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Dyspepsia - unidentified cause - Management
Which test is recommended for Helicobacter pylori?

  • For people who have not previously been diagnosed with Helicobacter pylori infection, test with:
    • Urea breath test (unless they have received a proton pump inhibitor [PPI] in the past 14 days or an antibiotic in the past 28 days), or
    • Stool antigen test (unless they have received a PPI in the past 14 days or an antibiotic in the past 28 days), or
    • Laboratory serology testing (where the performance of the test has been locally validated).
  • For people who have been previously diagnosed with H. pylori infection and treated with eradication therapy, re-test (if indicated) at least four weeks after treatment. Urea breath test is preferred. However, stool antigen test could be used if urea breath test is not available.
    • Stop PPI use 14 days prior to testing. Withhold testing for 28 days after treatment with an antibiotic.
Basis for recommendation
  • These recommendations are based on those issued by the National Institute for Health and Clinical Excellence (NICE) [North of England Dyspepsia Guideline Development Group, 2004], the British National Formulary (BNF) [BNF 55, 2008] and the Maastricht III Consensus report (based on expert opinion [50 experts from 26 countries] and published evidence) issued by the European Helicobacter Study Group (EHSG) [Malfertheiner et al, 2007].
  • For people who have not previously been diagnosed with Helicobacter pylori infection, all three tests may be used:
    • Evidence summarized by NICE show that the sensitivity of stool antigen testing, breath testing, and some serological tests to be over 90% [North of England Dyspepsia Guideline Development Group, 2004].
    • NICE considered this level of sensitivity adequate to recommend the use of these tests for detecting H. pylori infection.
  • For carbon urea breath test and stool antigen test, proton pump inhibitors should be stopped for at least two weeks before the test while any antibiotics must be stopped four weeks before [McNulty et al, 2005; BNF 55, 2008].
    • One systematic review found evidence that PPI treatment can reduce accuracy of stool antigen test and urea breath test [Gisbert and Pajares, 2004]. The negative effect of PPIs disappeared one to two weeks after stopping the PPI.
  • Re-testing for H. pylori after eradication therapy:
    • If re-testing is indicated, NICE recommends that the carbon urea breath test should be used as it found insufficient evidence to recommend the stool antigen test as a test of eradication [NICE, 2005].
    • The carbon urea breath test is also preferred by EHSG (as detailed in the Maastricht III Consensus report) based on assessment of the evidence which found the accuracy of the stool antigen tests to be less than that of the urea breath test in people re-tested after H. pylori eradication [Malfertheiner et al, 2007]. Nevertheless, expert consensus considered that the stool antigen test can be used if the carbon urea breath test is not available. They also recommended that retesting should be done at least four weeks after eradication treatment.

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