Synopsis
Select accurate active-infection testing, recognise alarm features, prescribe eradication therapy safely and confirm cure when the clinical indication requires it.
- Helicobacter pylori is a chronic gastric infection associated with peptic ulcer disease, gastric adenocarcinoma and gastric MALT lymphoma.
- Use urea breath testing or stool antigen testing for active infection; serology cannot reliably distinguish current from past infection.
- Withhold proton-pump inhibitors for two weeks and antibiotics and bismuth for four weeks before active-infection testing when clinically safe.
- Alarm features or suspected bleeding, perforation or cancer take priority over a routine test-and-treat dyspepsia pathway.
- NICE supports seven-day twice-daily proton-pump inhibitor triple therapy chosen around penicillin allergy, previous macrolide or metronidazole exposure and local resistance.
- Typical non-allergic regimens use amoxicillin 1 g twice daily plus clarithromycin 500 mg twice daily or metronidazole 400 mg twice daily.
- Penicillin allergy requires a non-amoxicillin regimen selected carefully, with specialist advice when previous clarithromycin and metronidazole exposure limits options.
- Confirm eradication with an active test when indicated, using the same medicine washouts and an adequate interval after treatment.
Key red flags
Haematemesis, melaena, syncope or haemodynamic instability requires emergency upper gastrointestinal bleeding care.
Sudden severe pain with guarding or rigidity suggests peptic ulcer perforation and requires urgent surgical assessment.
Progressive dysphagia, persistent vomiting, weight loss, anaemia or an epigastric mass requires urgent cancer-pathway assessment.
New dyspepsia in an older adult or a high-risk context should be managed using current age and alarm referral criteria.
Persistent symptoms after eradication require adherence, resistance, alternative diagnosis and malignancy risk review.
Melaena, haematemesis, iron-deficiency anaemia, postural symptoms or collapse may reflect an infected ulcer and requires an emergency bleeding pathway.
Progressive dysphagia, weight loss, persistent vomiting, anaemia, upper abdominal mass or appropriate age-risk criteria require urgent endoscopic assessment.
Investigation priorities
Detect active infection non-invasively before treatment or after eradication.
Management branches
Dyspepsia is suitable for non-invasive Helicobacter pylori test-and-treat management without alarm features.
- Check age and alarm referral criteria, ulcer history, NSAID or aspirin exposure, family history and whether symptoms need endoscopy rather than non-invasive testing.
- Stop proton-pump inhibitors for two weeks and antibiotics and bismuth for four weeks before urea breath or stool antigen testing when safe.
- Treat a confirmed active infection with a guideline-concordant seven-day regimen selected around allergy, previous antimicrobial exposure and local resistance.
- Give adherence and adverse-effect advice and explain which indication, symptom course or risk factor requires confirmation of eradication or endoscopy.