14 GASTROINTESTINAL ENDOSCOPY VOLUME 58, NO. 1, 2003 Dyspepsia, defined as pain or discomfort centered in the upper abdomen, is a common clinical problem. 1 In up to 60% of patients with dyspepsia, diagnostic investigation reveals no identifiable pathology, and a diagnosis is made of functional or nonulcer dys- pepsia (NUD). 2 Epidemiologic studies show that between 30% and 60% of all patients with dyspeptic symptoms are infected with H pylori. 3-10 A number of meta-analy- ses 11-13 have investigated the effect of H pylori eradi- cation on symptoms in patients with NUD. The results are inconsistent. Several studies, including the Received November 5, 2002. Accepted January 19, 2003. Current affiliations: Division of Gastroenterology, McGill University Health Center and Department of Clinical Epidemiology, McGill University, Montréal, Québec, Canada, Faculté de Médecine, Dijon Cedex, France, Abbott Laboratories, Ltd., St.-Laurent, Québec, Health Economics Unit, EORTC, Brussels, Belgium, Division of Gastroenterology, McGill University Health Center, Montréal, Québec, Canada. Presented in part at the 26th Pan American Congress of Digestive Diseases and 4th Canadian Digestive Diseases Week, August 27- September 2, 1999, Vancouver, BC, Canada; Digestive Disease Week, May 17-19, 1999 at Orlando, Florida; and Helicobacter Cost-effectiveness of routine endoscopic biopsies for Helicobacter pylori detection in patients with non-ulcer dyspepsia Nicholaos Makris, BPharm, MSc, Ralph Crott, PhD, MPH, Carlo A. Fallone, MD, Marc Bardou, MD, Alan Barkun, MD, MSc Montréal, Québec, Canada Background: The role of endoscopic biopsies in the detection of Helicobacter pylori in patients with nonulcer dyspepsia is poorly defined. This study assesses the cost-effectiveness of per- forming routine biopsies for the detection of H pylori at upper endoscopy in these patients. Methods: Clinical decision-making was modeled based on outcomes data from published articles and expert opinion. The target group was adults, less than 45 years of age, with nonulcer dyspepsia as defined by a normal endoscopy. Costs, expressed in Canadian dollars, were tabulated over a 1- year time horizon. The main outcome was relief of symptoms, defined as the absence of symptom persistence or recurrence over the 12 months. A strategy of performing a biopsy for the detection of H pylori with a rapid urease test during gastroscopy was compared with that of not performing a biopsy. In addition, as a secondary analysis, the cost-effectiveness of obtaining a biopsy specimen for histopathologic evaluation in patients after a negative rapid urease test was evaluated. Results: A strategy of endoscopy with biopsy and rapid urease testing costs $3940 per addition- al symptom-free patient as compared with endoscopy without biopsy.This result was sensitive to the difference in symptomatic recurrence rate at 1 year between patients in whom H pylori was successfully and unsuccessfully eradicated, which in this analysis, was set at 9.9%. Only when the difference in symptomatic recurrence in patients with successful versus unsuccessful eradication fell to less than 4% was endoscopy with biopsy over $10,000 per cured patient greater than endos- copy without biopsy.The conclusions were otherwise robust when varying the values of other vari- ables across clinically relevant ranges. There was little additional benefit associated with histopathologic assessment of biopsy specimens in patients with a negative rapid urease test and the cost per additional cure was $25,529. Conclusions: In adults with nonulcer dyspepsia under age 45 years undergoing endoscopy, rou- tine procurement of a biopsy specimen for detection of H pylori was more costly yet more effec- tive compared with not obtaining a specimen. The cost-effectiveness of a biopsy is dependent on the benefits of H pylori eradication in this patient population. The less likely a patient with nonul- cer dyspepsia is to become asymptomatic after successful H pylori eradication, the more costly a strategy of routinely obtaining a specimen at endoscopy. The additional cost of sending a speci- men for histopathologic analysis if the rapid urease test is negative does not appear warranted based on cost-effectiveness considerations. (Gastrointest Endosc 2003;58:14-22.) pylori: Basic Mechanisms to clinical cure 2000 symposium. March 26-29, 2000, Bermuda. Supported in part by an “at arms length” grant from AstraZeneca Canada. Reprint requests: Alan Barkun, MD, Division of Gastroenterology, Montréal General Hospital Site, The McGill University Health Centre, 1650 Cedar Ave., Room D7.148, Montréal, Québec, Canada, H3G 1A4. Copyright © 2003 by the American Society for Gastrointestinal Endoscopy 0016-5107/2003/$30.00 + 0 doi:10.1067/mge.2003.295