What is the recommended treatment and testing for a 27-year-old male (YOM) with dyspepsia suspected of having Helicobacter pylori (H. pylori) infection?

Management of H. pylori Testing and Treatment in a 27-Year-Old Male with Dyspepsia

For this 27-year-old male with dyspepsia and no alarm features, perform non-invasive H. pylori testing using either a 13C-urea breath test or stool antigen test, and if positive, provide eradication therapy without endoscopy. 1

Initial Diagnostic Approach

Non-Invasive Testing Strategy

• Use the "test and treat" approach for this patient, as he is under 55 years old and presumably without alarm features (weight loss, progressive dysphagia, recurrent vomiting, gastrointestinal bleeding, or family history of gastric cancer). 1
• The optimal non-invasive tests are the 13C-urea breath test or stool antigen test, which have superior accuracy compared to serological testing. 1, 2
• Avoid IgG or IgM antibody tests, as they have lower specificity and are less cost-effective than breath or stool tests. 2

When Endoscopy is NOT Needed

• Endoscopy is not indicated in this young patient without alarm features, as the yield for significant pathology is very low and the test-and-treat strategy is equally effective while being more cost-efficient. 1, 2
• This approach can avoid approximately 73% of unnecessary endoscopies with no detriment to clinical outcome. 3

Treatment Protocol if H. pylori Positive

First-Line Eradication Therapy

If H. pylori testing is positive, provide eradication therapy using one of these regimens:

Triple Therapy (Preferred): 4

• Amoxicillin 1 gram twice daily (every 12 hours)
• Clarithromycin 500 mg twice daily (every 12 hours)
• Lansoprazole 30 mg twice daily (every 12 hours)
• Duration: 14 days
• Take at the start of meals to minimize gastrointestinal intolerance 4

Alternative: Dual Therapy 4

• Amoxicillin 1 gram three times daily (every 8 hours)
• Lansoprazole 30 mg three times daily (every 8 hours)
• Duration: 14 days

Expected Outcomes

• Eradication therapy provides modest but significant benefit in dyspepsia and leads to long-term symptom improvement. 1
• It reduces the risk of developing peptic ulcer disease, atrophic gastritis, and gastric cancer. 5
• Adverse events are more common than with control therapy but are generally tolerable. 1

Post-Treatment Confirmation Testing

Do NOT routinely confirm eradication in this low-risk patient. 1

• Confirmation of successful eradication is only recommended for patients with increased risk of gastric cancer (age >40 years from high-risk areas, family history of gastric cancer, or personal history of gastric pathology). 1
• If confirmation is needed, use breath test or stool antigen test—never serology. 2

Management if H. pylori Negative

If the initial H. pylori test is negative:

• Offer empirical acid suppression therapy with a PPI for 4-8 weeks. 1
• Use the lowest effective PPI dose (e.g., omeprazole 20 mg once daily), taken 30-60 minutes before meals. 1, 6
• All commercially available PPIs have similar efficacy for symptom control. 6

When to Consider Endoscopy

Proceed to endoscopy only if: 1

• Symptoms persist despite H. pylori eradication and empirical PPI therapy
• Alarm features develop at any point
• The patient specifically requests it after discussion of risks and benefits

Important Caveats

• Avoid serology testing as the primary diagnostic method, as it cannot distinguish active from past infection and has lower accuracy. 2
• Regular aerobic exercise should be recommended as part of comprehensive management. 1
• If symptoms persist after treatment, reassess the diagnosis rather than immediately escalating to invasive testing. 1
• The test-and-treat strategy reduces long-term use of endoscopy and antisecretory medications compared to prompt endoscopy. 7