Original Article

Helicobacter pylori Stool Antigen Test

E. Mahir Gulcan,1 Aydin Varol2, Tufan Kutlu,3 Fugen Cullu3, Tulay Erkan,3 Erdal Adal,2
Onder Ulucakli4 and Sibel Erdamar5
1
SSK Bakirkoy Maternity and Childrens Training Hospital, Department of Pediatric Gastroenterology,
2
Department of Pediatrics, 4Department of Microbiology, 3Cerrahpasa
, Faculty of Medicine, Department of Pediatric
Gastroenterology, 5Department of Pathology, Istanbul, Turkey.

Abstract. Objective : Helicobacter pylori (H.pylori) infection is usually acquired in early childhood. Invasive techniques used
for diagnosis of H.pylori infection require endoscopic examination which is expensive and inconvenient and may cause
complications. The aim of this study was to evaluate the performance of a new noninvasive diagnostic method, stool antigen
test for H.pylori in untreated children with recurrent abdominal pain. Methods : Eighty children (35 female, 45 male) who have
undergone upper gastrointestinal endoscopy due to recurrent abdominal pain were included in the study. The H.pylori stool
antigen test (HpSA) is based on a sandwich enzyme immunoassay with antigen detection. HpSA sensitivity, specificity, and
positive and negative predictive values were determined with reference to the results of both histology and rapid urease test
as a gold standard (H. pylori status). Results : While 49 of the 80 children (61%) tested were positive for H.pylori according
to the results of both histology and rapid urease test, 28 children had negative H.pylori status. Among those 49 children, 48
were found to be positive by HpSA. Of 28 patients with negative H.pylori status, 28 were H.pylori-negative also in the stool test.
The sensitivity, specificity, and positive and negative predictive values of HpSA were found to be 98%, 100%, 100%, and 96.5%,
respectively. Conclusion : These findings have demonstrated that HpSA as a relatively simple, inexpensive and time saving
noninvasive test is a reliable method for detection of H.pylori infections in children. [Indian J Pediatr 2005; 72 (8) : 675-678]
E-mail: mahirgulcan@superonline.com

Key words: Recurrent abdominal pain; Helicobacter pylori, diagnosis, Helicobacter pylori stool antigen test, HpSA.

Helicobacter pylori (H.pylori) infection has been linked to
gastritis, duodenal ulcer, gastric cancer, and gastric
lymphomas. It is now generally agreed that H. pylori
infections are acquired during childhood or adolescence
in developing as well as developed countries.1
Since H.pylori infection is associated with many clinical
conditions in childhood, it requires to be diagnosed
during this period. There are two categories of diagnostic
methods used for detection of H.pylori: invasive tests such
as histology, rapid urease test and culture, and
noninvasive tests such as 13C-urea breath test (UBT) and
serology.2 A noninvasive and practical diagnostic tool for
detection of H.pylori infection is even more desirable in
pediatrics, because upper gastrointestinal endoscopies in
young children are usually performed in intubation
anesthesia or conscious sedation.3
Serological tests and UBT have certain disadvantages.
While serological tests lack in sufficient reliability in
children and adolescence, UBT is expensive, causes
administrative difficulties in young children and is not
available in all countries although it is as reliable as
invasive methods. 4 Because many studies support the
hypothesis of a fecal-oral route of infection, and because
H.pylori has been detected in the stool, interest has
Correspondence and Reprint requests : E.Mahir Gulcan, Cami sok.
Yesil Belgrat Evleri. F Blok. No:10. Gktrk-Kemerburgaz. 34077.
Eyup/Istanbul-Turkey. Fax: 00902125714790.
focused on the diagnostic detection of H.pylori antigens in
stool samples. 3 H.pylori stool antigen test (HpSA) is an
enzyme immunoassay (EIA) to detect H.pylori antigen in
stool specimen.5 This test was approved in USA in 1998
for both diagnosis and monitoring the response to
treatment of H.pylori infection in adult patients.4 HpSA
was found to have very reliable results particularly in
adult patients as a noninvasive method.2,6-8 Similar results
have also been obtained in recent studies conducted in
children.1,3,4,9
The aim of this study was to compare invasive
methods with a noninvasive method which detects
H.pylori antigen in stool specimens for the diagnosis of
H.pylori infection in untreated Turkish children with
recurrent abdominal pain.
MATERIAL AND METHODS
Eighty children admitted to the Department of Pediatric
Gastroenterology due to recurrent abdominal pain and
underwent upper gastrointestinal endoscopy were
included in the study. The mean age of the children (mean
SD) was 8.9 3.6 yr (age range: 2 to 15 year). Thirty-five
of them were girls and 45 were boys. Recurrent
abdominal pain was defined as occurrence of abdominal
pain limiting school or other activities at regular intervals
for more than 3 months in at least 1 year. Those who

Indian Journal of Pediatrics, Volume 72August, 2005 675

 E. Mahir Gulcan et al
received antibiotic treatment, H2-blockers or proton pump
inhibitors due to any reason for six weeks before
undergoing endoscopic examination were excluded from
the study. The study was performed according to the
Declaration of Helsinki, and all parents gave informed
consent for the participation of their child in the study.
Biopsy-based methods
Gastroscopy was performed in all patients. During
endoscopy, three biopsy specimens were collected in the
antrum of the stomach of each patient: two for histology
and one for rapid urease test. The rapid urease test (CLO
test; Delta West, Perth, WA, Australia) was considered as
positive for H.pylori if a color change from orange to
pinkish was seen within 24 hours. In the histological test,
the presence of H.pylori was based on the identification of
curved rods in the hematoxylin and eosin, or modified
Giemsa-stained sections.
Helicobacter pylori status
A patient was considered as H.pylori-infected if both
histology and rapid urease tests were positive, and as
H.pylori-negative when both tests gave negative results.
Patients who had only one positive test on rapid urease
test or histology were considered to be of indeterminate
status.
HpSA
A fresh stool sample with approximately the size of a
peanut was collected and stored at -20oC for analysis as
described previously. HpSA (Premier Platinum HpSA,
Meridian Diagnostics, Cincinnati, OH) was performed
according to the manufacturers recommendations
without knowledge of the H.pylori status. The test is based
on a sandwich EIA with antigen detection. This is a
qualitative test with a polyclonal rabbit anti-H.pylori
antibody adsorbed to microwells as capture antibody.
First, 100 l of a diluted stool sample (10 l stool in 0.5 ml
sample diluent) and thereafter, peroxidase-conjugated
polyclonal antibody solution were added to the wells and
incubated for 1 hour at room temperature. Unbound
material was removed by washing. After addition of a
substrate solution, H.pylori antigen could be detected by a
color change. A stop solution was added and the
absorbance was read at 450 nm by a spectrophotometer.
The results were interpreted as follows: OD450<0.140 was
negative, OD450 >0.160 was positive, and the value in
between was equivocal. Equivocal results should be
repeated.
Statistical analysis
The sensitivity, specificity, and positive and negative
predictive values of HpSA were calculated against the
H.pylori status for the results of HpSA.
RESULTS
Based on the proposed H.pylori status, 49 patients were
676
infected, 28 were not infected, and 3 were of
indeterminate status. In 48 of the 49 patients, H.pylori
antigen could be detected in stool. On the other hand, 28
children were negative by HpSA. There was only one
false-negative result, and none of the cases were false-
positive. None of the stool samples was read as equivocal
in the present study. The sensitivity, specificity, and
positive and negative predictive values of HpSA were
found to be 98%, 100%, 100%, and 96.5%, respectively
(Table 1).
TABLE 1. Results of HpSA Compared with H. pylori Status of
Children
H. pylori status Infected Noninfected
Histology and rapid urease test positive negative
(49) (28)
HpSA positive 48 0**
negative 1* 28
sensitivity (%) 98
specificity (%) 100
positive predictive value (%) 100
negative predictive value (%) 96.5
(*) false-negative test result
(**) false-positive test result
DISCUSSION
Detection of H. pylori infection in childhood today mostly
depends on the endoscopic biopsy of the gastric tissue
which is an invasive method performed for rapid urease
test, histology, and culture.10 These methods have been
recognized as gold standard. In pediatric patients,
however, invasive procedures have major disadvantages
such as risk of anesthesia, discomfort, and terrifying the
patients and their parents. For this reason, common use of
those procedures in children is limited.1,3 Therefore, a
noninvasive, practical, and sensitive diagnostic test for the
detection of H.pylori infection is desirable.3
The most common noninvasive tests are serology and
UBT.1,4 Serology is based on the detection of specific IgG
and IgA antibodies by using the ELISA method in
patients infected by H. pylori.11 It is not solely used in
diagnosis of the infection but particularly used for
epidemiological or screening studies. 12 Serological
methods are not reliable in children and fail in the
diagnosis and in monitoring the success of anti-H.pylori
therapy.13 Up to the present, UBT is the favorite diagnostic
tool in children for the diagnosis of H.pylori infection
because it avoids upper gastrointestinal endoscopy.14-16
The accuracy of noninvasive UBT in diagnosing H.pylori
infection has also been evaluated in children with
reference to histology and culture.17-21 UBT is based on the
stable isotope technique and combines the advantages of
noninvasiveness, excellent sensitivity and specificity.14-16
However, there are some disadvantages of the test
Indian Journal of Pediatrics, Volume 72August, 2005
 Helicobacter pylori Stool Antigen Test in Children
including its requirement of a mass spectrometer device
which is very expensive and its wrong results due to lack
of cooperation of young children for performing the
inhalation and exhalation exercises.1,20 Besides, this test is
available only in a very few centers in Turkey.
HpSA is a newly developed noninvasive EIA. It is not
time-consuming and is cheaper than the UBT. The
analytical technique of the immunoassay in stool samples
can be performed easily in any laboratory. Feces can be
obtained easily, even in newborn children. Spot samples
of the stool are sufficient; homogenization of the stool is
not required.3 This new test utilizes a polyclonal anti-
H.pylori capture antibody that is adsorbed to microwells
and shows good performance characteristics.5 HpSA has
been found to have comparable diagnostic value for
detection of H. pylori infection and for monitoring the
response to treatment in adult patients.22-25
In the present study, results of HpSA were compared
with H.pylori status. Positive H.pylori status and positive
HpSA results were consistent in 48 patients, while
negative H.pylori status and negative HpSA results were
consistent in all patients. We observed one false-negative
stool test result, but there was no false-positive test result.
Therefore, the sensitivity, specificity, and positive and
negative predictive values of HpSA in untreated children
were 98%, 100%, 100%, and 96,5%, respectively. Other
investigators have reported similar high sensitivities
(86.9-100%) and specificities (92-100%) of HpSA in
untreated children. Positive and negative predictive
values have been found similarly high in these
studies.1,3,9,26-30
Besides, it has been claimed that HpSA can be used for
monitoring treatment success and that successful
eradication of H.pylori can be confirmed after treatment.26
The accuracy of HpSA has been confirmed in children,
and this may be the optimal test to confirm the success of
eradication therapy.1,4,27 HpSA has been found to be a
useful method for post-treatment eradication testing of
H.pylori infection in children. 27 However, some
investigators have reported that results of HpSA reveal an
unsatisfactory sensitivity after treatment.26,31
In conclusion, HpSA as a noninvasive test, does not
have the disadvantages seen in UBT and is as reliable as
invasive tests. HpSA is suitable to use particularly in
developing countries like ours. Detection of H.pylori
antigens using HpSA shows a high sensitivity and
specificity and might be useful for noninvasive diagnosis
of H.pylori infection in children. HpSA may be useful
particularly in selection of the cases requiring endoscopic
examination, in monitoring the response to treatment and
in epidemiological studies.
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