H. pylori Test and Treat in Reflux: Why its clinically wrong and why you should push back.
If you've been to your GP with heartburn, throat symptoms or others likely to be caused by reflux, there's a good chance you've been offered an H. pylori test. But if your real problem is reflux - in any form - then if positive, its treatment with heavy-duty antibiotics and high doses of Proton Pump Inhibitors (PPIs) that follow may do more harm than good.
Written by Mr Nick Boyle
A quiet revolution in NHS primary care
There's a quiet revolution happening in UK NHS primary care. Faced with long endoscopy waiting lists and mounting pressure to reduce what are called "unnecessary" procedures, GPs and gastroenterologists are increasingly encouraged to use a "test and treat" strategy for upper gastrointestinal symptoms: test for the bacterial infection Helicobacter pylori, and if positive, eradicate it with antibiotics and high-dose PPIs. The aim is to direct patients into "alternative management pathways" as part of "Low-Value Gastroscopy Programmes."
NICE guidance (CG184) supports this approach, and NHS trusts across England have adopted it as a cost-effective way to manage dyspepsia without recourse to endoscopy. The appeal to the system is obvious: reduce the demand for endoscopy and effectively ration access. But there is a problem. This strategy is based upon evidence for its use in patients with dyspepsia - not reflux, specifically Gastro-Oesophageal Reflux Disease (GERD).
Test and treat has evidence - but only for dyspepsia
The test and treat approach has a legitimate evidence base - but only for dyspepsia. Dyspepsia means symptoms thought to originate from the stomach and duodenum: epigastric pain, bloating, early fullness, and upper abdominal discomfort among others. The most widely used definitions were first published in 1995 and subsequently updated, the most recent known as "Rome IV" (Drossman DA et al., Gastroenterology, 2016). These are internationally accepted as the gold standard for research. Of note, the most recent definition explicitly distinguishes dyspepsia from GERD: if reflux symptoms predominate, then patients should be classified as having a reflux disorder and not dyspepsia.
However, NICE uses a far more permissive definition, explicitly incorporating reflux symptoms, and goes on to add the instruction that "reflux-like" symptoms should be investigated as dyspepsia. In the context of dyspepsia, H. pylori eradication addresses a genuine potential cause, particularly peptic ulcer disease. However, even here, the benefits are modest. A landmark 2022 meta-analysis of 29 randomised controlled trials involving over 6,700 patients found that eradication therapy was superior to control for symptom cure, but the number needed to treat (NNT) was 14 - meaning only around one in fourteen patients who test positive and complete eradication therapy will achieve meaningful, lasting symptom relief (Moayyedi et al., Gut, 2022). More than 13 of 14 patients will have taken a week of dual antibiotics and a proton pump inhibitor for no symptomatic benefit, while facing the risks of side effects and adverse events.
GERD is a different disease entirely
Gastro-oesophageal reflux disease (GERD) is a different disease entirely. Reflux symptoms and the damage it can cause arise because excessive gastric contents - including acid and pepsin - escape upward from the stomach into the oesophagus. It is most often caused by failure of the lower oesophageal sphincter, usually a hiatus hernia, which of course is a structural problem. H. pylori does not cause GERD. There is no credible trial evidence that eradicating it improves reflux symptoms. And yet patients with classic reflux presentations are increasingly being funnelled through the test and treat pathway rather than being properly assessed and treated for GERD.
Worse still - eradication therapy may actively worsen reflux
H. pylori, particularly when it colonises the body of the stomach, suppresses acid production. Remove the infection and acid secretion can rebound. A 2025 systematic review and meta-analysis published in the Journal of Gastroenterology and Hepatology found that H. pylori eradication was associated with a significantly increased risk of developing GERD - with a pooled odds ratio of 2.01 across 25 studies (Wang et al., 2025). A 2023 prospective study went further, demonstrating that eradication measurably increased 24-hour oesophageal acid exposure on pH monitoring, and worsened GERD symptom scores in patients who had both conditions at baseline (Zhang et al., 2023).
The problem extends to laryngopharyngeal reflux (LPR)
LPR - where reflux travels all the way up to the throat, larynx, and airways - causes symptoms such as chronic cough, throat clearing, hoarseness, and globus sensation. Yet patients with these symptoms are also being offered H. pylori test and treat - an approach that has no evidence base whatsoever. Multiple studies have failed to find a meaningful association between H. pylori and LPR symptoms.
A systematic review and meta-analysis concluded that there is insufficient evidence to recommend testing and treating H. pylori in this population and called for well-designed trials before any such recommendation could be made (Liu et al., Journal of Voice, 2024). A prospective study using double pH probe monitoring found no statistically significant relationship between H. pylori status and proximal acid exposure - the defining feature of LPR (Ercan et al., Otolaryngology–Head and Neck Surgery, 2006).
Applying test and treat to LPR patients is not a shortcut - it is a detour that may delay appropriate diagnosis and make symptoms worse.
What about prevention of stomach cancer?
H. pylori is known to be associated with gastric cancer, and so its eradication has been used as a justification for the test and treat strategy. This is on the basis that there is some evidence from studies performed in Asia - where stomach cancer has a high prevalence - that eradicating H. pylori reduces its incidence. But, and it's a very big but, there is no data as yet from Europe or North America supporting test and treat in low-risk populations where the pattern of chronic gastritis is different.
To be clear: there is no UK-specific Randomised Controlled Trial evidence that test and treat in dyspeptic patients reduces gastric cancer incidence. The rationale is biologically plausible, but the magnitude of benefit in a UK dyspeptic cohort is unknown, and the NNT to prevent a single cancer case would almost certainly be very large. So while cancer prevention may be a reasonable secondary justification - albeit one as yet unproven - for the strategy in true dyspepsia, it should not be used to extend test and treat to reflux or LPR patients, where there is no proven symptom benefit and a potential for harm, irrespective of any theoretical cancer prevention argument.
But maybe this is a subject for another blog!
The cardinal rule: take the right history
The first step to reaching the right diagnosis for any condition is to take the right "history." This should always drive management and is what we teach medical students during their first days of learning clinical medicine. Listening to a patient's story - where symptoms are felt, how they started, their character and nature, what triggers or relieves them - in the case of suspected reflux, whether they are positional, whether they are associated with throat symptoms, how they respond to antacids, and whether there are any "alarm" symptoms - must be the first questions asked by your doctor. Whether oesophageal or laryngopharyngeal, or both, these will usually distinguish GERD from dyspepsia.
It is of course true that it's not always straightforward and there can be overlap between gastro-duodenal and oesophageal symptoms. But honestly, so many times we've seen patients with obvious GERD symptoms who've been sent down the H. pylori test and treat route with no benefit - in our opinion, wrongly.
The right test for the right condition
The NHS test and treat strategy has a legitimate, evidence-supported role in dyspepsia. But it is becoming a reflex response to any patient with upper GI or throat symptoms. This is mostly because of a deliberate strategy to "demand manage" NHS resources - and particularly access to endoscopy - rather than as a response to good scientific medical evidence.
If your main complaint is heartburn or throat-based reflux symptoms, the right path is investigation and treatment aimed at reflux - not a bacterial eradication programme designed for a different condition. The wrong test will not give you the right answer - and might even make it worse!
References
Drossman DA. Functional gastrointestinal disorders: history, pathophysiology, clinical features and Rome IV. Gastroenterology. 2016;150(6):1262–1279. doi:10.1053/j.gastro.2016.02.032
Moayyedi P et al. Efficacy of Helicobacter pylori eradication therapy for functional dyspepsia: updated systematic review and meta-analysis. Gut. 2022;71(9):1703–1714. doi:10.1136/gutjnl-2021-326583
Wang Y et al. Helicobacter pylori infection and eradication in relation to gastroesophageal reflux disease. Journal of Gastroenterology and Hepatology. 2025. doi:10.1111/jgh.70009
Zhang X et al. Effects of Helicobacter pylori eradication on esophageal motility, esophageal acid exposure, and gastroesophageal reflux disease symptoms. Frontiers in Cellular and Infection Microbiology. 2023;13:1082620. doi:10.3389/fcimb.2023.1082620
Liu S et al. Association between Helicobacter pylori and laryngopharyngeal reflux disease: a systematic review and meta-analysis. Journal of Voice. 2024. doi:10.1016/j.jvoice.2024.03.036
Ercan I et al. The role of gastric Helicobacter pylori infection in laryngopharyngeal reflux disease. Otolaryngology–Head and Neck Surgery. 2006;135(1):52–55. doi:10.1016/j.otohns.2006.03.020
NICE Clinical Guideline CG184. Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management. Updated September 2024.
