Helicobacter pylori: test and treat in primary care
The case
A 32-year-old woman presents with 4 weeks of episodic epigastric pain and bloating that is not relieved by antacids. She has no alarm features, no family history of gastrointestinal cancer and no NSAID use. Examination is normal. What is the most appropriate initial diagnostic test for Helicobacter pylori?
Options
- AUrea breath test
- BEndoscopy with biopsy urease testing
- CFaecal antigen test
- DSerum H. pylori IgG antibody
- EFaecal calprotectin
Think it through before you read on. Which single option is best, and why are the other four wrong?
Show the answer and explanation
Answer
A. Urea breath test
Why this is the right answer
This is uncomplicated dyspepsia in a young woman. There are no alarm features: no weight loss, vomiting, dysphagia, bleeding, anaemia or mass, and she is under 55. In this group Australian guidance uses a 'test and treat' approach: test non-invasively for H. pylori and treat if positive, without endoscopy [VERIFY].
The urea breath test is the preferred non-invasive test in Therapeutic Guidelines (Gastrointestinal) and Gastroenterological Society of Australia advice [VERIFY]. It has sensitivity and specificity above 95% and detects active infection only. The patient must stop proton pump inhibitors for 2 weeks and antibiotics for 4 weeks before the test, because these suppress the organism and cause false negatives.
The faecal antigen test is an acceptable alternative with similar accuracy when the breath test is not available, and has the same drug-withholding rules.
Serology is not recommended. It stays positive for years after the infection is gone, so it cannot distinguish current from past infection and cannot be used to confirm eradication.
If the test is positive, first-line treatment in Australia is a proton pump inhibitor with amoxicillin and clarithromycin for 7 to 14 days [VERIFY], followed by a repeat breath test at least 4 weeks after finishing antibiotics to confirm eradication.
Why the other options are wrong
- B
Endoscopy is reserved for alarm features, age over 55, or failure of initial management.
- C
Faecal antigen is a valid alternative but the breath test is preferred where available.
- D
Serology cannot separate active from past infection and is not recommended in Australian practice.
- E
Calprotectin measures bowel inflammation and has no role in H. pylori diagnosis.
High-yield takeaway
Under 55 with dyspepsia and no alarm features: test and treat with a urea breath test, off PPIs for 2 weeks first.
Reference: Therapeutic Guidelines: Gastrointestinal, Helicobacter pylori infection (2022)
Common questions
How long should PPIs be stopped before a urea breath test?
Two weeks. Antibiotics and bismuth should be stopped for four weeks.
How is eradication confirmed after treatment?
With a repeat urea breath test at least four weeks after the antibiotics finish. Serology cannot be used because it stays positive.
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