H pylori tests for dyspepsia

Current situation

  • Managing dyspepsia costs the NHS about £1.1 billion per year (Lancet 2000; 356: 1,965).
  • There is inadequate evidence to guide whether full-dose treatment with a proton pump inhibitor for one month or Helicobacter pylori test and treat approach is best.
  • There is currently plenty of debate regarding which is the best investigation for diagnosing H pylori.

What is the evidence?

  • The urea breath test is the most accurate way to detect H pylori.
  • One study has shown that screening for H pylori led to 15 per cent of those tested showing positive results; these were then given treatment. An accompanying editorial calculated that the cost of screening was £1,500–£2,000 per successful treatment. Therefore it is not likely to be offered to patients without dyspepsia (BMJ 2006; 199–204).
  • A recent Cochrane review showed that test and treat may be more effective than acid suppression alone (Cochrane Database Syst Rev 2005; (4): CD001961).
  • One analysis also found that an H pylori test-and-treat strategy was more cost-effective than prompt endoscopy in the initial management of dyspepsia in general practice. This was based on the drugs used, the number of GP visits, the number of diagnostic tests and the number of related referrals (Clin Ther 2005; 27: 1,647–57).
  • One study showed that test and treat was marginally less effective than management based on endoscopy, but still cost-effective (Scand J Gastroenterol 2004; 39: 913–8).
  • Serology is the main non-invasive test used in the UK but is notably less sensitive — half of all positive serology tests will be false positives (BMJ 2006: 332: 187–8).
  • The stool antigen test is almost as sensitive and specific as the urea breath test, and it is considerably cheaper. It is also acceptable to patients (J Med Microbiol 2004; 53: 623–7).

Implication for practice

  • Doctors are best advised to inform patients that the minor inconvenience of providing a stool or breath sample is far outweighed by the increased accuracy of these tests (BMJ 2005; 330: 105–6).

Available guidelines

  • The NICE guidelines on dyspepsia were published in 2004, and updated in 2005.
  • National Guideline Research and Development Unit has produced Dyspepsia: Managing Dyspepsia in Adults in Primary Care.

Useful websites

www.nice.org.uk — NICE guidelines 

Dr Louise Newson is a GP in the West Midlands and the author of the book Hot Topics for MRCGP and General Practitioners, PasTest 2006.

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