H. Pylori Testing

Validated tests for H. pylori include:

  • 13C-urea breath test (CUBT)
  • Faecal antigen tests
  • Serum ELISA tests
  • Campylobactor-like organism (CLO) testing of biopsy specimens

CUBT and faecal antigen tests confirm active infection, so are also useful for confirming H. pylori eradication after treatment. Serum ELISA tests cannot distinguish between active and previous infection [4]. CLO testing can be performed on biopsies taken at endoscopy and give a result within 30 minutes.

CUBT should not be performed within two weeks of PPI therapy or four weeks of antibiotic therapy as false negative results may occur [18].

Learning Bite

CUBT and faecal antigen tests are the non-invasive tests of choice for active H. pylori infection.

H. pylori positive patients

Antibiotic choice is determined by regional sensitivities. Adherence can be an issue and patient education is key. NICE recommend the following H. pylori eradication regimes, twice-daily for seven days [20]:

Fine line If penicillin allergy  Penicillin allergy and previous Clarithromycin
Amoxicillin Clarithromycin Metronidazole
or Metronidazole
Metronidazole Tetracycline


Second line Penicillin allergy and no previous fluoroquinolone Penicillin allergy and previous fluoroquinolone use
Amoxicillin Metronidazole Metronidazole
Either Clarithromycin or Metronidazole (whichever was not used first line).

If previous exposure to Clarithromycin and Metronidazole, offer Tetracycline or Levofloxacin

Levofloxacin Tetracycline

H. pylori negative patients

Patients who test negative for H. pylori should be offered 4-8 weeks of a PPI or HRA.

If the patient is taking regular NSAIDs, these should be discontinued if possible. The much-publicised COX-2 inhibitors were developed in an attempt to increase gastrointestinal tolerance. COX-2 inhibitors reduce but do not eliminate ulcers or their complications [15], and multiple studies have shown they increase cardiovascular mortality. Many have been withdrawn from the market [16, 17, 18]. Some patients will require long term acid-suppression, especially those over 65 years of age, with a history of PUD, or taking other ulcerogenic medications including aspirin, steroids, SSRIs or anticoagulants.

If symptoms do not resolve after PPI or HRA, patients should be referred for endoscopy. Other therapies can be considered in the interim including prostaglandins (misoprostol), a PGE1 analogue which decreases cAMP generation in parietal cells and enhances mucosal defences.

There is no high-level evidence base for the treatment of marginal ulcers (ulcers occurring in patients who have undergone gastric bypass surgery); they are often difficult to treat.