diagnosis and treatment of H pylori related diseases in children and adolescent

Health question

Source of guideline

Recommendation

Quality of evidence

Strength of recommendation

1-What are the GI symptoms?

JESPGHAN

H. pylori related diseases in children with gastric and/or duodenal ulcers.

High

Strong

1B

ESPGHAN/NASPGHAN

We recommend that testing for H pylori be performed in children with gastric or duodenal PUD. If H pylori infection is identified then treatment should be administered and eradication confirmed.

High

Strong

1C

ESPGHAN/NASPGHAN

We recommend against diagnostic testing for H pylori infection in children with functional abdominal pain disorders.

High

Strong

2A- Iron-deficiency anemia

ESPGHAN/NASPGHAN

We recommend against diagnostic testing for H pylori infection as part of the initial investigation in children with iron deficiency anemia (IDA).

Moderate

Strong

2B

ESPGHAN/NASPGHAN

We suggest that in children with refractory IDA in which other causes have been ruled out, testing for H pylori during upper endoscopy may be considered.

Low

Conditional

2C- Chronic ITP

ESPGHAN/NASPGHAN

We suggest that noninvasive diagnostic testing for H pylori infection may be considered when investigating causes of chronic immune thrombocytopenic purpura (ITP).

Low

Conditional

2E- Short stature

ESPGHAN/NASPGHAN

We recommend against diagnostic testing for H pylori infection when investigating causes of short stature.

Moderate

Strong

3A- What is the non-invasive test

ESPGHAN/NASPGHAN

We recommend that one of the following tests be used to determine whether H pylori treatment was successful: (1) The 13C-UBT. (2) A 2-step monoclonal stool H pylori antigen test.

High

Strong

3B- Precautions of stool antigen

ESPGHAN/NASPGHAN

To confirm eradication, we recommend that before testing for H pylori, wait at least 2 weeks after stopping PPIs and 4 weeks after stopping antibiotics.

 Low

Strong

3C

JAPANES

We recommend against tests to detect anti-H. pylori antibodies as single diagnostic tests in clinical settings to diagnose active H. pylori infection.

High

Strong

4- What are the uses of non-invasive

JESPGHAN

We recommend more than two H. pylori tests such as two non-invasive tests, i.e. breath test and stool test, or a biopsy-based and non-invasive test (i.e. breath test) for more accurate diagnosis of active infection.

Low

Strong

5A- When to do upper endoscopy

JESPGHAN

We recommend considering the performance of a rapid urease test directly on gastric biopsies to determine presence / absence of H. pylori as a diagnostic test for active infection.

Low

Conditional

5B

JESPGHAN

We recommend histological examination of gastric biopsies as a biopsy-based diagnostic test for active H. pylori infection.

Moderate

Conditional

5C

JESPGHAN

We recommend H. pylori culture because the culture method is the gold standard biopsy-based test for active infection and it can also be used for antimicrobial susceptibility testing for optimization of eradication therapy.

GPS

6A- Upper endo with histopathology

Diagnostic accuracy: pre‐eradication H&E staining sensitivity is 92%–98.8% and specificity is 89%–100%

GPS

6B

ESPGHAN/NASPGHAN

We recommend that at least 6 gastric biopsies should be obtained for the diagnosis of H pylori infection during upper endoscopy.

Low

Strong

7- upper endoscopy with bacteriology

JESPGHAN

Diagnostic accuracy: sensitivity of 68%–98% and specificity of 100%

GPS

8A- upper endoscopy with RUT

JESPGHAN

Diagnostic accuracy: Pre‐eradication sensitivities is 91.0%– 98.5% and specificity is 90.9%–100%. Post-eradication sensitivity is 58.8%–86% and specificity is 97.8%–99.2%.

GPS

8B

JESPGHAN

We recommend H. pylori tests when the following endoscopic findings are observed at diagnostic upper endoscopy: antrum-predominant nodularity, ulcerations or erosions in the stomach or duodenum disappearance of regular arrangement of collecting venules (RAC) in the gastric body.

Low

Strong

9A- who should be treated PUD

We recommend eradication therapy for H. pylori- infected children with gastric and/or duodenal ulcers.

High

Strong

9B

JESPGHAN

Eradication therapy should be considered for children, 5 years of age or more, determined to be infected with H. pylori by a test for active infection, taking account possible re-infection.

Low

Conditional

9C

JESPGHAN

We recommend consideration of eradication therapy for H. pylori-infected children who underwent diagnostic upper gastrointestinal endoscopy for abdominal symptoms.

Very low

Weak

9D

JESPGHAN

We recommend eradication therapy for H. pylori-infected children with gastric MALT lymphoma.

Moderate

Strong

9E

JESPGHAN

We recommend eradication therapy for H. pylori-infected children with IDA when the iron deficiency is recurrent or refractory to iron supplement therapy.

High

Strong

9F

JESPGHAN

We recommend eradication therapy for H. pylori-infected children with chronic ITP as the first line therapy.

Moderate

Strong

9G

JESPGHAN

We do not recommend eradication therapies for H. pylori-infected children with chronic idiopathic urticaria.

Low

Conditional

9H

JESPGHAN

We recommend against a “test-and treat” strategy for H. pylori infection for asymptomatic children to protect gastric cancer development.

Low

Conditional

9K

ESPGHAN/NASPGHAN

If H pylori is an incidental finding at endoscopy treatment may be considered following careful discussion of the risks and benefits of H pylori treatment with the patient/parents. When H pylori is detected by biopsy-based methods in absence of PUD, treatment may be considered.

Family history of gastric cancer

JESPGHAN

We recommend consideration of eradication therapies for children who have a family history of gastric cancer in their first- or second-degree relatives and in whom active H. pylori infection has been found.

Moderate

Weak

JESPGHAN

We recommend against a “test-and treat” strategy for asymptomatic children living in the household of an H. pylori-infected adult who received eradication therapy to prevent re-infection in that adult.

Moderate

Weak

ESPGHAN/NASPGHAN

We recommend that testing for H pylori be performed in children with gastric or duodenal PUD. If H pylori infection is identified then treatment should be administered and eradication confirmed.

High

Strong

10- how to treat

JESPGHAN

A proton pump inhibitor- based triple regimen with amoxicillin and clarithromycin as the first-line therapy if H. pylori strains are susceptible to clarithromycin or the antimicrobial susceptibility of the strains is unknown. a proton pump inhibitor- based triple regimen with amoxicillin and metronidazole as the first-line therapy, if H. pylori strains are shown to be resistant to clarithromycin.

Very low

Strong

Duration of eradication regimen

JESPGHAN

Regarding the duration of eradiation regimen in children, a 7-day course of treatment regimen is basically recommended. However, if clinicians judge that there is a therapeutic need according to individual risk of eradication failure, then the eradication regimen should be employed as a longer duration regimen for up to 14 days.

Moderate

Strong

Second-line therapies

Second-line therapies in H. pylori-infected children in whom the first-line therapy failed 1-a proton pump inhibitor- based triple regimen with amoxicillin and metronidazole was shown to be successful in children who failed in eradicating H. pylori with clarithromycin containing triple therapy. In patients with second-line eradication failure, antimicrobial susceptibility should be obtained for the infecting H. pylori strain and salvage therapy should be tailored accordingly.

Very low

Strong

Role of probiotic

Improvement of the eradication rate by a combination of probiotics is not clear. However, it has been shown to be effective for the prevention of side effects including diarrhea. Individual side-effect such as diarrhea, nausea, vomiting, dyspepsia or dysphagia, which occurred with the conventional eradication therapy, significantly decreased by combining with probiotics.

Low

Conditional

11- When and how to test eradication

ESPGHAN/NASPGHAN

We recommend that the outcome of anti–H pylori therapy be assessed at least 4 weeks after completion of therapy.

Moderate

Strong

ESPGHAN/NASPGHAN

We recommend that one of the following tests be used to determine whether H pylori treatment was successful: (1) The 13C-UBT. (2) A 2-step monoclonal stool H pylori antigen test.

High

Strong

JESPGHAN

We recommend H. pylori testing for active infection four weeks or more after completion of eradication therapy to avoid false negative results.

Low

Strong

JESPGHAN

We recommend that the 13C-urea breath test or stool antigen ELISA test using a monoclonal antibody be employed to confirm eradication.

High

Strong

JESPGHAN

We recommend against H. pylori tests using endoscopic biopsy specimens (rapid urease test, histological examination, and the culture method) to confirm the eradication of the infection

Low

Conditional.

JESPGHAN

We recommend against serological tests to detect anti-H. pylori antibodies as a single test to confirm eradication.

High

Strong