TOPLINE

A head-to-head comparison of six diagnostic tests for Helicobacter pylori in patients with peptic ulcer bleeding found that tissue polymerase chain reaction (PCR) was the best-performing single test. Although the widely used rapid urease testing (RUT) missed about 30% of infections when used alone and nearly 20% when paired with histology, adding PCR or a delayed breath test to the rapid test and histology identified every infection found in this study.

METHODOLOGY

• RUT is widely used to diagnose H pylori infections but is less reliable in patients with peptic ulcer bleeding, with the best overall diagnostic strategy for these patients remaining unclear.
• Researchers prospectively compared six tests for detecting H pylori (RUT, histology, tissue PCR, a urea breath test, a current infection marker test, and an anti-urease antibody test) in 135 adults with endoscopically confirmed peptic ulcer bleeding in Thailand between April 2024 and July 2025; the participants had a mean age of 70 years, 62.2% were men, and all received intravenous proton pump inhibitor (PPI) therapy before endoscopy.
• After receiving standard bleeding care and endoscopic treatment for the ulcer where indicated, all patients had 12 stomach biopsies taken for RUT, histology, and PCR, along with a blood sample for the two antibody tests.
• Patients with negative results on both RUT and histology (98 patients) were scheduled for a breath test after at least 2 weeks without PPIs; only 43 completed the breath test.
• H pylori infection was defined as a positive result on at least 2 of 4 tests, namely RUT, histology, PCR, and the breath test.

TAKEAWAY

• Among the 135 participants, 36 met the criteria for a confirmed H pylori infection.
• Tissue PCR performed best with 97.2% sensitivity and 92.9% specificity, showing significantly better overall diagnostic performance than RUT (P = .019). RUT and histology, by contrast, remained highly specific (specificity, 97.0% and 96.0%, respectively) but detected only 69.4% and 55.6% of true infections, respectively. Combining RUT and histology increased sensitivity to 83.3%, but this was still lower than the sensitivity of PCR alone.
• Pairing RUT and histology with either PCR or the breath test increased sensitivity to 100% and significantly improved overall diagnostic performance compared with RUT alone (P = .021 and P = .001, respectively). Adding blood-based CIM or anti-urease antibody testing to RUT and histology also boosted sensitivity but at the cost of noticeably lower specificity.
• Sequential addition of histology and PCR to RUT increased H pylori-attributed ulcers from 11.1% to 19.3% and reduced idiopathic ulcers from 34.8% to 26.7%.

IN PRACTICE

"Taken together, our findings suggest that PCR at index endoscopy may be the preferred strategy when available, whereas RUT plus histology is insufficient as a definitive diagnostic approach for HP [H pylori] in patients with PUB [peptic ulcer bleeding]. From a cost-effectiveness perspective, however, UBT remains an attractive strategy," the authors wrote.

SOURCE

The study was led by Tanawat Geeratragool, Division of Gastroenterology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand. It was published online in Clinical and Translational Gastroenterology.

LIMITATIONS

The number of H pylori-positive cases was small; therefore, some diagnostic estimates were less precise. Not every patient could complete the breath test when indicated. Histology did not include immunohistochemistry, possibly reducing its sensitivity.

DISCLOSURES

The study was funded by the Thai Healthy Gut Fund, Siriraj Foundation, Faculty of Medicine Siriraj Hospital, Mahidol University. The authors reported no conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.