When should I consider referring a patient for endoscopy in the context of H. pylori infection?

Consider referring a patient for endoscopy in the context of Helicobacter pylori infection if:

• There are refractory or recurrent symptoms despite optimal management in primary care, including after second-line H. pylori eradication therapy has been unsuccessful.
• There are limited antibiotic options available for H. pylori eradication therapy, necessitating specialist advice.
• The patient presents with significant acute gastrointestinal bleeding alongside dyspepsia, requiring immediate specialist referral.
• There is a family history of gastric malignancy or other risk factors that raise suspicion of malignancy.
• Symptoms are unexplained or non-responsive to treatment after initial assessment in primary care.

Routine early endoscopy is not recommended as it is not cost-effective and does not improve patient outcomes compared to a test-and-treat strategy for H. pylori infection.

Stopping acid suppression therapy at least two weeks before endoscopy is advised to avoid masking or delaying detection of gastric or oesophageal cancer.

Referral to a gastroenterologist should be considered for specialist investigations and management when indicated by the above criteria.

References: NICE CKS, NICE CKS, NICE CG184