:

  1. Well-designed and appropriately designed studies
  2. Well-designed, cohort or case-controlled studies, somewhat flawed evidence or persuasive indirect evidence
  3. Case reports, seriously flawed studies or suggestive indirect evidence
  4. Clinical experience
  5. Insufficient evidence to form an opinion

The strongly recommended indications are essentially unaltered from the 1996 meeting (peptic ulcers, MALToma, atrophic gastritis, post gastric cancer resection, first-degree relatives of gastric cancer patients).

More controversial are the 'advisable' indications, which include functional dyspepsia (non-ulcer dyspepsia; NUD) and gastro-oesophageal reflux disease (GORD) (see Table 1).

Table 1: Who to treat: advisable indications and relevant statements2


Indication (H. pylori positive)
Scientific evidence
Functional dyspepsia
  • H. pylori eradication is an appropriate option
  • This leads to long-term improvement in a subset of patients
Gastro-oesophageal reflux disease
H. pylori eradication:  
  • Is not associated with GORD development in most cases
  • Does not exacerbate existing GORD
H. pylori should be eradicated, though, in patients requiring long-term profound acid suppression
Non-steroidal anti-inflammatory drugs
H. pylori eradication:  
  • Reduces the incidence of ulcer, given prior to NSAID use
  • Alone, is insufficient to prevent recurrent ulcer bleeding in high-risk NSAID users
  • Does not enhance healing of GU or DU in patients receiving antisecretory therapy who continue to take NSAIDs
H. pylori and NSAIDs/aspirin are independent risk factors for PUD

There are now numerous studies of the effect of H. pylori eradication on symptoms in patients with NUD. Individual studies in the main do not prove any symptom improvement but a meta-analysis of 28 studies did demonstrate some improvement.3 In practical terms, a GP may have to treat some 15 NUD patients before seeing symptom improvement in one patient.

H. pylori does not seem to play a significant role in the pathogenesis of reflux disease. Eradication may unmask pre-existing reflux or lead to the development of de novo reflux and PPIs may be less effective in the absence of H. pylori infection. For this reason, another Consensus Conference did not recommend testing for H. pylori in patients with GORD.4

In selecting patients with NUD or GORD for eradication treatment the Maastricht-2 guidelines may be criticised for the use of the word 'advisable'. I believe there is still insufficient evidence for eradication treatment in these groups of patients, and more robust evidence is required.

On the other hand, if one accepts that not treating H. pylori infection may lead to an increased risk of future ulceration, of developing gastric cancer or infecting other members of the family, the argument fails. If the advisable indications were replaced by acceptable indications, this would make more sense.

Treatment options in Maastricht-2 are more clear-cut (see Table 2, below). It is widely accepted that first-line therapy should be a PPI (or RBC) and two antibiotics (from clarithromycin, metronidazole and amoxicillin) and for a minimum of one week.

Table 2: How to treat2

First-line therapy

PPI (RBC) standard dose bid + clarithromycin 500mg bid (C)

+ amoxicillin 1000mg bid (A) or metronidazole 500mg bid (M)*

for a minimum of 7 days

* CA is preferred to CM as it may favour best results with second-line PPI quadruple therapy


In case of failure

Second-line therapy

PPI standard dose bid + bismuth subsalicylate/subcitrate 120mg qid

+ metronidazole 500mg tid + tetracycline 500mg qid

for a minimum of 7 days

If bismuth is not available, PPI-based triple therapies should be used

Subsequent failures should be handled on a case by case basis

The statement that clarithromycin/amoxicillin should be preferred as first choice is logical – metronidazole being reserved for second-line therapy. The guidelines also recommend the use of a bismuth-based quadruple therapy for second-line therapy.

Finally, the guidelines list some selected key points that will have considerable relevance to GPs:

  • Serology testing is now not considered accurate enough for a diagnosis of infection, and a urea breath test (UBT) or stool antigen test is preferred. (Although UBTs are available on FP10 prescription in the UK, they are rarely used.)
  • In addition, all patients should be tested for successful eradication (whether symptomatic or not).
  • For uncomplicated duodenal ulcers, further antisecretory treatment is unnecessary, the eradication course being sufficient therapy.
  • Maastricht-2 recommends a 'search and treat' strategy: for practitioners to search out peptic ulcer patients on long-term or intermittent acid-lowering therapy.

Guidelines devised by enthusiasts? Well, yes. But like the 1996 recommendations, they should be welcomed as a framework to determine local guidelines based on local circumstances.


  1. The European Helicobacter Pylori Study Group. Current European concepts in the management of Helicobacter pylori infection. The Maastricht Consensus Report. Gut 1997; 41: 8-13.
  2. Malfertheiner P et al. Current Concepts in the Management of Helicobacter pylori Infection – The Maastricht Consensus Report 2-2000 (in preparation).
  3. Jaakkimainen RL et al. Is Helicobacter pylori associated with non-ulcer dyspepsia and will eradication improve symptoms? A meta-analysis. Br Med J 1999; 319: 1040-4.
  4. French-Belgian Consensus Conference on Adult Gastro-oesophageal Reflux Disease 'Diagnosis and Treatment': report of a meeting held in Paris, France, on 21-22 January 1999. The jury of the consensus conference. Eur J Gastroenterol Hepatol; 12: 129-37.

Guidelines in Practice, November 2000, Volume 3
© 2000 MGP Ltd
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