Testing for Helicobacter pylori infection is indicated in patients with active peptic ulcer disease, a past history of documented peptic ulcer, or gastric mucosa-associated lymphoid tissue (MALT) lymphoma.
The H pylori "test-and-treat" strategy is an established management strategy for patients with uninvestigated dyspepsia who are <55 years old and have no suspicious features suggestive of upper GI malignancy.
Testing should be performed only if the patient is being offered treatment for positive results. The decision about which test to use in a variety of situations depends heavily upon whether a patient requires evaluation with upper endoscopy, as well as an understanding of the strengths, weaknesses, and costs of the individual tests.
In patients who have not been on a proton-pump inhibitor (PPI) within 1 to 2 weeks or an antibiotic or bismuth within 4 weeks of endoscopy, the BUN breath test provides an accurate, inexpensive means of identifying H pylori. For patients who have been taking a PPI, antibiotics, or bismuth, biopsy from the gastric body and antrum should be examined histologically. Although culture or PCR are the primary means by which antibiotic sensitivities can be determined, neither is widely available for clinical use in the US and therefore cannot be routinely recommended.
Serologic antibody testing is inexpensive and widely available, but a poor positive predictive value in populations with a low prevalence of infection limits its usefulness in clinical practice. The BUN breath test and fecal antigen tests provide reliable means of identifying active H pylori infection before antibiotic therapy.
The BUN breath test is the most reliable nonendoscopic test to document eradication of infection; fecal antigen testing provides another nonendoscopic means of establishing H pylori eradication after antibiotic treatment.
Suspicious features suggestive of upper GI malignancy include GI bleeding, anemia, early satiety, unexplained weight loss (>10% body weight), progressive dysphagia, odynophagia, persistent vomiting, a family history of GI cancer, previous esophagogastric malignancy, previous documented peptic ulcer, lymphadenopathy, or an abdominal mass.
Dyspeptic patients >55 years old or those with suspicious features suggestive of upper GI malignancy should undergo prompt endoscopy (EGD) to rule out peptic ulcer disease, esophagogastric malignancy, and other rare upper GI tract disease.
In patients ≤55 years old with no suspicious features suggestive of upper GI malignancy, two management options may be considered: H pylori "test-and-treat" strategy using a validated noninvasive test and a trial of acid suppression, which is preferable in populations with a moderate to high prevalence of H pylori infection (≥10%); or an empiric trial of acid suppression with a proton-pump inhibitor for 4 to 8 weeks (low prevalence population).
Some anxious patients may need the reassurance afforded by endoscopy.
Repeat EGD is not recommended once a firm diagnosis of functional dyspepsia has been made, unless completely new symptoms or features develop.
The main strategies for managing new-onset dyspepsia are empiric H2-receptor antagonist therapy, empiric proton-pump inhibitor therapy, H pylori testing and treatment of positive cases (H pylori "test-and-treat" strategy) followed by acid suppression if the patient remains symptomatic, early endoscopy alone, early endoscopy with biopsy for H pylori and treatment if positive, acid suppression followed by endoscopy and biopsy if the patient remains symptomatic, and H pylori "test and treat" with endoscopy if the patient remains symptomatic.
Factors identified as placing patients at increased risk for NSAID-related GI complications include prior history of GI event (ulcer, hemorrhage), age >60 years, high dosage of NSAID, and concurrent use of corticosteroids or anticoagulants.
Patients requiring NSAID therapy who are at high risk (e.g., prior ulcer bleeding or multiple GI risk factors) should receive alternative therapy, or if anti-inflammatory treatment is absolutely necessary, a COX-2 inhibitor and co-therapy with misoprostol or high-dose PPI.
Patients at moderate risk can be treated with a COX-2 inhibitor alone or with a traditional nonselective NSAID plus misoprostol or a PPI. Patients at low risk (i.e., no risk factors) can be treated with a nonselective NSAID.
Patients for whom anti-inflammatory analgesics are recommended and who also require low-dose aspirin therapy for cardiovascular disease can be treated with naproxen plus misoprostol or a PPI.
Patients at moderate GI risk who also are at high CV risk should be treated with naproxen plus misoprostol or a PPI. Patients at high GI and high CV risk should avoid using NSAIDs or coxibs. Alternative therapy should be prescribed.
All patients, regardless of risk status, who are about to start long-term traditional NSAID therapy should be considered for testing for H pylori and treated, if positive.
Recommended primary therapy for H pylori infection includes a proton-pump inhibitor (PPI), clarithromycin, and amoxicillin, or metronidazole (clarithromycin-based triple therapy) for 14 days, or a PPI or H2 antagonist, bismuth, metronidazole, and tetracycline (bismuth-based quadruple therapy) for 10 to14 days.
Sequential therapy consisting of a PPI and amoxicillin for 5 days followed by a PPI, clarithromycin, and tinidazole for an additional 5 days may provide an alternative to clarithromycin-based triple or bismuth-based quadruple therapy but requires validation before it can be recommended as a first-line therapy.
Salvage therapy in patients with persistent H pylori infection should avoid antibiotics that have been previously taken by the patient. Bismuth-based quadruple therapy for 7 to 14 days is an accepted salvage therapy. Levofloxacin-based triple therapy for 10 days is another option in patients with persistent infection, which requires validation in the US.
The risk of malignancy increases with age and therefore empiric therapy is not recommended in people >55 years old who develop new dyspeptic symptoms.
The application of a "test-and-treat" strategy for Helicobacter pylori should be based on the practice setting.
High-prevalence populations (e.g., recent immigrants from developing countries) should undergo "test and treat" as the preferable nonendoscopic strategy.
In low-prevalence populations (e.g., high socioeconomic areas, where the background prevalence of ulcer or H pylori infection is low), an alternative strategy is to prescribe a course of antisecretory therapy empirically for 4 to 8 weeks. If the patient fails to respond or relapses rapidly on stopping antisecretory therapy, then the test-and-treat strategy is best applied before consideration of referral for endoscopy (EGD). However, as the yield is low, the decision to endoscope or not must be based on clinical judgment.
In H pylori-negative patients with uninvestigated dyspepsia and no suspicious features suggestive of upper GI malignancy, an empiric trial of acid suppression for 4 to 8 weeks is recommended first-line therapy. If initial acid suppression fails after 2 to 4 weeks, it is reasonable to step up therapy; this may require changing drug class or dosing. In patients who do respond to initial therapy, it is recommended that treatment be stopped after 4 to 8 weeks, and if symptoms recur, another course of the same treatment is justified.
There are no data on long-term self-directed therapy in this condition, although this may be worth considering in some patients.