How is H. pylori eradication confirmed?

Confirmation of H. pylori Eradication

H. pylori eradication should be confirmed using the 13C-urea breath test (UBT) performed at least 4 weeks after completion of treatment, as it is the non-invasive gold standard with high sensitivity and specificity for post-treatment evaluation. 1, 2

When to Confirm Eradication

Confirmation of H. pylori eradication is strongly recommended in:

• Complicated peptic ulcer disease
• Gastric ulcer
• Low-grade gastric MALT lymphoma
• Cases where treatment has low efficacy
• Patients with poor compliance
• Patients with high risk of complications if infection persists

In these high-risk scenarios, confirmation is essential as persistent infection is a negative prognostic marker for disease recurrence and complications 1.

Timing of Confirmation Testing

• Tests should be performed no earlier than 4 weeks after completion of treatment 1, 2
• Patients should stop proton pump inhibitors (PPIs) for at least 2 weeks before testing to avoid false negatives 2

Recommended Testing Methods

For High-Risk Conditions (Endoscopy-Based Testing)

For complicated peptic ulcer disease, gastric ulcer, and MALT lymphoma, endoscopy-based testing is recommended:

• Obtain full-thickness mucosal biopsy specimens from both antrum and body (at least two from each site)
• Include one biopsy for rapid urease test
• Perform histological assessment with special stains (e.g., modified Giemsa stain) 1, 2

This approach is necessary when additional histological assessment of mucosal abnormalities is required.

For Uncomplicated Cases (Non-Invasive Testing)

For uncomplicated peptic ulcer and non-ulcer dyspepsia:

• 13C-Urea Breath Test (UBT): The gold standard non-invasive test with sensitivity of 97% and specificity of 71% at 6 weeks post-treatment 1, 3
• Stool Antigen Test: A validated laboratory stool test (not rapid test) can be used with high sensitivity (97.47%) and specificity (98.73%) 4

Tests to Avoid

• Serology: Not recommended for early confirmation as antibody titers take up to 6 months to decrease by 50% 1
• Rapid stool tests: These have lower sensitivity (58.14%) and specificity (76.4%) in post-treatment settings 4

Clinical Approach Algorithm

1. Determine risk category:

   • High-risk patients (complicated ulcers, gastric ulcers, MALT lymphoma)
   • Standard-risk patients (uncomplicated duodenal ulcers, non-ulcer dyspepsia)

2. For high-risk patients:

   • Schedule endoscopy with biopsies at least 4 weeks after treatment completion
   • Ensure PPI cessation for 2 weeks prior to testing
   • Obtain multiple biopsies from antrum and body

3. For standard-risk patients:

   • Schedule 13C-UBT at least 4 weeks after treatment completion
   • Ensure PPI cessation for 2 weeks prior to testing
   • If UBT unavailable, use validated laboratory stool antigen test

4. For patients with symptom resolution:

   • In uncomplicated duodenal ulcer, symptom assessment at 3-6 months may be as valuable as UBT 1

Common Pitfalls to Avoid

• Testing too early (before 4 weeks post-treatment)
• Failing to discontinue PPIs before testing
• Using serology for early confirmation
• Relying on rapid stool tests which have lower accuracy
• Not confirming eradication in high-risk patients even when symptoms resolve

By following these evidence-based recommendations for confirming H. pylori eradication, clinicians can ensure appropriate follow-up and reduce the risk of complications from persistent infection, ultimately improving patient outcomes in terms of morbidity and mortality.