I’m a middle‑aged man with abdominal pain; CT abdomen/pelvis shows no acute abnormality but reveals fatty liver, a simple renal cyst, prostatomegaly, small inguinal/umbilical hernias and sigmoid diverticulosis. I suspect Helicobacter pylori infection—what diagnostic test and first‑line treatment should I use, and how should I manage the incidental findings?

Management of Abdominal Pain with Suspected H. pylori and Incidental CT Findings

H. pylori Diagnostic Testing

You should proceed with non-invasive H. pylori testing using either a urea breath test or stool antigen test, as your CT abdomen/pelvis shows no acute pathology requiring urgent endoscopy. 1

Recommended Testing Approach

• Breath or stool testing for H. pylori is the baseline investigation recommended by the British Society of Gastroenterology for patients with dyspepsia without alarm features. 1

• The urea breath test has sensitivity of 94.7-97% and specificity of 95-100%, making it the gold standard non-invasive test. 2

• Monoclonal stool antigen testing provides sensitivity and specificity >90%, serving as an equally accurate alternative. 2

• You do NOT need endoscopy at this time because you lack alarm features (no weight loss, no evidence of bleeding, no dysphagia) and your age does not automatically trigger urgent endoscopy unless you are from a high-risk gastric cancer region or have family history of gastro-oesophageal malignancy. 1

Critical Testing Precautions

• If you are currently taking proton pump inhibitors (PPIs), discontinue them for at least 2 weeks before testing to prevent false-negative results. 2

• Antibiotics must also be stopped at least 2 weeks before testing. 2

First-Line H. pylori Treatment (If Positive)

If H. pylori is detected, bismuth quadruple therapy for 14 days is the preferred first-line treatment when antibiotic susceptibility is unknown. 3

Treatment Regimen Details

• Bismuth quadruple therapy (BQT) consists of: a proton pump inhibitor, bismuth subsalicylate, tetracycline, and metronidazole for 14 days. 3

• Alternative empiric regimens include rifabutin triple therapy or potassium-competitive acid blocker dual therapy for 14 days if you have no penicillin allergy. 3

• Eradication therapy is highly efficacious for H. pylori-positive functional dyspepsia and should be offered to all infected patients. 1

Post-Treatment Confirmation

• Confirm successful eradication at least 4 weeks after completing treatment using urea breath test or stool antigen test. 1, 2

• Wait the full 4 weeks to allow gastric mucosa recovery and avoid false-negative results. 2

• Serology should NOT be used to assess early treatment success, as antibody titers take up to 6 months to fall by 50%. 1

Management of Incidental CT Findings

Fatty Liver (Hepatic Steatosis)

• No specific follow-up imaging is required for fatty liver detected on CT. The finding is extremely common and management focuses on metabolic risk factor modification rather than imaging surveillance.

• Assess for metabolic syndrome components: obtain fasting glucose, lipid panel, and blood pressure measurement.

• Recommend weight loss if overweight (target 7-10% body weight reduction), regular aerobic exercise, and avoidance of excessive alcohol.

Simple Renal Cyst (Bosniak Type 1)

• The 10-mm simple cortical cyst requires no follow-up imaging, as explicitly stated in your CT report. [@Report findings@]

• Bosniak type 1 cysts are benign with essentially 0% malignancy risk and need no surveillance.

Prostatomegaly (67 mL)

• Prostatomegaly of 67 mL is moderate enlargement (normal <30 mL) and warrants evaluation only if you have lower urinary tract symptoms.

• If you experience urinary frequency, urgency, weak stream, or nocturia, obtain urinalysis to exclude infection and consider urology referral for symptom management.

• If asymptomatic, no immediate intervention is needed, but discuss with your primary care physician at routine follow-up.

Small Inguinal and Umbilical Hernias

• Fat-containing inguinal and umbilical hernias that are asymptomatic require only clinical monitoring, not urgent surgical repair.

• Seek immediate evaluation if you develop sudden severe pain, nausea/vomiting, or a firm, tender, irreducible bulge—these suggest incarceration or strangulation requiring emergency surgery.

• Elective hernia repair should be discussed with a general surgeon if hernias become symptomatic (pain, enlargement, interference with activities).

Sigmoid Diverticulosis

• Diverticulosis without diverticulitis requires no treatment, only dietary counseling. 1

• Increase dietary fiber intake (25-30 grams daily) through fruits, vegetables, and whole grains to reduce risk of future diverticulitis.

• Your CT explicitly states "without signs of diverticulitis," meaning no inflammation, abscess, or perforation is present. [@Report findings@]

• Do NOT undergo colonoscopy during acute abdominal pain episodes, as endoscopy is contraindicated when obstruction or perforation is possible. 4

Common Pitfalls to Avoid

• Do not assume your abdominal pain is definitely from H. pylori until testing confirms infection—functional dyspepsia can occur without H. pylori and requires different management strategies. 1

• Do not request endoscopy prematurely—the British Society of Gastroenterology reserves non-urgent endoscopy for treatment-resistant dyspepsia in patients ≥55 years, not as first-line investigation. 1

• Do not use serology (blood antibody tests) for initial H. pylori diagnosis—breath and stool tests are far superior for detecting active infection. 1, 2

• Do not ignore the need for test-of-cure after H. pylori treatment—up to 20-30% of patients fail first-line therapy, and persistent infection perpetuates symptoms and ulcer risk. 3