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
- 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
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.