Clinician reference tool — not medical advice. This is a clinical decision-aid intended for healthcare professionals: it gives deterministic suggestions to think with, not a diagnosis or a prescription. If you’re a patient, you’re welcome to look around — but please review anything here with your own doctor; it isn’t a substitute for personalized medical care.
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Helicobacter pylori testing (urea breath test, stool antigen, or serology)

GI / immune · specimen: breath

Indicated in specific situations

Also called: H pylori breath test, urea breath test, H pylori stool antigen, H pylori antibody test, H pylori serology, H. pylori test

Chart note

Pick Ordered or Not ordered to see the note.

Indicated when

  • Dyspepsia in a patient under 60 without alarm features: guideline recommends a non-invasive H pylori test and treatment if positive, as first-line management [1]
  • Peptic ulcer disease, gastric MALT lymphoma, or a first-degree relative with gastric cancer, where Public Health Ontario's testing indications specifically include gastric cancer risk factors [2]
  • Unexplained iron-deficiency anemia after standard evaluation, or unexplained dyspepsia lasting at least one month without predominant reflux symptoms [2]

Not indicated when

  • Using serology (antibody testing) as the test of choice when a treatment decision is planned: PHO's own test information notes that 'seropositivity alone does not distinguish active from resolved infection,' so a positive antibody result does not confirm a current, treatable infection [2]
  • Testing without any planned follow-up for treatment if positive

Why not

The main pitfall is choosing the wrong test: antibody (serology) testing has a sensitivity traditionally estimated at 85-95% and specificity at 70-90%, but 'due to the lower test specificity, false positives may occur in low prevalence settings,' and a positive antibody result cannot distinguish an active infection from a past, already-resolved one [2]. The urea breath test and stool antigen test are better suited to confirming an active infection that needs treatment, but their community-lab billing status in Ontario is unverified.

Better first step

For a patient under 60 with dyspepsia and no alarm features, order a non-invasive H pylori test (urea breath test or stool antigen, preferred over serology when confirming an active, treatable infection is the goal) and treat if positive [1, 2].

Typical ND rationale

An ND may order H pylori testing, often serology, in a patient with dyspepsia, reflux, or unexplained GI symptoms, reasoning that this common, treatable infection is a real and frequently underdiagnosed contributor to upper GI symptoms and should be ruled out.

Where the ND is right

This is a place the ND is often right: H pylori is a real, common, and treatable infection, and testing for it in a patient with dyspepsia or a relevant risk factor is guideline-endorsed, not an overreach [1, 2]. The caveat is choosing the right test: serology alone cannot confirm an active infection worth treating, and any positive result should come with a plan to treat if confirmed.

Ontario coverage & CONO orderability

OHIP status
unverified
docs/research/ontario-coverage.md lists the H pylori urea breath test as absent from the current community Schedule of Benefits, and a full-text search of the 2026 Schedule in this session for 'pylori' found no listing, so community-lab billing status for the breath test or stool antigen test if a physician ordered one is unverified. Separately, Public Health Ontario performs H pylori antibody (serology) testing directly, with routine acceptance criteria (effective July 22, 2026) restricted to the indications above; PHO explicitly does not perform the urea breath test, stool antigen, or stool PCR, noting these 'may be available at other community or hospital laboratories' [2]. ND-ordered testing is privately paid regardless of modality (Reg. 552 s.22(1)).
CONO orderable
Yes — CONO list #194
CONO 194 'Urea breath test for H. pylori', breath specimen. The CONO list does not separately enumerate a stool antigen test; a stool-based H pylori antigen test is not confirmed orderable through this list and is not asserted here.

Linked conditions

Counselling script

“H. pylori is a common, treatable infection, and testing makes sense with ongoing indigestion or upper stomach pain, or unexplained low iron. I'd use the breath or stool test rather than the blood antibody test, because antibodies can stay positive long after the infection is gone, and I want a result we can act on.”

Revisit if

  • Dyspepsia, upper GI symptoms, or unexplained iron-deficiency anemia develop or persist
  • Alarm features develop (weight loss, GI bleeding, dysphagia, persistent vomiting)

References

  1. [1]American College of Gastroenterology / Canadian Association of Gastroenterology (2017). ACG and CAG Clinical Guideline: Management of Dyspepsia. linkACG/CAG guideline: patients under 60 with dyspepsia should have a non-invasive H pylori test and treatment if positive
  2. [2]Public Health Ontario (2026). Helicobacter pylori – Antibody (Test Information Index). linkPHO testing indications (peptic ulcer disease, gastric cancer risk, unexplained dyspepsia, refractory iron-deficiency anemia); serology sensitivity/specificity and inability to distinguish active from resolved infection; PHO does not perform breath/stool antigen/stool PCR testing
  3. [3]Ontario Ministry of Health (2026). Ontario Health Insurance Plan: Schedule of Benefits for Laboratory Services (effective April 1, 2026). linkCommunity lab tests are insured only when ordered under the Schedule by an authorized prescriber
  4. [4]Government of Ontario (e-Laws) (2026). Health Insurance Act, R.R.O. 1990, Reg. 552: General, s. 22 (insured laboratory services). linkInsured lab testing requires ordering by an authorized provider who has clinically assessed the patient
  5. [5]Ontario Ministry of Health (2026). Ontario Health Insurance Plan: Schedule of Benefits for Laboratory Services (effective April 1, 2026). linkTests ordered by anyone other than an authorized provider, including NDs, are not insured services
Evidence notes

The Toronto Consensus (Fallone et al. 2016), suggested in the batch notes, was fetched in full text (Gastroenterology 2016;151:51-69, via CAG's own PDF) but is a treatment-focused consensus statement; a full-text search within it for 'breath test', 'stool', and 'serology' found no diagnostic-testing-modality content, so it is not cited in this record. The PHO indications list was retrieved with an 'other indications with limited or conflicting evidence' section truncated during fetch; only the clearly stated main indications are asserted here, and the truncated secondary list (which began with 'refractory iron deficiency anemia after appropriate evalua...') is not exhaustively reproduced. No condition id in the batch's provided list maps well to dyspepsia/H pylori specifically, so linked_conditions is left empty; flagging this as a gap for the condition-batch team. Reviewer: urea breath test and stool antigen are not in the 2026 community Schedule by name, so physician-ordered coverage stays unverified. Check PHO or hospital funding before Phase 2.