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.
Key red flags
Haematemesis, melaena, syncope or haemodynamic instability requires emergency upper gastrointestinal bleeding care.
Melaena, haematemesis, iron-deficiency anaemia, postural symptoms or collapse may reflect an infected ulcer and requires an emergency bleeding pathway.
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.
Key medicines
PPI, amoxicillin and clarithromycinGive a standard-dose proton-pump inhibitor twice daily, amoxicillin 1 g twice daily and clarithromycin 500 mg twice daily for seven days.
PPI, amoxicillin and metronidazoleGive a standard-dose proton-pump inhibitor twice daily, amoxicillin 1 g twice daily and metronidazole 400 mg twice daily for seven days.