H.pylori gastritis guideline recommendations

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Yamuna Kondapally, M.B.B.S[2]


Evidence-based guidelines for H. pylori infection in children and adolescents in North America and Europe.


Evidence-based guidelines from ESPGHAN and NASPGHAN for Helicobacter pylori infection in children.[1]

Recommendation Grade of evidence
Who should be tested
1 The primary goal of clinical investigation of gastrointestinal symptoms is to determine the underlying cause of the symptoms and not solely the presence of Helicobacter pylori infection Not applicable
2 Diagnostic testing for H. pylori infection is not recommended in children with functional abdominal pain. High
3 In children with first-degree relatives with gastric cancer, testing for H. pylori may be considered. Low
4 In children with refractory iron-deficiency anemia in which other causes have been ruled out, testing for H. pylori infection may be considered. Low
5 There is insufficient evidence that H. pylori infection is causally related to otitis media, upper respiratory tract infections, periodontal disease, food allergy, sudden infant death syndrome (SIDS), idiopathic thrombocytopenic purpura, and short stature. Low
Which diagnostic test should be used
6 For the diagnosis of H. pylori infection during esophagogastroduodenoscopy (EGD), it is recommended that gastric biopsies (antrum and corpus) for histopathology are obtained. Moderate
7 It is recommended that the initial diagnosis of H. pylori infection be based on either positive histopathology + positive rapid urease test or a positive culture. Moderate
8 The 13C-urea breath test (UBT) is a reliable noninvasive test to determine whether H. pylori has been eradicated. High
9 A validated enzyme-linked immunosorbent assay (ELISA) for detection of H. pylori antigen in stool is a reliable noninvasive test to determine whether H. pylori has been eradicated. Moderate
10 Tests based on the detection of antibodies (immunoglobulin G IgG, immunoglobulin A IgA) against H. pylori in serum, whole blood, urine, and saliva are not reliable for use in the clinical setting. High
11 It is recommended that clinicians wait at least 2 weeks after stopping proton pump inhibitor (PPI) therapy and 4 weeks after stopping antibiotics to perform biopsy-based and noninvasive tests (UBT, stool test) for H. pylori. High
Who should be treated
12 In the presence of H. pylori–positive peptic ulcer disease (PUD), eradication of the organism is recommended. High
13 When H. pylori infection is detected by biopsy-based methods in the absence of PUD, H. pylori treatment may be considered. Low
14 A "test and treat" strategy is not recommended in children. Moderate
Which treatment should be applied
15 In children who are infected with H. pylori and whose first-degree relative has gastric cancer, treatment can be offered. Low
16 Surveillance of antibiotic resistance rates of H. pylori strains in children and adolescents is recommended in different countries and geographic areas. Not applicable
17 First-line eradication regimens are the following: triple therapy with a PPI + amoxicillin + imidazole; or PPI + amoxicillin + clarithromycin; or bismuth salts + amoxicillin + imidazole; or sequential therapy. Moderate
18 Antibiotic susceptibility testing for clarithromycin is recommended before initial clarithromycin-based triple therapy in areas/populations with a known high resistance rate (>20%) of H. pylori to clarithromycin. Moderate
19 It is recommended that the duration of triple therapy be 7 to 14 days. Costs, compliance, and adverse effects should be taken into account. Suggested doses are given in Table 1 of the original guideline document. Moderate
20 A reliable noninvasive test for eradication is recommended at least 4 to 8 weeks following completion of therapy. Low
21 If treatment has failed, there are 3 options recommended: Not applicable
a. EGD, with culture and susceptibility testing, including alternate antibiotics if not performed before guide therapy
b. Fluorescence in situ hybridization (FISH) on previous paraffin-embedded biopsies if clarithromycin susceptibility testing has not been performed before guide therapy.
c. Modify therapy by adding an antibiotic, using different antibiotics, adding bismuth, and/or increasing dose and/or duration of therapy
  • Recommendations for children and adolescents with H. pylori infection in North America and Europe.
  • Not applicable for children and adolescents living in other continents, particularly in developing countries due to high H. pylori rate and with limited resources for health care.[1]

Grades of evidence

1. High: Further research is unlikely to change confidence in the estimate of effect.

2. Moderate: Further research is likely to have an important influence on confidence in the estimate of effect and may change the estimate.

3. Low: Further research is very likely to have an important influence on confidence in the estimate of effect and may change the estimate.

4: Very low: Any estimate of effect is uncertain.

5: Not applicable: The grades of evidence were not relevant for a particular statement.


  1. 1.0 1.1 Koletzko S, Jones NL, Goodman KJ, Gold B, Rowland M, Cadranel S; et al. (2011). "Evidence-based guidelines from ESPGHAN and NASPGHAN for Helicobacter pylori infection in children". J Pediatr Gastroenterol Nutr. 53 (2): 230–43. doi:10.1097/MPG.0b013e3182227e90. PMID 21558964.