When to Test for H. pylori or Porphyria in Children with Recurrent Abdominal Pain
Routine testing for H. pylori is not recommended in children with recurrent abdominal pain, and porphyria testing should be reserved for children with specific systemic symptoms beyond isolated abdominal pain.
H. pylori Testing in Recurrent Abdominal Pain
Do Not Test Routinely
Testing for H. pylori should not be performed in the majority of children presenting with recurrent abdominal pain based on Apley's criteria alone (at least three discrete episodes of abdominal pain severe enough to interrupt normal activities over three or more months) 1, 2.
The evidence shows no consistent association between H. pylori infection and recurrent abdominal pain in children, with studies showing conflicting odds ratios ranging from 0.32 to 1.80 1.
Community-based studies demonstrate that H. pylori seropositivity rates in children with recurrent abdominal pain are not significantly different from asymptomatic controls in many populations 2.
When H. pylori Testing IS Indicated
Test for H. pylori only when endoscopy is being performed for other clinical indications, specifically:
Children with alarm symptoms requiring endoscopy: unexplained weight loss, progressive dysphagia, recurrent vomiting, evidence of gastrointestinal bleeding, or family history of gastric cancer 3.
Children over age 55 years with new-onset dyspepsia (though this rarely applies to pediatric populations) 3.
When endoscopy reveals antral nodular gastritis or peptic ulcer disease, at which point biopsy-based testing (rapid urease test, histology, culture) should be performed 4.
Children with persistent symptoms despite empirical therapy who undergo endoscopy for diagnostic reassessment 3.
Testing Methodology Considerations
If testing is indicated, proper preparation is essential:
Stop proton pump inhibitors for at least 2 weeks before testing with culture, histology, rapid urease test, urea breath test, or stool antigen test, as PPIs cause false-negative results in up to 40% of cases 3, 5.
Stop antibiotics and bismuth for at least 4 weeks before testing 5.
If stopping PPIs is not feasible due to symptom management, validated IgG serology can be used as it detects antibodies rather than active infection 3, 5.
The stool antigen test has sensitivity and specificity exceeding 90% in untreated patients but requires proper medication washout 3, 5.
Porphyria Testing in Recurrent Abdominal Pain
When to Consider Porphyria
Porphyria testing should be considered only when children present with recurrent abdominal pain PLUS systemic manifestations, including:
- Neurological symptoms (peripheral neuropathy, seizures, mental status changes).
- Photosensitivity or skin manifestations.
- Dark or reddish urine.
- Family history of porphyria.
- Unexplained tachycardia or hypertension during pain episodes.
Why Routine Testing is Not Warranted
- Porphyria is an extremely rare cause of isolated recurrent abdominal pain in children.
- The provided evidence does not support routine porphyria screening in children with uncomplicated recurrent abdominal pain.
- Testing should be guided by the presence of characteristic systemic features rather than abdominal pain alone.
Common Pitfalls to Avoid
Do not perform "shotgun" testing for H. pylori in all children with recurrent abdominal pain, as this leads to unnecessary treatment and does not improve outcomes 1, 2.
Do not test for H. pylori while the child is taking PPIs without proper washout, as this produces false-negative results in a substantial proportion of cases 3, 5.
Do not use rapid in-office serological tests for H. pylori, as they have limited accuracy compared to laboratory ELISA tests 5.
Do not assume H. pylori eradication will resolve recurrent abdominal pain, as the evidence for causation is inconsistent and many children remain symptomatic despite successful eradication 1.
Do not test for porphyria based solely on abdominal pain without accompanying systemic features, as this represents poor resource utilization in a condition with extremely low pretest probability.
Practical Algorithm
For children presenting with recurrent abdominal pain:
Assess for alarm symptoms (weight loss, dysphagia, bleeding, family history of GI malignancy) 3.
If alarm symptoms present: Proceed to endoscopy and test for H. pylori via biopsy-based methods at that time 3.
If no alarm symptoms: Do NOT routinely test for H. pylori; focus on functional abdominal pain management 1, 2.
For porphyria consideration: Only test if systemic manifestations (neurological, dermatological, characteristic urine changes) are present alongside abdominal pain.
If testing for H. pylori is deemed necessary: Ensure 2-week PPI washout and 4-week antibiotic/bismuth washout before testing 3, 5.