Dyspepsia and H. pylori
Not for pregnancy, breastfeeding or children. H. pylori is not associated with GERD; GERD treatment is not covered here.
Diagnose
- INESSS Institut national d'excellence en santé et services sociaux
- CAG Canadian Association of Gastroenterology (with ACG)
| Decision | Guideline |
|---|---|
| Warning signs | Any of:Unexplained anemia Progressive dysphagia Hematemesis Digestive bleeding Abdominal mass Persistent vomiting Unexplained weight loss Family history of gastric cancer |
| Age 60 and older | New or progressive symptoms at 60 or older are a warning sign.By clinical judgment, a lower age may be used for Indigenous people, or people born or raised in some regions (e.g. Southeast Asia, South America, Africa), given the higher cancer risk. ACG/CAG 2017 suggests endoscopy for every dyspepsia patient aged 60 or older to exclude upper GI neoplasia (conditional, very low quality evidence).Québec leads: follow INESSS. |
| With a warning sign | Upper endoscopy or a specialist consultation is usually needed.Age, a severe sign or several signs together may suggest a complicated peptic ulcer or gastric cancer. ACG/CAG 2017 does not suggest endoscopy for alarm features alone under 60 (conditional, moderate quality evidence).It leaves endoscopy to case-by-case judgment.
Québec leads: follow INESSS. |
| Suspect H. pylori | Most dyspepsia is not caused by H. pylori.Suggestive signs:
Dyspepsia: epigastric pain or burning, early satiety after a meal, postprandial fullness
Unexplained iron-deficiency anemia
Immune thrombocytopenia
Vitamin B12 deficiency with no known cause
|
| Rule out other causes | Review drugs and habits:NSAIDs, Aspirin, opioids
GLP-1 agonists, bisphosphonates, iron, glucocorticoids, Metformin, nitrates
Alcohol, salt, smoking, diet
|
| Test: recommended | Test for active infection in:Persistent or recurrent dyspepsia, after other causes are ruled out Past peptic ulcer, unless eradication was documented Gastric cancer in a first-degree relative, by clinical judgment Past early gastric cancer resection, with no documented H. pylori workup |
| Test: consider | By clinical judgment:Long-term low-dose Aspirin in someone at risk of GI bleeding Starting a long-term NSAID, with no documented H. pylori workup |
| Test only to treat | Base the decision to test on the intention to treat.Weigh benefits and harms with the person before ordering a test. GERD alone does not usually justify testing. |
Investigate
- INESSS Institut national d'excellence en santé et services sociaux
| Decision | Guideline |
|---|---|
| Dyspepsia without a warning sign | Stool antigen test or 13C urea breath test.Stool antigen is the preferred non-invasive test. Endoscopy is generally not recommended. |
| Dyspepsia with a warning sign | Upper endoscopy with biopsies for histology or a rapid urease test.Non-invasive tests are generally not recommended. |
| Serology | Generally not recommended.It cannot tell active infection from past exposure. |
| Before any test | Stop before a stool antigen test, breath test or endoscopy with biopsies:PPIs 2 weeks before
Antibiotics or bismuth 4 weeks before
|
| Breath test | Not after partial gastrectomy or bariatric surgery. Needs at least 3 hours of fasting. |
Treat
- INESSS Institut national d'excellence en santé et services sociaux
- CAG Canadian Association of Gastroenterology (with ACG)
| Decision | Guideline |
|---|---|
| First-line | 14-day quadruple therapy.Bismuth quadruple, or concomitant quadruple without bismuth. Clarithromycin resistance is unknown in Québec. |
| Do not | No triple therapy (PPI, Clarithromycin and Amoxicillin or Metronidazole). |
| Before prescribing | Check:Allergy to the chosen antibiotics Past Clarithromycin or fluoroquinolone use for any infection Significant drug interactions |
| Second-line | After a failed test of cure:Bismuth quadruple, if not used first Levofloxacin triple, preferred after prior Metronidazole exposure |
| PPI standard dose | Esomeprazole 20 mg, Dexlansoprazole 30 mg, Lansoprazole 30 mg, Omeprazole 20 mg, Pantoprazole 40 mg or Rabeprazole 20 mg. |
| Drug cautions | No alcohol with Metronidazole. Clarithromycin is a potent CYP3A4 inhibitor. Do not combine it with drugs that use this pathway (e.g. Cyclosporine, Tacrolimus). Fluoroquinolones carry a risk of aortic aneurysm and dissection, tendinopathy and C. difficile diarrhea or colitis, and add to resistance. |
| Negative test or still symptomatic | Negative test, at diagnosis or test of cure.Assess the need for follow-up.
Refer if symptoms persist. ACG/CAG 2017 recommends empirical PPI therapy under 60 if H. pylori negative or still symptomatic after eradication (strong, high quality evidence).If no response, a prokinetic or a TCA (conditional, very low or low quality evidence). |
| Regimens with Amoxicillin | Concomitant quadruple and Levofloxacin triple contain Amoxicillin. Bismuth quadruple contains no penicillin. |
| Drug | Dose |
|---|---|
| Bismuth quadruple: first-line, or second-line if not used first | |
| PPI | Standard dose PO BID |
| Bismuth subsalicylate | 524 mg PO QID |
| Metronidazole | 500 mg PO TID or QID |
| Tetracycline | 500 mg PO QID |
| Concomitant quadruple without bismuth: first-line | |
| PPI | Standard dose PO BID |
| Amoxicillin | 1000 mg PO BID |
| Metronidazole | 500 mg PO BID |
| Clarithromycin | 500 mg PO BID |
| Levofloxacin triple: second-line, preferred after prior Metronidazole | |
| PPI | Standard dose PO BID |
| Amoxicillin | 1000 mg PO BID |
| Levofloxacin | 250 mg PO BID |
Follow-up
- INESSS Institut national d'excellence en santé et services sociaux
| Decision | Guideline |
|---|---|
| Test of cure | At least 4 weeks after the end of treatment.Stop PPIs 2 weeks before the test. Use only a test for active infection. |
| Which test | No gastric ulcer before treatment:Stool antigen or breath test
Endoscopy is generally not recommended Gastric ulcer before treatment
|
| Serology | Not for a test of cure.Antibodies can persist for months or even years. |
| Treatment failure | H. pylori found on a test of cure is a treatment failure.Start second-line treatment. |
| Refer | Consider referral:Suspected H. pylori with an unexplained warning sign: progressive dysphagia, hematemesis, digestive bleeding, abdominal mass, persistent vomiting, weight loss or anemia After 2 failed eradication treatments Persistent GI symptoms despite successful eradication and symptomatic treatment (e.g. PPI) Suspected true penicillin allergy and failed bismuth quadruple |
Long-term PPI
- INESSS Institut national d'excellence en santé et services sociaux
| Decision | Guideline |
|---|---|
| Who | Adults on a PPI for more than 8 weeks.The algorithm covers deprescribing only, not GERD or dyspepsia management. |
| Indication for more than 8 weeks | Do not deprescribe.If BID, consider DIE case by case. Indications: INESSS algorithm, appendix A opens in a new tab. |
| Indication unclear | Check:History (e.g. endoscopy, admission for a bleeding ulcer, past chronic NSAID or ASA use) Over-the-counter drugs (e.g. NSAIDs, ASA) |
| Symptoms despite good adherence | Stop the PPI (ineffective).Look for other causes, such as habits or drug side effects. Consider further workup. |
| No indication | Deprescribe, by a plan agreed with the person:Lower the dose: DIE if BID, every other day, or the lowest effective dose Take it PRN: regularly but only in periods, for the shortest time at the lowest effective dose Stop it: abrupt and tapered stops do not differ in symptom recurrence |
| Tell the person | Symptoms may come back for a few days, then usually settle.
Non-drug measures, antacids or an H2 blocker can ease them.
Symptoms over 1 week, or that limit daily activities despite those measures: restart the previous dose without waiting for a visit.
See a clinician for symptoms over 2 months despite restarting, or for alarm symptoms.
|
| Follow-up | Reassess after 4–12 weeks.Document GERD or dyspepsia symptoms and how well other measures work. Restart the last effective dose if symptoms persist despite other measures. If restarted, try again after 4–12 weeks, then yearly while it continues. |
| H. pylori | Consider H. pylori testing for persistent dyspepsia.Not for classic GERD. |
Reviewed 17 October 2026 against the official sources below.
Sources
Blue square: Québec · red round: Canada. The code names the body; each section's key gives its full name.