Peptic ulcer screening
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2017 ACG Guidelines for Peptic Ulcer Disease |
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Guidelines for the Indications to Test for, and to Treat, H. pylori Infection |
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Guidlines for factors that predict the successful eradication when treating H. pylori infection |
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Guidelines to document H. pylori antimicrobial resistance in the North America |
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Guidelines for evaluation and testing of H. pylori antibiotic resistance |
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Guidelines for when to test for treatment success after H. pylori eradication therapy |
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Guidelines for penicillin allergy in patients with H. pylori infection |
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Peptic ulcer screening On the Web |
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American Roentgen Ray Society Images of Peptic ulcer screening |
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Risk calculators and risk factors for Peptic ulcer screening |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ;Associate Editor(s)-in-Chief: Fahad Hasan, M.D.[2] Manpreet Kaur, MD [3]
Overview
There is no role for universal, population-based screening for peptic ulcer disease (PUD), including routine endoscopic screening, in asymptomatic average-risk adults.[1] Instead, PUD prevention relies on targeted, risk-based testing for Helicobacter pylori (with treatment of all positive results) and on ulcer-risk assessment before starting chronic NSAID or low-dose aspirin therapy.[2][3] The 2024 American College of Gastroenterology (ACG) guideline and the 2018 Houston Consensus Conference define the populations in whom H. pylori testing is indicated, using non-invasive urea breath testing or stool antigen testing.[2][4] Population-wide H. pylori screen-and-treat programs are endorsed only in regions with high gastric cancer incidence.[5]
Screening
Average-risk asymptomatic adults
- Routine screening for PUD (endoscopic or non-invasive) is not recommended in asymptomatic average-risk individuals.[1]
- H. pylori prevalence in North America is approximately 30–40%, but testing is directed at defined risk groups rather than the general population.[2]
Targeted H. pylori testing ("test-and-treat")
H. pylori is the dominant modifiable cause of PUD; all patients with a positive test for active infection should be offered treatment.[2]
| Population | Guideline support | Comment |
|---|---|---|
| Current or past peptic ulcer disease (without documented eradication) | ACG 2024; Houston 2018 | Highest-yield indication; test all patients diagnosed with PUD[2][4] |
| Uninvestigated dyspepsia in patients not meeting criteria for endoscopy | ACG/CAG 2017; ACG 2024; Houston 2018 | Non-invasive test-and-treat preferred over empiric endoscopy in patients <60 years without alarm features[6][2] |
| Starting or on long-term NSAID or low-dose aspirin therapy | ACG 2024; ACG 2017 | H. pylori and NSAIDs act synergistically on ulcer and ulcer-bleeding risk[2][7] |
| Unexplained iron deficiency anemia; immune thrombocytopenic purpura | ACG 2024 | Extra-gastric indications[2] |
| Gastric MALT lymphoma; gastric premalignant conditions; history of gastric cancer or endoscopic resection of early gastric cancer | ACG 2024; Houston 2018 (MALT lymphoma) | Premalignant/malignant indications[2][4] |
| Adult household members of a person with a positive non-serologic test | ACG 2024; Houston 2018 | Newly endorsed by ACG in 2024[2][4] |
| Family history of gastric cancer; first-generation immigrants from high-prevalence/high-incidence regions; higher-risk racial or ethnic groups | ACG 2024; Houston 2018 | Gastric cancer–prevention indications[2][4] |
| Family history of PUD | Houston 2018 only | Not adopted by ACG[4] |
Choice of test
- Use a test of active infection: urea breath test, stool antigen test, or biopsy-based testing during endoscopy.[2]
- Hold proton pump inhibitors for 2 weeks before urea breath or stool antigen testing to avoid false-negative results.[2]
- Serology cannot distinguish active from past infection and has a low positive predictive value in low-prevalence populations; a positive serology should not by itself trigger treatment.[8][9]
- Confirm eradication at least 4 weeks after completing therapy with a non-serologic test.[2]
Test-and-treat versus endoscopy in dyspepsia
- Patients aged ≥60 years with dyspepsia should undergo endoscopy; patients <60 years should undergo non-invasive H. pylori testing and treatment rather than empiric endoscopy.[6]
- For patients with dyspepsia and alarm features (vomiting, GI bleeding, unexplained iron deficiency, weight loss) or risk factors for gastric cancer, prompt endoscopy with biopsies — rather than test-and-treat — is recommended.[2]
- A lower age threshold may be considered in populations at higher gastric cancer risk.[2]
- The American Society for Gastrointestinal Endoscopy (ASGE) instead recommends initial endoscopy for new-onset dyspepsia at age ≥50 years or with alarm features, and bases test-and-treat versus empiric PPI therapy in younger patients on local H. pylori prevalence (test-and-treat preferred if prevalence >20%) — an age threshold that differs from the ACG 60-year cutoff.[10][11]
| Uninvestigated dyspepsia | |||||||||||||||||||||||||||||
| Age ≥60 years, alarm features, or gastric cancer risk factors? | |||||||||||||||||||||||||||||
| Yes: EGD with biopsies | No: urea breath or stool antigen test | ||||||||||||||||||||||||||||
| Positive: treat, then confirm eradication ≥4 weeks later | |||||||||||||||||||||||||||||
NSAID and aspirin users
- Before initiating chronic NSAID therapy, assess ulcer risk factors: age >65 years, high-dose NSAID, prior uncomplicated ulcer, and concurrent aspirin, corticosteroids, or anticoagulants; a prior complicated ulcer or more than 2 risk factors confers high risk.[3]
- H. pylori infection and NSAID use independently and synergistically increase the risk of peptic ulcer and ulcer bleeding.[7]
- In the HEAT trial (long-term aspirin users ≥60 years with a positive urea breath test), eradication reduced hospitalization or death from peptic ulcer bleeding during the first 2.5 years of follow-up (HR 0.35, 95% CI 0.14–0.89); the benefit was not sustained with longer follow-up.[12][13]
- Test for H. pylori before long-term NSAID or low-dose aspirin therapy and treat if positive.[2]
- Selection of gastroprotective strategies is covered in Peptic ulcer disease primary prevention.
Population-based H. pylori screen-and-treat
- Population screen-and-treat for gastric cancer prevention is recommended in regions with high gastric cancer incidence (e.g., East Asia), ideally in young adults before development of atrophic gastritis and intestinal metaplasia.[14][5][15]
- The 2025 Taipei Global Consensus II recommends prioritizing H. pylori screening in high-risk populations and supports family-based testing, since transmission occurs primarily within households.[16] The 2025 AGA Clinical Practice Update recommends opportunistic (not universal) H. pylori screening for US individuals at increased gastric cancer risk, including first-generation immigrants from high-incidence regions, possibly other non-White racial and ethnic groups, those with a first-degree relative with gastric cancer, and those with hereditary gastrointestinal polyposis or cancer syndromes.[17]
- Population screening is not recommended in low-incidence settings such as the United States; targeted testing of higher-risk groups is preferred.[2][5]
Guideline disagreement and uncertainty
- The Houston Consensus Conference endorses testing based on family history of PUD, which ACG has not adopted.[4][2]
- Routine H. pylori testing is not recommended for patients on long-term PPI therapy or with reflux symptoms alone; this Houston Consensus statement was not approved by the external validation group and has not been adopted by the ACG. Testing for reflux symptoms is reasonable only when patients are otherwise at high risk for H. pylori-related disease.[18]
- In a US validation cohort (n=942), individual risk-factor statements from ACG and the Houston Consensus Conference had generally low predictive performance for H. pylori infection; first-generation immigrant status and Black or Hispanic race/ethnicity performed best, and a combined model performed better than any single factor.[18]
- The optimal age threshold for test-and-treat versus endoscopy varies across societies (ACG/CAG 60 years; ASGE 50 years) and with regional gastric cancer incidence.[6][10][2]
- The 2017 ACG/CAG dyspepsia guideline does not recommend endoscopy for alarm features alone in patients <60 years, whereas the 2024 ACG H. pylori guideline recommends endoscopy with biopsies for dyspepsia with alarm features.[6][2]
References
- ↑ 1.0 1.1 Lanas A, Chan FKL (2017). "Peptic ulcer disease". Lancet. 390 (10094): 613–624. doi:10.1016/S0140-6736(16)32404-7. PMID 28242110.
- ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 2.18 2.19 2.20 Chey WD, Howden CW, Moss SF, Morgan DR, Greer KB, Grover S, Shah SC (2024). "ACG Clinical Guideline: Treatment of Helicobacter pylori Infection". Am J Gastroenterol. 119 (9): 1730–1753. doi:10.14309/ajg.0000000000002968. PMID 39626064 Check
|pmid=value (help). - ↑ 3.0 3.1 Lanza FL, Chan FK, Quigley EM; Practice Parameters Committee of the American College of Gastroenterology (2009). "Guidelines for prevention of NSAID-related ulcer complications". Am J Gastroenterol. 104 (3): 728–738. doi:10.1038/ajg.2009.115. PMID 19240698.
- ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 El-Serag HB, Kao JY, Kanwal F; et al. (2018). "Houston Consensus Conference on Testing for Helicobacter pylori Infection in the United States". Clin Gastroenterol Hepatol. 16 (7): 992–1002.e6. doi:10.1016/j.cgh.2018.03.013. PMID 29559361.
- ↑ 5.0 5.1 5.2 Liou JM, Malfertheiner P, Lee YC; et al. (2020). "Screening and eradication of Helicobacter pylori for gastric cancer prevention: the Taipei global consensus". Gut. 69 (12): 2093–2112. doi:10.1136/gutjnl-2020-322368. PMID 33004546 Check
|pmid=value (help). - ↑ 6.0 6.1 6.2 6.3 Moayyedi PM, Lacy BE, Andrews CN, Enns RA, Howden CW, Vakil N (2017). "ACG and CAG Clinical Guideline: Management of Dyspepsia". Am J Gastroenterol. 112 (7): 988–1013. doi:10.1038/ajg.2017.154. PMID 28631728.
- ↑ 7.0 7.1 Huang JQ, Sridhar S, Hunt RH (2002). "Role of Helicobacter pylori infection and non-steroidal anti-inflammatory drugs in peptic-ulcer disease: a meta-analysis". Lancet. 359 (9300): 14–22. doi:10.1016/S0140-6736(02)07273-2. PMID 11809181.
- ↑ Crowe SE (2019). "Helicobacter pylori Infection". N Engl J Med. 380 (12): 1158–1165. doi:10.1056/NEJMcp1710945. PMID 30893536.
- ↑ Chey WD, Leontiadis GI, Howden CW, Moss SF (2017). "ACG Clinical Guideline: Treatment of Helicobacter pylori Infection". Am J Gastroenterol. 112 (2): 212–239. doi:10.1038/ajg.2016.563. PMID 28071659.
- ↑ 10.0 10.1 Shaukat A, Wang A, Acosta RD, et al.; ASGE Standards of Practice Committee (2015). "The role of endoscopy in dyspepsia". Gastrointest Endosc. 82 (2): 227–232. doi:10.1016/j.gie.2015.04.003.
- ↑ Malfertheiner P, Camargo MC, El-Omar E; et al. (2023). "Helicobacter pylori infection". Nat Rev Dis Primers. 9 (1): 19. doi:10.1038/s41572-023-00431-8. PMID 37081005 Check
|pmid=value (help). - ↑ Hawkey C, Avery A, Coupland CAC; et al. (2022). "Helicobacter pylori eradication for primary prevention of peptic ulcer bleeding in older patients prescribed aspirin in primary care (HEAT): a randomised, double-blind, placebo-controlled trial". Lancet. 400 (10363): 1597–1606. doi:10.1016/S0140-6736(22)01843-8. PMID 36335970 Check
|pmid=value (help). - ↑ Almadi MA, Lu Y, Alali AA, Barkun AN (2024). "Peptic ulcer disease". Lancet. 404 (10447): 68–81. PMID 38885678 Check
|pmid=value (help). - ↑ Sugano K, Tack J, Kuipers EJ; et al. (2015). "Kyoto global consensus report on Helicobacter pylori gastritis". Gut. 64 (9): 1353–1367. doi:10.1136/gutjnl-2015-309252. PMID 26187502.
- ↑ Malfertheiner P, Megraud F, Rokkas T; et al. (2022). "Management of Helicobacter pylori infection: the Maastricht VI/Florence consensus report". Gut. 71: 1724–1762. doi:10.1136/gutjnl-2022-327745. PMID 35944925 Check
|pmid=value (help). - ↑ Liou JM, Malfertheiner P, Hong TC, Cheng HC; et al. (2025). "Screening and eradication of Helicobacter pylori for gastric cancer prevention: Taipei Global Consensus II". Gut. 74 (11): 1767–1791. doi:10.1136/gutjnl-2025-336027. PMID 40912906 Check
|pmid=value (help). - ↑ Shah SC, Wang AY, Wallace MB, Hwang JH (2025). "AGA Clinical Practice Update on Screening and Surveillance in Individuals at Increased Risk for Gastric Cancer in the United States: Expert Review". Gastroenterology.
- ↑ 18.0 18.1 Nguyen Wenker T, Peng FB, Emelogu I, Mallepally N, Kanwal F, El-Serag HB, Tan MC (2023). "The Predictive Performance of Contemporary Guideline Recommendations for Helicobacter pylori Testing in a United States Population". Clin Gastroenterol Hepatol. 21 (7): 1771–1780. doi:10.1016/j.cgh.2022.10.009. PMID 36270616 Check
|pmid=value (help).