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The diagnosis of Helicobacter pylori (H. pylori) infection may be reached using a number of both “direct” and “indirect” methods (1). The former rely on the "direct" identification of this organism via the histologic and microbiologic study of samples obtained with gastric biopsy. Therefore, they require endoscopy, which is certainly inconvenient for patients. This inconvenience and the relatively high cost of endoscopy has prompted the search for simpler alternatives, particularly in developing countries (2). “Indirect” methods are based upon the study and detection of selected bacterial characteristics, including the organism's ability to hydrolyze urea –property underlying the C-urea breath test (1)– and the host's immune system response to infection (detection of specific antibodies using serologic tests). As a result, these "non-invasive" techniques add to their diagnostic accuracy the benefits of lower aggression and better tolerability by patients, but also the drawback that virulence or strain resistance patterns cannot be studied. Thus far, when aiming at H. pylori collection for the performance of more or less complex techniques such as microscopy, culture, DNA analysis, cytotoxin screening, strain differentiation, or antimicrobial susceptibility analyses, endoscopy with gastric biopsy sampling was mandatory. The alarming, progressive increase of bacterial resistance rates has led to an increasing number of failed eradication procedures –approximately 20% of therapy-naïve individuals (3). Such lost efficacy makes sometimes advisable the collection of samples for culture, so that an antibiogram may be performed, and a more effective therapy is initiated according to bacterial susceptibility. Regarding this, there is some consensus on the performance of H. pylori cultures following a second failed eradication (4), while some authors have recommended this even prior to the index therapy, based on this strategy's higher cost-benefit ratio (5). As resistance rates keep increasing, there is a growing need for a pre-treatment routine susceptibility test –as little aggressive as possible and efficient enough for H. pylori detection. The enterotest or string test is a method including the ingestion of a capsule attached to a long string, which is then extracted and analyzed for gastric secretions. This review attempts to assess the role of the string test in the diagnosis of H. pylori infection.

Is the string test a useful alternative to gastroscopy with biopsy for H. pylori identification?