ORIGINAL ARTICLE
Clinical Evaluation of Dyspepsia in Patients with Functional
Dyspepsia, with The History of Helicobacter pylori Eradication
Therapy in Cipto Mangunkusumo Hospital, Jakarta
Khaira Utia, Ari F. Syam, Marcellus Simadibrata, Siti Setiati, Chudahman Manan
Department of Internal Medicine Faculty of Medicine, University of Indonesia - dr. Cipto Mangunkusumo Hospital.
Jl. Diponegoro no. 71, Jakarta Pusat 10430, Indonesia.
Correspondence mail to: ari_syam@hotmail.com
ABSTRACT
Aim: to obtain the proportion of dyspepsia symptom in
non-ulcerative dyspepsia patient after eradication treatment
of H. pylori, and recent status of H. pylori after eradication
therapy.
Methods: cross-sectional study in patients with history
symptoms of dyspepsia in non ulcer dyspepsia with positive
H. pylori and had been administered eradication treatment
of H. pylori for 1 week in 2002-2007 period. Conditions that
influence the result of urea breath test such as proton pump
inhibitor, antibiotic treatment, and gastric malignancy have
been excluded. Patients were invited to be interviewed about
current symptoms of dyspepsia and then underwent urea
breath test (UBT) examination to identify H. pylori. Global
overall symptom of dyspepsia scale was used to assess the
symptoms of dyspepsia.
Results: twenty one patients (14 male and 11 female)
fulfilled the eligibility criteria for this study, 9 patients with
eradication treatment history less than 1 year, and 12
patients more than 1 year. The symptoms of dyspepsia were
evaluated and as many as 17 patients (81%) dyspepsia
symptoms’ were subsided and 4 patients had persistent
symptoms after eradication. After eradication treatment, 17
patients (81%) resulted with negative Helicobacter pylori
findings, and 4 patients remained positive. One patient of
the positive group was reinfected by H. pylori, proved by
previous negative result of UBT. In the negative group, 13
patients (76,4%) dyspepsia symptoms’ were free from
dyspepsia symptoms, and 4 patients had persistent
symptoms. All the symptoms of the patients in the positive
group were relieved.
Conclusion: majority of patients had improvement of
dyspepsia symptoms after eradication treatment, and 81% of
patients had negative H. pylori findings, proved by UBT after
eradication . The percentage of symptomatic improvement on
H. pylori negative patients after eradication is 76, 4%.
Key words: Helicobacter pylori, dyspepsia, improvement.
86
INTRODUCTION
Helicobacter pylori is the main cause of peptic
ulcer, and many studies have proved the strong relation-
ship between H. pylori infection with gastric lymphoma
and corpus adenocarcinoma and gastric antrum.
Eradication therapy for H. pylori is strongly thought to
decrease the risk of cancer.1-3
Result of a clinical study in Indonesia showed that
the prevalence of Helicobacter pylori in peptic ulcer
patients was around 90-100%. 4 In non-ulcerative
dyspepsia patients, the prevalence of H. pylori infection
was reported to be 20-40% with different diagnostic
methods: serology, culture, and histopathology.4 On the
other hand, the prevalence of H. pylori in dyspepsia
patients undergoing endoscopy in a multicenter study in
5 large cities in Indonesia in 2003-2004 was 10.2%, with
the highest prevalence in Jogjakarta (30.6%) and the
lowest in Jakarta (8%). 5 This number was lower
compared to a previous study in M. Djamil Hospital
Padang which found the H. pylori prevalence in
dyspepsia patients to be 60% with serologic assay and
45% with histopathologic assay.6 Temporary report from
an epidemiological study currently enrolled in Jakarta by
the Gastroenterology Division on H. pylori prevalence
in DKI Jakarta shows that the prevalence of H. Pylori
infection was 52.3% out of 310 patients.7
From a number of studies, H.pylori eradication
results in several different effects, especially the symp-
toms related to the the increased acidity. An increase in
oesophageal reflux incidence after eradication therapy
was first reported in 1991. However, several studies later
gave different results.8 Success of eradicaton with triple
therapy ranges between 80 and 100%. Unlike the
response in patients with ulcer, post-therapeutic clinic
Vol 42 • Number 2 • April 2010 Clinical Evaluation of Dyspepsia in Patients with Functional Dyspepsia
response in non-ulcerative patients vary around 21-
58%.9,10 Study by Jaakkimainen reported relationship
between H.pylori and non-ulcerative dyspepsia
symptom.11-13 Dyspepsia problem is essential to the
researchers, because most patients with positive
H .pylori status presented with dyspepsia symptom,
however until now in Indonesia there are no study exist
about percentage of reduction in dyspepsia symptom
after eradication therapy and relationship between this
symptom relieve with H. pylori status. A study by Ford
AC et al supported that dyspepsia symptom should be
reevaluated after eradication therapy, where this study
concluded the low quality of life in patients with
dyspepsia symptom.14
The objective of this study is to identify the
improvement of dyspepsia symptom in patients with the
history of non-ulcerative dyspepsia after H. pylori
eradication therapy in Cipto Mangunkusumo Hospital,
and in particular to study the proportion of dyspepsia
symptom improvement in non-ulcerative dyspepsia
patient after H. Pylori eradication therapy, to know the
H. pylori status after eradication therapy, to study the
proportion of dyspepsia symptom improvement in non-
ulcerative patients with currently negative H. pylori
status.
METHODS
A descriptive cross-sectional study was carried out
in March to June 2007 at the Gastroenterology Clinic
and Procedure Room, Department of Internal Medicine,
Cipto Mangunkusumo Hospital, Jakarta.
The source population of this study is patients with
history of non-ulcer dyspepsia with H. pylori infection
at the Gastroenterology Clinic, Cipto Mangunkusumo
Hospital, who have obtained triple eradication therapy
during February 2002-February 2007. The sample
consisted of members of the source population who
fulfilled inclusion criteria.
Study subjects were all patients with non-ulcer
dyspepsia who have had eradication therapy during
February 2002-February 2007. However, the minimum
sample size to determine the proportion of non-ulcer
dyspepsia patients with improvement of symptoms post-
eradication therapy was calculated using the sample size
formula for proportion testing and the minimum sample
size required was 49 subjects.
Study subjects were recruited from all patients with
history of non-ulcer dyspepsia who have obtained
eradication therapy at the Gastroenterology Clinic of
Cipto Mangunkusumo Hospital during February 2002-
February 2007 who fulfilled inclusion criteria.
Patients who have obtained H. pylori eradication
therapy during the aforementioned period were invited
back to the clinic. Those who consented to enroll in the
study and fulfilled inclusion criteria were subjected to
anamnesis on current dyspepsia complaints and urea
breath test to evaluate the patient’s current H. pylori
status.
Inclusion criteria were patients with history of non-
ulcer dyspepsia with positive H. pylori test prior to
therapy and having completed triple eradication therapy
for at least 1 week. Exclusion criteria were patients
obtaining eradication therapy or proton pump inhibitor at
the time of study, gastrointestinal malignancy, and
refusal to participate.
Measurements included urea breath test, which was
performed after the following preparations: The subject
was asked to fast for 8 hours prior to testing. Upon
arrival at the place of examination, the patient was asked
to rest for 5 minutes, then to ingest a urea tablet labeled
with 14C. After resting for 10 minutes, the subject was
asked to blow repeatedly into a device until the color of
a balloon turned entirely from orange to yellow. The
balloon was then measured on the UBT device and the
results were noted as positive (2) or negative (0).
Other measurements were done through anamnesis
of medication history, smoking, alcohol use, presence of
anxiety or depression, and current complaints of
dyspepsia by the Global Overall Symptoms of
Dyspepsia Scale (GOS).
Study results were processed using SPSS 10.0 to
obtain subject characteristics, proportions of dyspepsia
complaints in conjunction with various risk factors,
proportions of successful H. pylori eradication in
patients who obtained therapy for less than and more
than 1 year, respectively, and proportion of dyspepsia
complaints in conjunction with the patient’s current
H. pylori status.
All study subjects were given oral and written
information on the study objectives and procedures, prior
to being asked for written consent to participate in the
study.
RESULTS
In the medical record data, we obtained 62 patients
with dyspepsia symptom who have been receiving
complete triple eradication therapy for 1 week within
February 2002-2007. Among the 62 people with history
of dyspepsia who had completed eradication therapy for
H. pylori in RSCM, only 25 people could be invited to
the outpatient clinic and gastroenterology procedure
room, because 12 people were living out of town, 6 people
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Khaira Utia Acta Med Indones-Indones J Intern Med

had gastrointestinal cancer, 5 geriatric patients passed One of the 4 patients had previously had negative result
away, 11 people with unclear address and phone from the UBT test the previous year, and thus this result
number could not be contacted, and 3 people refused to is thought to be H. pylori reinfection.
participate in the study. From February to July 2007, there Of all the patients receiving H pylori eradication
were 25 people willing to be re-invited to the outpatient therapy for 1 week, omeprazole therapy was continued
clinic and Gastroenterology procedure room at Cipto until 1 month after the end of eradication therapy.
Mangunkusumo Hospital. From the 25 patients we found
21 subjects with non-ulcerative appearance in the Dyspepsia Symptom in Study Subjects
previous endoscopy, which consisted of 11 males and 10 As mentioned in Table 1, from 21 study subjects 17
females. people (81%) no longer had dyspepsia symptom or only
From Table 1 it is seen that most subjects were minimally insignificant dyspepsia symptom which
between 41-60 years of age (52,4%) with mean age 48,4 spontaneously resolved without efforts such as taking
years, Bataknese, non-smoker, non-alcoholic, not medications. On the other hand, 4 people still had
suffering from anxiety nor depression, and also not persistent dyspepsia symptom after eradication therapy,
consuming NSAIDs. From 21 subjects, there were 17 or only slightly better than previous symptom.
people whose dyspepsia symptoms resolved, and 4 Several risk factors found from the 4 patients are: 1
people with constant dyspepsia symptoms. On further patient with anxiety problem, 2 patients were mild smoker
workup 17 people were found to have Helicobacter (6 cigarettes/day), and 1 patient was a long-term aspirin
pylori – negative with urea breath test (UBT) user (Table 2).
examination, and positive result was found in 4 people. Dyspepsia symptoms felt in the 4 patients with
persistent dyspepsia were bloating, epigastric pain, and
nausea. From the 4 patients, 4 had bloating, 3 had
Table 1. Characteristics of study subjects epigastric pain, and 3 had nausea.
Characteristics Number of subjects
(n=21)
Age (year)
20 – 40 6 Table 2. Proportion of dyspepsia symptom in various risk
41 – 60 11 factors
> 60 4
Sex Dyspepsia Dyspepsia
Risk factor resolved persisted
Male 11
Female 10 (n=17) (n=4)
Ethnicity Age (year)
Bataknese 16 20 – 40 5 1
Javanese 1 41 – 60 8 3
Ambonese 1 > 60 4 0
Manadonese 1 Sex
Betawinese 1 Male 9 2
Dayaknese 1 Female 8 2
Smoking
Nonsmoker 12 Ethnicity
Previous history of smoking 7 Bataknese 14 2
Mild smoker 2 Non-bataknese 3 2
Alcohol consumption Smoking
Never 14 Nonsmoker 11 1
Previous history of alcohol consumption 6 Previous history of smoking 6 1
Mild alcohol drinker 1 Mild smoker 0 2
Anxiety-Depression Alcohol consumption
Positive 2 Never 12 2
Negative 19 Previous history of alcohol
Antiinflammatory agents consumption 4 2
None 15 Mild alcohol drinker 1 0
NSAIDs 3
Aspirin 3 Anxiety-Depression
Eradication time Positive 1 1
< 1 year 9 Negative 16 3
> 1 year 12 Antiinflammatory agents
Dyspepsia None 12 3
Resolved (score 1-2) 17 NSAIDs 3 0
Persisted (score 3-7) 4 Aspirin 2 1
Result of UBT test H. Pylori
Positive 17 Positive 4 0
Negative 4 Negative 13 4

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Vol 42 • Number 2 • April 2010 Clinical Evaluation of Dyspepsia in Patients with Functional Dyspepsia
Urea Breath Test Result
From 21 study subjects, 17 patients (81%) showed
negative H pylori result on UBT test, and 4 were shown
to be positive. Based on anamnesis from the patients,
only 7 subjects (33%) have underwent previous
H. pylori test after eradication therapy. Six among them
had negative result after eradication therapy, and 1
subject had positive result. Among the 4 subjects who
currently showed positive result, 1 subject was known
to have previous negative result on UBT test..
Proportion of Negative Dyspepsia at Present in
Patients with Eradication < 1 Year and > 1 Year ago
From 21 subjects, 9 of them received eradication
therapy less than 1 year from the time of sample
collection, and in the other 12 sampling was performed
after more than 1 year of eradication. In the less than 1
year group, only 1 patient had persistent dyspepsia
symptom, while in the more than 1 year group 3 patients
still complained of dyspepsia (Table 3).
Table 3. Proportion of negative dyspepsia at present in patients
with eradication phase < 1 year and > 1 year ago
Dyspepsia Dyspepsia
Total
resolved persisted
< 1 year 8 1 9
> 1 year 9 3 12
Total 17 4 21
Proportion of Negative Helicobacter pylori at Present
in Patients with Eradication Phase < 1 Year and > 1
Year Ago
From 9 subjects in the less than 1 year group, 1
patient still had positive H. pylori, while from 12
subjects in the more than 1 year group, 3 patients still
had positive results (Table 4).
Table 4. Proportion of negative Helicobacter pylori at present
in patients with eradication phase < 1 year and > 1 year ago
H. pylori negative H pylori positive Total
< 1 year 8 1 9 such as smoking, alcohol consumption, anti-inflamma-
> 1 year 9 3 12
Total 17 4 21
Proportion of Dyspepsia and Helicobacter pylori
Status
From 17 patients with resolved dyspepsia, 5 subjects
had positive H. pylori result. On the other hand, in the
dyspepsia group, all 4 patients had negative H. pylori
status (Table 5). Table 5 also illustrates that the
percentage of improved dyspepsia symptom was lower
in H. pylori-negative group, only 76.4% (13/17
subjects) compared to the H. pylori-positive group whose
all subjects no longer felt dyspepsia symptoms.
Table 5. Proportion of dyspepsia and H. pylori status
Dispepsia Dispepsia
Total
resolved persisted
H. pylori-negative 13 4 17
H. pylori-positive 4 0 4
Total 17 4 21
DISCUSSION
Picture of Dyspepsia Symptoms
This study performed an assessment of dyspepsia
symptoms using global overall symptoms of
dyspepsia (GOS) scale, and obtained 81% of subjects
with resolved dyspepsia symptoms (score 1-2). Several
factors thought to be related with improvement of
dyspepsia symptoms in both negative and positive for
H. pylori group are relieved of gastritis as a result of
long-term omeprazole therapy after eradication therapy.
From all the subjects, omeprazole/PPI therapy was
continued for 1 month after eradication therapy.
Several studies reported recovery of gastric lesion
in patients with positive H. pylori result after long-term
omeprazole therapy for 1 month. Some of those studies
were reported by Bayerdorfer and colleagues in 1992
who found ulcer healing in 25 out of 26 patients, and
Sung and colleagues in 1994 who found ulcer healing in
61 of 77 patients receiving omeprazole therapy without
triple therapy. Although the studies did not find good
eradication level (0% in the study by Bayerdorfer and
colleagues, and 6.9% in the study by Sung and
colleagues), but they found relatively high ulcer
reccurency within the first year after therapy, 12 out of
25 patients (48%) in Bayerdorfer and colleagues study,
and 22 out of 61 patients (36%) in Sung and colleagues
study.58
Most patients had avoided risk factors of dyspepsia
tory agents, and prolonged stress. From the 21 subjects,
only 2 patients (9,5%) were mild smoker, 1 patient
(4,7%) was still consuming a small amount of alcohol,
and 2 patients (9,5%) had anxiety, 2 patients consumed
NSAIDs although not routinely (9,5%), and 3 others
(14,3%) regularly consumed aspirin.
In persistent dyspepsia, the dyspepsia symptoms felt
were bloating, nausea, and epigastric pain.
Length of Evaluation Time with Dyspepsia Episode
In 21 subjects, proportion of eradication time with
improvement of dyspepsia symptom was different
89
Khaira Utia
between eradication group less than 1 year (88.8% or 8/
9), and with eradication group more than 1 year (75% or
9/12). Similar to the study by Rosengren and Polson who
found dyspepsia improvement in 88.2% after 1 month of
therapy, but 4 months after the therapy 2 patients felt
the dyspepsia symptom again, and although the other 2
did not feel any more dyspepsia, once in a while they
still consumed antacids or anti H2-receptor, thus the
percentage of dyspepsia improvement decreased at the
fourth month to 76.5%.42 The study by Rosengren and
Polson proved that as the time advanced, a decrease of
dyspepsia improvement occurred in the patients, as seen
by re-consumption of medications to relieve dyspepsia.
Length of Evaluation Time with H. pylori Status
Length of H. pylori status evaluation after
eradication therapy was influenced by the possibility of
reinfection during that time period. In this study, from 4
people with positive H. pylori status, 1 was known to
have reinfection, proved by previously negative UBT test
on evaluation after eradication therapy. Reinfection in
adults was reported to be only 0.3-0.7% each year, and
Cullen DJ and colleagues who performed long-term
cohort study for 21 years from 1969 to 1990 only found
7% of reinfection in 86 previously seronegative patients
after therapy.1,13 In this study, we could not conclude
the prevalence of reinfection in patients after H. pylori
eradication therapy only from this 1 patient, because the
sample size did not meet requirements for calculation of
proportion and statistical analysis. However, these data
show that reinfection could occur in adults within 5 years’
time.
Dyspepsia Symptom and H. pylori Status
Looking at the proportion of dyspepsia resolution and
negative H. pylori status, we found lower proportion
symptom improvement in the H. pylori-negative group
compared with the H. pylori-positive group, 76.4 % and
100% respectively. This result is different from previ-
ous meta-analysis by Laheij and colleagues, who found
better improvement of dyspepsia symptom in the
negative group (73%) compared to the positive group
(45%).48
Talley had previously reported no significant
relationship in the improvement of dyspepsia symptom
with H. pylori eradication, in patients with functional
dyspepsia infected with H. pylori, and concluded that
H. pylori eradication was not proved to improve
symptoms of functional dyspepsia after 12 months of
therapy. In that particular study they obtained 85%
H. pylori eradication rate, however, after 12 months of
follow up, no significant difference in the improvement
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Acta Med Indones-Indones J Intern Med
of dyspepsia symptom was found in the therapeutic
group, 24% compared to 22% in the control group.50
On the other hand, Chiba and colleagues who
evaluated improvement in dyspepsia symptom after
eradication therapy in patients with functional and
organic dyspepsia found the improvement up to 54%51
The difference in symptom improvement found in
several studies above might be because of the
differences in study population. Laheij and Talley
studies were performed in the non-ulcerative patients,
while Chiba did not differentiate between the two groups.
Failure of Triple Therapy
After eradication therapy was performed,
evaluation on the 25 subjects with different evaluation
time found 4 patients with positive H. pylori infection,
and 1 among them was thought to be caused by H.
pylori reinfection, since the patient had previously
undergone UBT test after eradication therapy which
|revealed negative result. In all 4 subjects (19%),
positive H. pylori status could result from failure of
previous eradication therapy or reinfection. Thus,
success of eradication therapy in 21 subjects was
reported to be 81% of all samples. This figure is slightly
lower than several previous studies. Wu and colleagues
had up to 98% success rate after eradication with triple
therapy in patients with reflux esophagitis symptoms, and
in another study Manes G reported 94% eradication
success in patients with dyspepsia symptoms. 40,41
Rosengren and Polson performed an evaluation 1 month
after eradication using triple therapy, and found 100%
eradication rate with 13C UBT.42
Therapeutic failure in patients after eradication
therapy could have several causes, among them are
antibiotic resistance, adherence to antibiotics due to
adverse events, and reinfection. However in this study
the failure was thought to be due to antibiotics
resistance and reinfection, since all of the patients had
completed triple therapy. Resistance was thought to be
due to previous irrational antibiotics use. This was
reported by Mc Mahon BJ and colleagues, that history
of consuming the same type of antibiotics within the last
10 years were related with resistance, where 92% of
clarythromycin-resistant patients had previously received
clarythromycin, and 60% of metronidazole-resistant
patients have received metronidazole within the last 6-8
years.32 Microbial resistance test to antibiotics is not
routinely performed in Cipto Mangunkusumo Hospital
nor in other hospitals in Jakarta, since this resistance
test is exclusive, expensive, and is only used for
research purposes.
Vol 42 • Number 2 • April 2010 Clinical Evaluation of Dyspepsia in Patients with Functional Dyspepsia
Limitations of Study
In this study, the number of subjects fulfilling the study
criteria were only 21 subjects, while on the minimal
sample size calculation at least 49 subjects were required
for statistical analysis. This inadequate sample size was
due to the low prevalence of H. pylori in Cipto
Mangunkusumo Hospital. A multicenter study in 5 large
cities in Indonesia in 2003-2004 found H. pylori
prevalence in patients with ulcerative and non-ulcerative
dyspepsia symptom to be 10.2%, with the lowest
prevalence in Jakarta, only 8%.5 Within 5 years in 2002-
2007, 62 H. pylori-positive cases with dyspepsia as early
symptom were found in Cipto Mangunkusumo Hospital.
From the 62 cases, only 21 patients were able to
participate in this study, since 12 people were living out
of town (some of them in Medan, Kalimantan, and
Central Java), 6 people had gastrointestinal cancer, 4
people with ulcerative appearance on previous
endoscopy, 5 geriatric patients passed away, 11 people
with unclear address and phone number could not be
contacted, and 3 people refused to participate in the study
because they did not feel any symptoms anymore and
previous test were found to be negative. The limited
sample size and unbalanced proportion between risk
factors for H. pylori and the incidence of dyspepsia in
patients with history of H. pylori eradication had caused
difficulties in performing statistical relationship in this
study. Therefore, our initial plan at the beginning of the
study to proof hypotheses using statistical analysis was
not able to put into realization.
Several issues that also turned to be the limitation of
our study were sample collection that required 5 years
to complete due to the low prevalence of H. pylori in
Cipto Mangunkusumo Hospital each year, i.e. only
between 10-12 cases annually. Thus, many other
factors possibly have their influence in the incidence of
dyspepsia in study subjects. However, in this study, other
risk factors related to the incidence of dyspepsia found
relatively similar proportion to patients with and without
risk factors, with persistent dyspepsia symptoms.
CONCLUSION
Improvement of dyspepsia symptom after
eradication therapy was found in most subjects and
symptoms found in persistent dyspepsia were bloating,
epigastric pain, and nausea. There were 81% of
subjects with negative H. pylori status after eradication
therapy through urea breath test (UBT) evaluation.
Proportion of dyspepsia symptom improvement in
H. pylori who are currently negative were 76.4%.
Assessment of H. pylori status using urea breath
test (UBT) should be performed 1 month after
eradication therapy, considering failure of eradication
using triple therapy was found. Efforts are needed for
availability of H. pylori culture and resistance in CMH,
so that whenever therapeutic failure occurs, right choice
of antibiotics could be given to the patient. This is a pilot
study, further study is required with representative sample
size, in order to be able to perform statistical analysis to
evaluate the success of eradication therapy and
improvement of dyspepsia symptom
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