These questions and answers make recommendations about when and how primary care should test for Helicobacter pylori
. This guidance is based on evidence discussed in detail in other national dyspepsia guidelines available—NICE, the Scottish Intercollegiate Guideline Network, and the Health Protection Agency—therefore, referencing is limited because much of the information can be found in their publications or at their websites.38–41
This subject is not addressed in the GMS contract.
Who should I test for H pylori?
We recommend testing:
- Patients with a past history of gastric ulcer (GU) or duodenal ulcer (DU) who have not previously been tested.
- Patients with uncomplicated, uninvestigated dyspepsia that is not responsive to lifestyle changes, antacids, H2 antagonists, or proton pump inhibitors (PPIs).42–46
- Patients using non-steroidal anti-inflammatory drugs with diagnosed or previous GU.38
Eradication of H pylori
in patients with DU and GU cures the ulcer and prevents recurrence.38,47
In patients using non-steroidal anti-inflammatory drugs, H pylori
eradication reduces the risk of the first occurrence of a GU and reduces recurrence of a GU.38,47
Symptoms will improve naturally in 36% of patients with uninvestigated dyspepsia, 7% will improve as a result of eradication treatment, and in 57% substantial symptoms will remain over a three to 12 month period.46
Which non-invasive helicobacter test should I use?
We recommend the urea breath test or stool antigen test.
The most accurate test (95% specificity and sensitivity) is the urea breath test, which detects current infection.48
This is available on prescription (FP10 BNF section 1.3.1). It requires the patient to swallow a capsule and requires a breath sample at 0 and 20 minutes. This will need to be supervised by a trained individual. The 2003 cost of the breath test was £19.00, including nurse time.
The stool antigen test also detects current infection and is very accurate, but there have been fewer studies on its accuracy than for the breath test.48,49
(Current information indicates a specificity and sensitivity of 92–96% and 93–97%, respectively, depending on the kit manufacturer.) It is a laboratory based test. The patient provides a pea sized piece of stool in the usual laboratory stool pot. No practice nurse time is needed. Specimens should be refrigerated after collection. The 2003 cost of the stool test, including nurse time, is £11.00.
The patient must not take proton PPIs or antibiotics for at least two weeks (ideally four) before, or H2
antagonists for 24 hours before, these tests because these drugs suppress the organism and can lead to false negative results.50–52
Laboratory based and near patient blood tests are not as accurate48,53
(sensitivity and specificity of 88%–92%). They should only be used if no other tests are available. This test detects antibody to helicobacter. A positive serology result can mean that54
- The patient is infected at the time of the test.
- The patient had an infection earlier that has resolved, either spontaneously or after specific treatment.
- The test is detecting non-specific, crossreacting antibodies.
What do I do if I find that my patient has helicobacter?
We recommend that the bacterium is eradicated using triple treatment with a PPI or ranitidine bismuth citrate plus two antibiotics. The importance of compliance with treatment should be stressed.
Analysis of randomised controlled trials by NICE has shown that the most cost effective regimen is PPI once daily plus metronidazole 400 mg twice daily and clarithromycin 250 mg twice daily.38
Other combinations of acid reducing agent (PPI or ranitidine bismuth citrate) in combination with two antibiotics may be used as shown in table 1.
Table 1 Antibiotics for use in eradicating helicobacter
However, because amoxicillin is inactivated at acid pH, PPI twice daily must be used with this drug, and a higher dose of clarithromycin is needed in other combinations.38
Do I retest for helicobacter after treatment?
No, as long as compliance with treatment is good this is unnecessary in most patients with dyspepsia.
Only retest in:
- Patients who have DU and are still symptomatic.
- Patients with maltoma (very rare and should be under the care of a specialist).
About 40% of patients will be asymptomatic after treatment.46
In the 60% with ongoing symptoms of dyspepsia, do not retest unless symptoms suggest that you do. Treat as functional dyspepsia and prescribe PPI or H2
antagonists. The addition of further tests and second line eradication greatly increases costs and there are no reliable data to model further reductions either in risk of infection or dyspepsia symptoms.38
Which test should I use if I need to retest?
We recommend the urea breath test or stool antigen test. PPIs and antibiotics should be stopped for at least two, or preferably four, weeks.50–52,55
The urea breath test is the most accurate test after treatment49,54
; monoclonal stool antigen tests may also be used.49
Serology should not be used after treatment because it may detect persisting antibodies.48,54
When should I refer patients for endoscopy to diagnose helicobacter?
We recommend that patients who have complied with two courses of eradication treatment and are still helicobacter positive or patients who are allergic to penicillin and have received clarithromycin and/or metronidazole for other infections should be referred for endoscopy.
Resistance is more common if patients have had courses of clarithromycin or metronidazole for helicobacter or other infections.56
When patients are hypersensitive to the recommended antibiotics this reduces the treatment options. In these more complicated scenarios, clinicians should contact their local microbiologist and discuss the possibility of antibiotic susceptibility testing via the helicobacter reference laboratory at the Health Protection Agency.