When should Helicobacter pylori be tested for and treated in patients with acid‑peptic disease, based on the presence or absence of alarm features?

When to Test and Treat for H. pylori in Acid Peptic Disease

Test and treat H. pylori in patients under 55 years old without alarm symptoms using non-invasive testing (urea breath test or stool antigen test), and refer patients ≥55 years or those with any alarm symptoms for endoscopy with biopsy-based H. pylori testing. 1, 2

Age-Based Diagnostic Algorithm

Patients Under 55 Years Without Alarm Symptoms

• Use the "test and treat" strategy as the first-line approach, which is equally effective as endoscopy but significantly more cost-effective, reducing endoscopy workload by 62% 3, 2
• Perform non-invasive testing with either 13C-urea breath test (sensitivity 94.7-97%, specificity 95-100%) or monoclonal stool antigen test (sensitivity and specificity >90%) 1, 4
• Avoid serology testing (IgG/IgM antibodies) as the primary diagnostic method due to lower specificity and poor cost-effectiveness, particularly in low-prevalence populations 1, 2
• If H. pylori positive: Initiate eradication therapy immediately with bismuth quadruple therapy or concomitant therapy for 14 days 2, 5
• If H. pylori negative: Offer empirical acid suppression with a proton pump inhibitor for 4-8 weeks 2

Patients ≥55 Years or With Alarm Symptoms (Any Age)

• Proceed directly to endoscopy regardless of H. pylori status, as the standardized incidence of gastric cancer rises significantly after age 45-55 years (19 per 100,000 for men, 9 per 100,000 for women in Europe) 3
• Obtain biopsy specimens at the time of endoscopy for H. pylori testing via rapid urease test, histology, or culture 1
• Treat H. pylori if positive to reduce the risk of subsequent peptic ulcer disease and gastric malignancy 3

Defining Alarm Symptoms

Alarm features requiring immediate endoscopy include: 3

• Unintentional weight loss
• Progressive dysphagia
• Recurrent vomiting
• Evidence of gastrointestinal bleeding (anemia, melena, hematemesis)
• Palpable abdominal mass
• Family history of gastric cancer
• Malabsorption symptoms

Post-Treatment Confirmation Testing

When to Confirm Eradication

• Mandatory confirmation is required only in high-risk patients: those with gastric ulcer, complicated peptic ulcer disease, gastric MALT lymphoma, or increased gastric cancer risk 2, 4
• Not routinely needed in uncomplicated duodenal ulcer patients with symptom resolution 2

How to Confirm Eradication

• Wait at least 4 weeks after completing treatment before testing to avoid false-negative results from temporary bacterial suppression 4
• Use urea breath test or stool antigen test—never serology, which cannot distinguish active infection from past exposure 4
• Discontinue PPIs for 2 weeks and antibiotics/bismuth for 4 weeks before testing 4

Common Pitfalls to Avoid

• Do not perform unnecessary endoscopy in young patients without alarm symptoms—the test-and-treat strategy costs £205.67 per patient per year versus £404.31 for endoscopy 3
• Do not use serology for diagnosis or confirmation of eradication—it has no role in determining treatment success 1, 4
• Do not test too early after treatment—testing before 4 weeks yields unreliable results due to incomplete mucosal recovery 4
• Do not ignore regional variations—the age cutoff for endoscopy may be lower than 45 years in regions with higher gastric cancer incidence 3

Special Considerations

NSAID Users

• Eradicate H. pylori in NSAID users to reduce peptic ulcer risk by 50%, as the combination of H. pylori and NSAIDs synergistically increases bleeding ulcer risk more than sixfold 5

Treatment Failure

• After two failed eradication attempts, pursue antimicrobial susceptibility testing to guide third-line therapy 2
• Never repeat the same regimen after treatment failure—select a completely different antibiotic combination avoiding previously used agents 2