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In this summary

  • As per NICE guidance, patients over the age of 55 with recent onset, unexplained, and persistent dyspepsia (over 4–6 weeks) should be referred urgently for endoscopy to exclude cancer

When should I test for Helicobacter pylori?

  • Patients with uncomplicated dyspepsia unresponsive to lifestyle change and antacids, following a single 1 month course of proton pump inhibitor (PPI), without alarm symptoms
    • options should be discussed with patients, as the prevalence of Helicobacter pylori (HP) in developed countries is falling, and is lower than 15% in many areas in the UK. A trial of PPI should usually be prescribed before testing, unless the likelihood of HP is higher than 20% (older people; people of North African ethnicity; those living in a known high-risk area), in which case the patient should have a test for HP first, or in parallel with a course of PPI
  • Patients with a history of gastric ulcer or duodenal ulcer who have not previously been tested
  • Patients before taking NSAIDs, if they have a prior history of gastro-duodenal ulcers
    • both HP and NSAIDs are independent risk factors for peptic ulcers, so eradication will not remove all risk
  • Patients with unexplained iron-deficiency anaemia, after negative endoscopic investigation has excluded gastric and colonic malignancy, and investigations have been carried out for other causes, including: cancer; idiopathic thrombocytopenic purpura; vitamin B12 deficiency

When should I not test for Helicobacter pylori?

  • Patients with proven oesophagitis, or predominant symptoms of reflux, suggesting gastro-oesophageal reflux disease (GORD)
  • Children with functional dyspepsia

Which non-invasive test should be used in uncomplicated dyspepsia?

  • Urea breath tests (UBTs) and stool antigen tests (SATs) are the preferred tests
  • Urea breath test:
    • most accurate test
    • needs a prescription and staff time to perform
  • Stool Helicobacter antigen test (SAT):
    • check test availability
    • pea-sized piece of stool sent to local laboratory
  • Do not perform UBT or SAT within two weeks of PPI, or four weeks of antibiotics, as these drugs suppress bacteria and can lead to false negatives
  • Serology:
    • whole blood in plain bottle; low cost, lower accuracy
    • not recommended for most patients, and positives should be confirmed by a second test such as UBT, SAT, or biopsy
    • has very good negative predictive value at current; low prevalence in the developed countries
    • most useful in patients with acute gastrointestinal bleed, to confirm negative UBT or SAT, when blood and PPI use interacts with tests
    • detects IgG antibody; does not differentiate active from past infection
  • Do not use near patient serology tests, as they are not accurate
  • Do not use serology post-treatment
  • Do not use serology in the elderly or in children

Algorithm for deciding on treatment based on presentation and test results

When should I treat Helicobacter pyloriDownload a PDF of this algorithm.

Treatment regimens for Helicobacter pylori

  • Check antibiotic history as each additional course of clarithromycin, metronidazole, or quinolone increases resistance risk. Stress the importance of compliance

Treatment regimens for Helicobacter pylori. Download a PDF of this algorithm.

  • PPI medication: lansoprazole 30 mg b.d., omeprazole 20–40 mg b.d., pantoprazole 40 mg b.d., esomeprazole 20 mg b.d., rabeprazole 20 mg b.d.
  • If post gastro-duodenal bleed, start HP treatment only when patient can take oral medication
  • If diarrhoea develops, consider Clostridium difficile and review need for treatment
  • Only offer longer duration or third-line eradication on advice from a specialist
    • third line: 10 days of PPI twice daily, plus bismuth subsalicylate 525 mg q.d.s, plus  2 antibiotics as above not previously used, or rifabutin 150 mg b.d., or furazolidone 200 mg b.d.

When should I retest for Helicobacter pylori?

  • As 64% of patients with functional dyspepsia will have persistent recurrent symptoms, do not routinely offer re-testing after eradication
  • Retest if:
    • compliance poor, or high local resistance rates
    • persistent symptoms, and HP test performed within two weeks of taking PPI, or within four weeks of taking antibiotics
    • patients with an associated peptic ulcer or MALT lymphoma, or after resection of an early gastric carcinoma
    • patients requiring aspirin, where PPI is not co-prescribed
    • patients with severe persistent or recurrent symptoms, particularly if not typical of GORD
  • UBT is most accurate
  • SAT is an alternative
  • Wait at least 4 weeks (ideally 8 weeks) after treatment. If acid suppression needed use H2 antagonist
  • Use second-line treatment if UBT or SAT remains positive
  • Do not use serology for re-testing

What should I do in eradication failure?

  • Reassess need for eradication. In patients with GORD or non-ulcer dyspepsia, with no family history of cancer or peptic ulcer disease, a maintenance PPI may be appropriate

When should I refer for endoscopy, culture and susceptibility testing?

  • Patients in whom the choice of antibiotic is reduced due to hypersensitivity, known local high resistance rates, or previous use of clarithromycin, metronidazole, and a quinolone
  • Patients who have received two courses of antibiotic treatment, and remain HP positive
  • For any advice, speak to your local microbiologist, or the Helicobacter Reference Laboratory

full guideline available from…

Public Health England. Helicobacter pylori in dyspepsia: test and treat. London: Public Health England. October 2016, updated September 2019.
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First included: January 2017, updated December 2019.