What is the recommended approach for diagnosing and treating H. Pylori (Helicobacter Pylori) infection?

Diagnosis of Helicobacter pylori Infection

The recommended approach for diagnosing H. pylori infection is to use the Urea Breath Test (UBT) as the first-line non-invasive test due to its highest accuracy (sensitivity 94.7%, specificity 95.7%), followed by stool antigen testing as an excellent alternative. 1

Non-Invasive Testing Options

Primary Testing Methods

• Urea Breath Test (UBT)

  • Gold standard non-invasive test recommended by the American Gastroenterological Association
  • Highest accuracy with sensitivity of 94.7% and specificity of 95.7%
  • Requires patient to stop PPIs for at least 2 weeks before testing
  • Can be used for both initial diagnosis and post-treatment confirmation

• Stool Antigen Test

  • Excellent alternative to UBT
  • High accuracy with sensitivity of 94-95% and specificity of 97-100%
  • Can be used as early as 14 days after treatment to confirm eradication
  • More convenient for some patients as it doesn't require specialized equipment

• Serology Testing

  • Not recommended as initial test due to limited specificity (79%)
  • Cannot distinguish between active and past infection
  • Only useful in specific circumstances:
    • When patient cannot stop PPI therapy
    • For initial screening in high-prevalence populations

Invasive Testing Options

Endoscopy with biopsy is indicated in specific clinical scenarios:

• Patients with alarm symptoms (bleeding, weight loss, dysphagia, anemia)
• Patients over 45-50 years with new-onset dyspepsia
• Patients who have failed eradication therapy and need culture and antimicrobial sensitivity testing 2

During endoscopy, several tests can be performed:

• Rapid Urease Test (RUT)

  • Quick results before patient leaves endoscopy unit
  • Cheaper than histology
  • Allows immediate discussion and treatment initiation

• Histology

  • Provides additional information about gastritis patterns
  • Can detect other pathologies
  • Multiple biopsies (at least two from antrum and body) improve sensitivity
  • Special staining methods improve detection

• Culture

  • Allows antimicrobial sensitivity testing
  • Useful for patients who have failed initial therapy

Testing Strategy Based on Clinical Scenario

For Young Patients (<45-50 years) with Dyspepsia and No Alarm Symptoms

1. Use "test and treat" strategy with non-invasive testing
2. UBT as first choice, or stool antigen test as alternative
3. Treat if positive without endoscopy

For Patients with Alarm Symptoms or Older Patients (>45-50 years)

1. Proceed directly to endoscopy
2. Perform RUT and/or histology during endoscopy
3. Treat based on results

For Post-Treatment Confirmation

1. Wait at least 4-8 weeks after completing therapy
2. Stop PPIs for at least 2 weeks before testing
3. Use UBT or stool antigen test (not serology)

Common Pitfalls to Avoid

• Testing too soon after treatment completion
• Failing to stop PPIs, bismuth, or antibiotics before testing (can lead to false negatives)
• Using serology to confirm eradication (cannot distinguish active from past infection)
• Relying on a single biopsy sample during endoscopy (sampling errors due to patchy distribution)
• Not considering local antibiotic resistance patterns when selecting therapy

Treatment Recommendations

For first-line treatment of H. pylori infection:

• Triple therapy consisting of amoxicillin (1g), clarithromycin (500mg), and lansoprazole (30mg), all given twice daily for 14 days 1, 3
• In areas with high clarithromycin resistance (≥15%), consider bismuth quadruple therapy
• For penicillin-allergic patients, use dual therapy with lansoprazole and clarithromycin or bismuth quadruple therapy without amoxicillin

The combination of accurate diagnosis and appropriate treatment is essential for successful management of H. pylori infection, reducing the risk of complications such as peptic ulcer disease, gastric cancer, and gastric MALT lymphoma.