Investigations
Your Organisational Guidance
ebpracticenet urges you to prioritise the following organisational guidance:
MaagklachtenPublished by: NHGLast published: 20251st investigations to order
Helicobacter pylori urea breath test
Test
Current guidelines recommend patients with uninvestigated dyspepsia aged <60 years without alarm features suggestive of upper GI malignancy undergo non-invasive testing for H pylori.[3]
This test has >90% sensitivity and 96% specificity for presence of active infection.[44][46][47]
It can be used to monitor response to therapy.
Proton-pump inhibitors (PPIs), bismuth, antibiotics, and possibly potassium-competitive acid blockers (PCABs) can interfere with this test.[3][45] It is generally recommended that, in the post-treatment setting, PPIs and PCABs are withheld for 7-14 days and antibiotics and bismuth withheld for at least 28 days prior to use of the urea breath test to assess H pylori eradication.[3]
Result
positive in H pylori infection
Helicobacter pylori faecal antigen test
Test
A faecal antigen test identifies H pylori antigen in the stool to diagnose active infection.[22]
Both monoclonal and polyclonal assays are available, each with >90% sensitivity and specificity; monoclonal assay has a sensitivity of 96% and specificity of 97%.[48][49]
It can be used to monitor response to therapy.
Proton-pump inhibitors (PPIs), bismuth, antibiotics, and possibly potassium-competitive acid blockers (PCABs) can interfere with the test.[3][45] It is generally recommended that, in the post-treatment setting, PPIs and PCABs are withheld for 7-14 days and antibiotics and bismuth withheld for at least 28 days prior to use of the urea breath test to assess H pylori eradication.[3]
Result
positive in H pylori infection
Investigations to consider
endoscopy
Test
The American College of Gastroenterology (ACG) and the Canadian Association of Gastroenterology (CAG) guidelines on dyspepsia recommend endoscopy for patients aged 60 years or older presenting with dyspepsia, and only on a case-by-case basis in younger patients with dyspepsia who have alarm features (weight loss, anaemia, dysphagia and persistent vomiting).[40]
The National Institute for Health and Care Excellence recommends same day referral to a specialist for any patient presenting with dyspepsia and significant gastrointestinal bleeding.[39]
Consider in patients with symptoms that are unresponsive to treatment.[39][40]
Patients with confirmed pernicious anaemia should undergo endoscopy to evaluate for any associated gastric malignancy.[41]
Endoscopy allows assessment of the gastric mucosa for alternative pathology and enables biopsy for histological assessment and testing for Helicobacter pylori infection (using tissue rapid urease testing and direct culture or molecular studies).[2][40][41]
Proton-pump inhibitors (PPIs), bismuth, antibiotics, and possibly potassium-competitive acid blockers (PCABs) can interfere with the test.[3][45] It is generally recommended that, in the post-treatment setting, PPIs and PCABs are withheld for 7-14 days and antibiotics and bismuth withheld for at least 28 days prior to use of the urea breath test to assess H pylori eradication.[3]
Result
variable; evidence of gastric erosions and/or atrophy
Helicobacter pylori rapid urease test
Test
Can be performed on a single biopsy specimen from the antrum and a single biopsy specimen from the posterior corpus.[44] The tissue is placed in an agar gel or on a reaction strip containing urea, a buffer, and a pH-sensitive indicator. In the presence of H pylori urease, the urea is metabolised to ammonia and bicarbonate and detected as a colour change. This test has a 90% sensitivity and 100% specificity, as long as the patient does not have an acute gastrointestinal bleed and is not taking a proton-pump inhibitor (PPI) or an antibiotic.[46][47][50][51]
Result
positive in H pylori infection
gastric mucosal histology
Test
Provides histological diagnosis and classification of gastritis.
Use of Warthin-Starry silver stain has 93% sensitivity and 99% specificity for Helicobacter pylori.[46]
If the patient has an acute gastrointestinal bleed or is taking a proton-pump inhibitor (PPI) or an antibiotic, histological evaluation rather than H pylori rapid urease test is recommended.[51]
Result
variable; positive for H pylori; features of acute or chronic gastritis
serum vitamin B12
Test
Check in patients presenting with dyspeptic symptoms with signs and symptoms consistent with clinical vitamin B12 deficiency (e.g., unexplained neurological disease, depression/dementia, angular cheilitis, atrophic glossitis).[2][29][31] Check in patients with atrophic gastritis.[42]
This is most commonly due to chronic gastritis in older people and is also associated with autoimmune gastritis.[53]
Result
normal or low in autoimmune gastritis; findings of pernicious anaemia are indicative of late-stage autoimmune gastritis, and patients should undergo oesophagogastroduodenoscopy with biopsies to assess for neoplastic changes
upper gastrointestinal (GI) contrast series
blood/fluid cultures
parietal cell antibodies
Test
Present in about 90% of patients with atrophic gastritis.[29]
Result
positive in autoimmune gastritis
intrinsic factor antibodies
Test
Highly sensitive for pernicious anaemia.[31]
Result
positive in autoimmune gastritis
Emerging tests
Helicobacter pylori culture/polymerase chain reaction (PCR)
Test
Can be performed on a single biopsy specimen from the antrum and a single biopsy specimen from the posterior corpus.[44]
High sensitivity and specificity for H pylori infection, although less sensitive than rapid urease testing.[46][47][50]
Limited availability; primarily used in research situations.
Result
positive in H pylori infection
Use of this content is subject to our disclaimer