When to Get H. Pylori Testing
Test for H. pylori in patients under 50 years old with dyspepsia who lack alarm symptoms (bleeding, weight loss, dysphagia, anemia, palpable mass), using a non-invasive test-and-treat strategy without requiring endoscopy. 1
Age-Based Testing Algorithm
Patients Under 40-45 Years
- Proceed with non-invasive H. pylori testing (urea breath test or stool antigen test) if dyspeptic symptoms are present and no alarm symptoms exist 2
- Rule out family history of gastric cancer before testing without endoscopy, as this constitutes a risk factor requiring specialist referral 2
- This approach is cost-effective and captures patients with uncomplicated duodenal ulcer disease who will benefit from eradication 2
Patients Over 45-50 Years
- Refer for endoscopy with invasive testing if severe dyspeptic symptoms are present, as gastric cancer incidence rises significantly (19 per 100,000 for men, 9 per 100,000 for women in the European Community) 2, 1
- The age cutoff may be lower in regions with higher gastric cancer prevalence 2
Alarm Symptoms Requiring Immediate Endoscopy (Any Age)
- Proceed directly to endoscopy regardless of age if any of the following are present: 2, 1
- Anemia
- Unintentional weight loss
- Dysphagia (difficulty swallowing)
- Palpable abdominal mass
- Gastrointestinal bleeding
- Malabsorption
Specific Clinical Indications for Testing
Definite Indications
- Active peptic ulcer disease (gastric or duodenal ulcers) 1
- History of peptic ulcer disease, especially with complications like bleeding 1
- Gastric MALT lymphoma 1
- Atrophic gastritis or intestinal metaplasia (high-risk precancerous conditions) 1
- Long-term PPI therapy (>1 year) due to increased risk of atrophic gastritis 1
Test-and-Treat Strategy
- Young patients (<50 years) with uninvestigated dyspepsia without alarm symptoms should undergo non-invasive testing followed by immediate treatment if positive 1
- This strategy reduces unnecessary endoscopies by 62% while maintaining equivalent safety and symptom resolution 1
Critical Pre-Testing Medication Washout
Proton Pump Inhibitors (PPIs)
- Stop PPIs for at least 2 weeks before testing with urea breath test, stool antigen test, rapid urease test, histology, or culture 2, 1
- PPIs cause 10-40% false-negative rates by reducing bacterial load, particularly in the antrum 2
- Exception: Serology is the only test unaffected by PPI use and can be performed without stopping PPIs 2, 1
Antibiotics and Bismuth
- Stop for at least 4 weeks before testing to avoid false-negative results 1
Choosing the Right Test
Non-Invasive Tests (Primary Care Setting)
- First choice: 13C-urea breath test (sensitivity 94.7-97%, specificity 95-95.7%) or laboratory-based monoclonal stool antigen test (sensitivity and specificity ~93%) 1
- Avoid: Rapid in-office serological tests due to disappointing accuracy (sensitivity 63-97%, specificity 68-92%) 2, 1
- Limited role for serology: Only use validated IgG ELISA serology when patients cannot stop PPIs/antibiotics, or in cases of gastric atrophy, malignancy, or ulcer bleeding where bacterial load may be low 2, 1
Invasive Tests (During Endoscopy)
- Rapid urease test for quick results during endoscopy 1
- Histology with Giemsa staining (sensitivity 90-95%) requires at least two biopsies from both antrum and body 1
- Culture with susceptibility testing in regions with high clarithromycin resistance (>15-20%) or after treatment failure 2, 1
Common Pitfalls to Avoid
- Do not use serology to confirm eradication after treatment, as antibodies remain elevated for months to years after bacterial elimination 1
- Do not rely on single antral biopsies, which miss infections in 10% of cases due to patchy colonization 1
- Do not test patients on PPIs without either stopping the medication for 2 weeks or using serology instead 2, 1
- Avoid commercial ELISA serology tests with accuracy <90%, as overall average accuracy is only 78% 1