Review article: Practical management issues for the Helicobacter pylori-infected patient at risk of gastric cancer.

The public health implications of H. pylori infection are considerable in view of the universality of the infection and its attributable risk in cancer causation. Education of the population as to hygiene and nutrition are prerequisites. Total testing/screening and treatment of the infected population, although cost-effective, appears impractical given the current costs of effective antimicrobial treatment, difficulties with compliance, possibilities of side-effects and especially induction of resistance, and the potential for re-infection. A useful vaccine, probably the best hope, is years away from clinical applicability. Current recommendations focus on a selective test and treatment approach which concentrates on asymptomatic individuals at enhanced risk (gastric cancer families; recognized premalignant lesions such as atrophy, intestinal metaplasia, dysplasia, adenomatous polyps); (hypo)achlorhydria, spontaneous or drug-induced; immunodeficiency; ethnic groups; individual demand and wishes. Clinicians will need to establish their individual set of guidelines regarding 'test and treat' of asymptomatic individuals until the outcome of desperately needed clinical trials becomes available.