What is the first test for patients presenting with dyspepsia, endoscopy or H. pylori (Helicobacter pylori) testing?

First Test for Dyspepsia: H. pylori Testing vs Endoscopy

For patients under 55 years old without alarm symptoms, non-invasive H. pylori testing (urea breath test or stool antigen test) should be the first test, not endoscopy. 1

Age-Based Algorithm for Initial Testing

Patients Under 55 Years Without Alarm Symptoms

• Start with non-invasive H. pylori testing using either urea breath test (UBT) or laboratory-based monoclonal stool antigen test as the first-line diagnostic approach. 1, 2
• The UBT demonstrates excellent accuracy with sensitivity of 94.7-97% and specificity of 95-95.7%. 2
• The stool antigen test shows comparable performance with sensitivity and specificity of approximately 93%. 2, 3
• This "test and treat" strategy reduces unnecessary endoscopies by 62% compared to immediate endoscopy while maintaining equivalent safety and symptom resolution. 1, 2

Patients 55 Years or Older

• Proceed directly to endoscopy if they have new-onset dyspepsia with weight loss. 1
• Consider non-urgent endoscopy for those aged ≥55 years with treatment-resistant dyspepsia or dyspepsia with raised platelet count, nausea, or vomiting. 1

When Endoscopy Must Be First

Mandatory Immediate Endoscopy Indications

• Patients over 40 years from areas at increased risk of gastric cancer or with family history of gastro-oesophageal cancer require urgent endoscopy. 1
• Any patient with alarm symptoms (bleeding, weight loss, dysphagia, palpable mass, anemia, malabsorption) regardless of age should undergo endoscopy first. 1, 2
• Patients aged ≥60 years with abdominal pain and weight loss should have urgent abdominal CT scanning to exclude pancreatic cancer. 1

Critical Testing Considerations

Medication Washout Requirements

• Stop proton pump inhibitors at least 2 weeks before performing UBT or stool antigen testing to avoid false-negative results. 2, 4
• Discontinue antibiotics and bismuth for at least 4 weeks before H. pylori testing. 2
• These medications do not affect serology results, but serology cannot distinguish active infection from past exposure and should not be used for initial diagnosis. 2, 4

Why Serology Should Not Be Used

• Serological tests have inadequate accuracy averaging only 78% (range 68-82%). 2
• Serology cannot differentiate between active infection and previous exposure, with antibodies persisting long after eradication. 2, 4
• The positive predictive value falls dramatically in populations with low disease prevalence. 1

Management After Initial H. pylori Testing

If H. pylori Positive

• Provide eradication therapy immediately without requiring endoscopy in young patients without alarm symptoms. 1
• Eradication reduces future peptic ulcer risk, complications from NSAIDs, and gastric cancer risk. 1, 5

If H. pylori Negative or Symptoms Persist After Eradication

• Offer empirical acid suppression therapy with proton pump inhibitors. 1
• Reserve endoscopy for patients who fail to respond to empirical treatment. 6

Common Pitfalls to Avoid

• Do not use rapid in-office immunochromatographic tests for H. pylori—these have significantly lower accuracy (80-81%) compared to laboratory-based tests. 4, 3
• Do not perform endoscopy first in young patients without alarm symptoms—this approach is more expensive (£404.31 vs £205.67 per patient per year) without improving outcomes. 1
• Do not test patients currently taking PPIs or antibiotics without appropriate medication washout periods, as this leads to false-negative results. 2, 4
• Do not use serology to confirm eradication—antibodies remain elevated after successful treatment. 2, 4