When is Helicobacter pylori (H. pylori) testing and treatment recommended?

H. pylori Testing and Treatment Indications

H. pylori testing and treatment is primarily indicated for uninvestigated dyspepsia in populations with high H. pylori prevalence (≥20%), peptic ulcer disease, gastric cancer prevention, and specific conditions like MALT lymphoma. 1, 2

Primary Indications for Testing

• Uninvestigated dyspepsia in populations with H. pylori prevalence ≥20%

  • Using a "test-and-treat" strategy
  • Not applicable to patients with alarm symptoms or older patients 1

• Patients with peptic ulcer disease (active or history)

  • Requires endoscopic follow-up until healing is confirmed for gastric ulcers 2

• Patients with alarm symptoms requiring immediate endoscopy:

  • Anemia
  • Weight loss
  • Dysphagia
  • Patients over 45 years with severe dyspeptic symptoms 2

• Specific conditions with established H. pylori association:

  • Gastric MALT lymphoma
  • History of gastric cancer
  • Unexplained iron deficiency anemia not responding to supplementation 2

Diagnostic Testing Methods

The main non-invasive tests recommended for H. pylori detection are:

1. 13C-Urea Breath Test (UBT) - 95% sensitivity and specificity 2
2. Stool Antigen Test (SAT) - 88-90% sensitivity, 91-100% specificity 2
3. Validated serological tests (ELISA) - 90% sensitivity, 95% specificity 1, 2

Important testing considerations:

• Proton pump inhibitors should be stopped before testing
• Serology should not be used to confirm eradication (antibodies remain elevated for months) 2
• Confirm eradication at least 4 weeks after completion of therapy using UBT or SAT 2

Treatment Approaches

For treatment-naive patients with H. pylori infection:

• Bismuth quadruple therapy for 14 days is preferred when antibiotic susceptibility is unknown 3
• Complete the full course of antibiotics even if symptoms improve 2

For treatment-experienced patients with persistent infection:

• "Optimized" bismuth quadruple therapy for 14 days is preferred 3
• Rifabutin triple therapy for 14 days is suitable for those previously treated with optimized bismuth quadruple therapy 3

Expected Outcomes

• H. pylori eradication produces long-term relief of dyspepsia in 1 of 12 patients with functional dyspepsia 1
• Eradication therapy leads to 25% reduction in dyspepsia consultations between 2-7 years of follow-up 1
• Eradication removes a risk factor for gastric cancer 1

Common Pitfalls to Avoid

• Using serology to confirm eradication (remains positive for months after successful treatment)
• Failing to stop PPIs before testing (can lead to false-negative results)
• Overlooking iron deficiency which may be exacerbated by H. pylori infection
• Unnecessary testing when results won't change management
• Poor compliance with treatment regimens, leading to antibiotic resistance 2

H. pylori management requires careful consideration of testing methods, treatment regimens, and follow-up strategies to ensure successful eradication and prevention of serious complications like peptic ulcer disease and gastric cancer.