Helicobacter pylori in dyspepsia: test and treat

• 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

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

• 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