The best is the enemy of the good: Time for a biopsy-sparing approach for Helicobacter pylori diagnosis and treatment in children in the COVID-19 era?

The Joint ESPGHAN/NASPGHAN Guidelines for the Management of Helicobacter pylori (H. pylori) in Children and Adolescents recommend against a “test and treat” strategy for H. pylori infection, while recommending antimicrobial sensitivity testing and tailoring eradication therapy accordingly.1 It is strongly recommended (with a high quality of evidence and 100% agreement) that “the initial diagnosis of H. pylori infection be performed using invasive gastric biopsy-based methods including the following: a. positive bacterial culture OR b. H. pylori gastritis on histopathology using the updated Sydney classification with at least 1 other positive test such as rapid urease test, or molecular-based assays where available, including polymerase chain reaction or fluorescent in situ hybridization”.1 However, in the new healthcare scenario emerged during the novel coronavirus disease (COVID-19) pandemic, elective pediatric diagnostic endoscopy has been substantially suspended, except for emergency cases,2, 3 with a minimization of the total number of procedures. As the diagnosis of H. pylori could hardly represent an emergency, unless in the cases of a bleeding ulcer, many children could remain undiagnosed for a long time and, therefore, untreated in the absence of antimicrobial sensitivity to guide the eradication strategy. To face this temporary difficulty in performing upper gastrointestinal endoscopy, a more extensive biopsy-sparing approach has been recently proposed for the diagnosis of celiac disease,4 considering a temporary reduction in the threshold of TGA-IgA between 5 and 10 ULN in EMA-positive children. Similarly, we would like to bring to your attention the feasibility of a temporary biopsy-sparing approach for the diagnosis and treatment of H. pylori infection in children and adolescents.