Peptic disease: can we afford current management?
BACKGROUND
While surgery has the potential to cure peptic disease (ulceration and reflux), the development in the 1970s of H2 receptor antagonists saw them replace surgery in the management of peptic symptoms, controlling disease while the medication was taken. Medical cure at least in the case of a duodenal ulcer is now also possible by the use of anti-Helicobacter therapy.


METHODS
Australian Pharmaceutical Benefits Scheme (PBS) and Medicare data on the treatment of peptic disease were reviewed.


RESULTS
The data showed that medical cure of duodenal ulcer is rarely attempted. While elective surgical treatment for duodenal ulcer, highly selective vagotomy, has decreased 10-fold in 10 years, prescriptions for antisecretory agents (H2 and proton pump) are doubling every 2 years (increasing from 6.7 to 7.8% of PBS budget). Meanwhile upper gastrointestinal endoscopy rates are doubling every 5 years. By comparison, the most appropriate treatment, anti-Helicobacter therapy, is prescribed at 1/50th the rate of antisecretory agents and over 2 years decreased to 1/80th. Antisecretory treatment has not been effective in reducing mortality from duodenal ulcer, at least not in New South Wales.


CONCLUSIONS
If the principle of treatment is to decrease cost and prevent complications by curing duodenal ulcer, then current practice is a failure. A management algorithm for peptic symptoms which has the potential to relieve symptoms, cure ulcer when present, minimize surgery and reduce complications and cost is proposed for the purpose of debate.
Fletcher
D R
DR
University Department of Surgery, Fremantle Hospital, Australia.
D000465:Algorithms; D000863:Antacids / Q000627:therapeutic use; D000897:Anti-Ulcer Agents / Q000627:therapeutic use; D001729:Bismuth / Q000627:therapeutic use; D003362:Cost-Benefit Analysis; D004381:Duodenal Ulcer / Q000382:microbiology / Q000601:surgery / Q000628:therapy; D016099:Endoscopy, Gastrointestinal / Q000191:economics; D016481:Helicobacter Infections / Q000188:drug therapy*; D016480:Helicobacter pylori; D006635:Histamine H2 Antagonists / Q000627:therapeutic use; D006801:Humans; D010535:Laparoscopy; D010437:Peptic Ulcer / Q000382:microbiology / Q000601:surgery / Q000628:therapy*; D014629:Vagotomy, Proximal Gastric / Q000191:economics
D000863:Antacids; D000897:Anti-Ulcer Agents; D006635:Histamine H2 Antagonists; D001729:Bismuth