PHE H. pylori in dyspepsia guideline

9 Comments

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

When should I treat Helicobacter pylori? Download 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:

www.gov.uk/government/publications/helicobacter-pylori-diagnosis-and-treatment

Published date: 21 November 2017.

Last updated: 05 September 2019.