When should H. pylori (Helicobacter pylori) testing be considered?

When to Consider H. pylori Testing

H. pylori testing should be considered in patients with uninvestigated dyspepsia under 50 years without alarm symptoms, as well as in patients with peptic ulcer disease, gastric MALT lymphoma, and those requiring long-term PPI therapy. 1

Primary Indications for H. pylori Testing

• The "test and treat" strategy is strongly recommended for young (<50 years) dyspeptic patients without alarm symptoms to reduce unnecessary endoscopies 1
• Patients with active peptic ulcer disease (gastric or duodenal ulcers) should be tested for H. pylori infection 2
• Patients with a history of peptic ulcer disease, especially those with complications such as bleeding, should be tested 2
• Testing is indicated in patients with gastric MALT lymphoma 2
• Patients requiring long-term PPI therapy (>1 year) should be tested due to increased risk of atrophic gastritis 2
• Patients with atrophic gastritis or intestinal metaplasia should be tested as these are high-risk conditions for developing gastric cancer 2

Situations Requiring Endoscopy and Invasive Testing

• Patients with alarm symptoms (bleeding, weight loss, dysphagia, palpable mass, or signs of malabsorption) should undergo endoscopy with biopsy-based testing 1
• Older patients (≥50 years) with new-onset dyspepsia should undergo endoscopy due to increased risk of malignancy 1
• Patients who have failed eradication therapy, especially when culture and antimicrobial sensitivity testing are needed to guide subsequent treatment 1
• In regions with high clarithromycin resistance, culture and susceptibility testing should be performed before first-line treatment if standard clarithromycin-containing triple therapy is being considered 1

Recommended Testing Methods

Non-invasive Tests

• Urea Breath Test (UBT) is the preferred non-invasive test with excellent sensitivity (94.7-97%) and specificity (95-95.7%) 1
• Laboratory-based validated monoclonal stool antigen test is also recommended with sensitivity and specificity of approximately 93% 2, 1
• Serology should not be used as the primary diagnostic method as it cannot distinguish between active infection and past exposure 1

Invasive Tests (During Endoscopy)

• Rapid Urease Test provides quick results during endoscopy 1
• Histology allows visualization of bacteria and assessment of mucosal damage 1
• Culture permits antimicrobial susceptibility testing, especially valuable after treatment failure 1

Important Testing Considerations

• Proton pump inhibitors (PPIs) should be stopped for at least 2 weeks before testing by culture, histology, rapid urease test, UBT, or stool test 2
• If stopping PPIs is not possible, validated IgG serology can be performed as it is not affected by local changes in the stomach 2
• Antibiotics and bismuth compounds should be discontinued at least 4 weeks before testing 1
• For confirmation of eradication, testing should be performed no earlier than 4 weeks after completion of treatment 2
• The UBT or laboratory-based validated monoclonal stool test are recommended for determining the success of eradication treatment 2

Special Populations and Considerations

• Confirmation of H. pylori eradication is strongly recommended in complicated peptic ulcer disease, gastric ulcer, and cases of low-grade gastric MALT lymphoma 2
• In patients with bleeding ulcers, H. pylori eradication treatment should be started at reintroduction of oral feeding 2
• In areas with high prevalence of gastric cancer, H. pylori testing followed by endoscopy in positive patients may be appropriate 2

Pitfalls to Avoid

• Rapid in-office serological tests have limited accuracy and should be avoided 2
• Serology should not be used to confirm eradication after treatment as antibodies remain elevated after H. pylori elimination 1
• The positive predictive value of serology tests falls dramatically in populations with low disease prevalence 1
• Failure to stop PPIs before testing can lead to false-negative results in all tests except serology 2, 1

By following these evidence-based recommendations for H. pylori testing, clinicians can appropriately identify and manage patients who would benefit from eradication therapy, ultimately reducing the risk of peptic ulcer disease complications and potentially gastric cancer.