Unifying Concepts

Indications for Testing for Helicobacter pylori Infection

Testing for H. pylori is recommended in patients with peptic ulcer disease, gastric cancer, or gastric mucosa–associated lymphoid tissue lymphoma (MALToma). Other recommended indications for testing include dyspepsia, prolonged use of nonsteroidal antiinflammatory drugs or aspirin, unexplained iron-deficiency anemia, and immune thrombocytopenia.
Testing for H. pylori can be performed directly on biopsy specimens obtained during endoscopy or performed by means of the stool antigen test or urea breath test. Proton-pump inhibitors (PPIs) interfere with the detection of bacteria and must be discontinued before any testing is performed.


Indications for Testing for Helicobacter pylori Infection

  • Active peptic ulcer disease or a history of peptic ulcer disease, unless H. pylori has been eradicated
  • Low-grade gastric mucosa-associated lymphoid tissue lymphoma (MALToma) or a history of endoscopic resection of early gastric cancer
  • Uninvestigated dyspepsia, with noninvasive testing in patients <60 yr of age who do not have alarm symptoms (e.g., weight loss, severe abdominal pain, dysphagia, vomiting, gastrointestinal bleeding, and others), but esophagogastroduodenoscopy is recommended in patients ≥60 yr of age or if alarm symptoms are present
  • Long-term aspirin use
  • Long-term NSAID use
  • Unexplained iron-deficiency anemia after thorough evaluation for other causes
  • Immune thrombocytopenia in adults
  • Completion of treatment for documented H. pylori infection in order to confirm eradication; testing should be performed ≥30 days after the completion of treatment and while the patient is not taking a PPI

Other indications for testing have been suggested, including various demographic features that have been associated with increased risk such as a family history of gastric cancer, status of being a first-generation immigrant from an area with high prevalence of H. pylori infection, and black race or Hispanic ethnic group and long-term
use of a proton-pump inhibitor (PPI). The indication regarding PPIs is based on observational studies that have shown an increased risk of atrophic gastritis, a precursor of gastric cancer, in association with long-term use of PPIs.
Anyone with the indications for testing who has a positive test result should be treated; after the completion of treatment, eradication should be confirmed, according to the adage “Test. Treat. Test.” NSAID denotes nonsteroidal antiinflammatory drug.



  1. Crowe SE. Helicobacter pylori Infection. N Engl J Med 2019;380:1158-1165 [Medline]
  2. Chey WD, Leontiadis GI, Howden CW, Moss SF. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol. 2017 Feb;112(2):212-239. [Medline]
  3. Malfertheiner P, Megraud F, O’Morain CA, Gisbert JP, Kuipers EJ, Axon AT, Bazzoli F, Gasbarrini A, Atherton J, Graham DY, Hunt R, Moayyedi P, Rokkas T, Rugge M, Selgrad M, Suerbaum S, Sugano K, El-Omar EM; European Helicobacter and Microbiota Study Group and Consensus panel. Management of Helicobacter pylori infection-the Maastricht V/Florence Consensus Report. Gut. 2017 Jan;66(1):6-30. [Medline]


Created Mar 25, 2019.

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