Urea breath test for Helicobacter pylori infection in adult dyspeptic patients: A meta-analysis of diagnostic test accuracy

Abstract

Background: Helicobacter pylori (H. pylori) infection has been well-established as a significant risk factor for several gastrointestinal disorders. The urea breath test (UBT) has emerged as a leading non-invasive method for detecting H. pylori. Despite numerous studies confirming its substantial accuracy, the reliability of UBT results is often compromised by inherent limitations. These findings underscore the need for a rigorous statistical synthesis to clarify and reconcile the diagnostic accuracy of the UBT for the diagnosis of H. pylori infection.

Aim: To determine and compare the diagnostic accuracy of ¹³C-UBT and ¹⁴C-UBT for H. pylori infection in adult patients with dyspepsia.

Methods: We conducted an independent search of the PubMed/MEDLINE, EMBASE, and Cochrane Central databases until April 2022. Our search included diagnostic accuracy studies that evaluated at least one of the index tests (¹³C-UBT or ¹⁴C-UBT) against a reference standard. We used the QUADAS-2 tool to assess the methodological quality of the studies. We utilized the bivariate random-effects model to calculate sensitivity, specificity, positive and negative test likelihood ratios (LR+ and LR-), as well as the diagnostic odds ratio (DOR), and their 95% confidence intervals. We conducted subgroup analyses based on urea dosing, time after urea administration, and assessment technique. To investigate a possible threshold effect, we conducted Spearman correlation analysis, and we generated summary receiver operating characteristic (SROC) curves to assess heterogeneity. Finally, we visually inspected a funnel plot and used Egger's test to evaluate publication bias.

Results: The titles and abstracts of 4621 studies were screened; 79 articles were retrieved and selected for full-text reading. Finally, 60 studies were included in the diagnostic test accuracy meta-analysis. Our analysis demonstrates superior diagnostic accuracy of ¹³C-UBT over ¹⁴C-UBT, indicated by higher sensitivity (96.60% vs 96.15%), specificity (96.93% vs 89.84%), likelihood ratios (LR+ 22.00 vs 10.10; LR- 0.05 vs 0.06), and area under the curve (AUC; 0.979 vs 0.968). Notably, ¹³C-UBT's DOR (586.47) significantly outperforms ¹⁴C-UBT (DOR 226.50), making it the preferred diagnostic tool for dyspeptic individuals with H. pylori infection. Correlation analysis revealed no threshold effect (¹³C-UBT: r = 0.48; ¹⁴C-UBT: r = -0.01), and SROC curves showed consistent accuracy. Both ¹³C-UBT and ¹⁴C-UBT showed high AUC values (¹³C-UBT 0.979; ¹⁴C-UBT 0.968) near 1.00, reinforcing their excellent accuracy and endorsing both as reliable diagnostic tools in clinical practice.

Conclusion: In summary, our study has demonstrated that ¹³C-UBT has been found to outperform the ¹⁴C-UBT, making it the preferred diagnostic approach. Additionally, our results emphasize the significance of carefully considering urea dosage, assessment timing, and measurement techniques for both tests to enhance diagnostic precision. Nevertheless, it is crucial for researchers and clinicians to evaluate the strengths and limitations of our findings before implementing them in practice.

Keywords: Diagnosis; Diagnostic test accuracy; Helicobacter pylori; Meta-analysis; Urea breath test.

Figure 1

PRISMA 2020 flow diagram. This flowchart delineates the progression of information throughout various phases of the systematic review, illustrating the quantities of records identified, included, and excluded, along with the rationales for study exclusion.

Figure 2

QUADAS-2 methodological quality graph. The QUADAS-2 methodological quality graph consists of four sections, each representing one of the key domains assessed.

Figure 3

Forest plot for studies based on the ¹³C-urea breath test for Helicobacter pylori infection in dyspeptic patients. A: Forest plot for overall sensitivity; B: Forest plot for overall specificity. 95%CI: 95% confidence interval.

Figure 4

Forest plot for studies based on the ¹⁴C-urea breath test for Helicobacter pylori infection in dyspeptic patients by time after urea administration. A: Forest plot for overall sensitivity; B: Forest plot for overall specificity. 95%CI: 95% confidence interval.

Figure 5

Summary operating characteristics curve curves for studies based on the ¹³C-urea breath test and the ¹⁴C-urea breath test for Helicobacter pylori infection in dyspeptic patients. The summary operating characteristics curve (SROC) curve is a graphical representation that combines sensitivity and specificity data from multiple studies or diagnostic tests. It illustrates how these measures change with different threshold settings or study parameters. The curve is accompanied by the area under the curve (AUC), which provides a quantitative assessment of the test's overall performance. A higher AUC value indicates better discriminatory ability across tested thresholds. Furthermore, the diagnostic odds ratio (DOR) is derived from the ROC curve and offers an evaluation of the test's diagnostic precision. A higher DOR signifies stronger discriminatory power, reflecting the odds of a positive test result in individuals with the condition compared to those without it. A: SROC curve for studies based on the ¹³C-urea breath test (UBT) for Helicobacter pylori (H. pylori) infection in dyspeptic patients; B: SROC curve for studies based on the ¹⁴C-UBT for H. pylori infection in dyspeptic patients. SROC: Summary operating characteristics curve; AUC: Area under the curve; DOR: Diagnostic odds ratio.

Figure 6

Funnel plots for studies based on ¹³C-urea breath test and ¹⁴C-urea breath test for Helicobacter pylori infection in dyspeptic patients. A: Funnel plot for studies based on ¹³C-urea breath test (UBT); B: Funnel plot for studies based on ¹⁴C-UBT.