Diagnosis of H. pylori Infection

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Non-invasive testing

In patients <50 years with uncomplicated dyspepsia, non-invasive testing is recommended.

The Urea breath test is the recommended non-invasive test for H. pylori. If the Urea breath is unavailable, the monoclonal stool antigen test is an alternative non-invasive test if locally validated.

Invasive testing

Endoscopy is recommended for those with dyspepsia symptom onset >50 years, those of any age with alarm symptoms (such as weight loss, dysphagia, overt gastrointestinal bleeding, abdominal mass or iron-deficient anaemia) or a family history of gastric cancer. 

For invasive H. pylori testing during endoscopy, a combination of histology and the rapid urease test is recommended. In all patients with dyspepsia, even with a normal-appearing mucosa, testing is advised. 

Histology

Sampling should include two antrum biopsies (2–3 cm in front of the pylorus) and two corpus biopsies, which should be submitted in separate containers.

For gastritis staging (intestinal metaplasia, atrophy), the lesser and greater curvatures of the antrum and an additional biopsy from the incisura, as well as samples from the anterior and posterior proximal corpus, should be taken as per OLGA (operative link on gastric atrophy) and OLGIM (operative link on gastric intestinal metaplasia) recommendations. Any additional lesions should also be sampled.

Immunohistochemical staining is recommended in cases of chronic active gastritis where H. pylori has not been detected by histochemistry alone. 

Rapid urease test

A biopsy from the antrum and the corpus should be taken for the rapid urease test to account for the patchy distribution of H. pylori.

Proton pump inhibitors significantly reduce the accuracy of the recommended H. pylori tests; therefore, proton pump inhibitors should be stopped 14 days before non-invasive testing, histology or the rapid urease test.