What are the symptoms and treatment options for Helicobacter (H.) Pylori infection?

H. Pylori Symptoms and Treatment

H. pylori infection typically causes dyspeptic symptoms including epigastric pain, bloating, nausea, and belching, though many infected individuals remain asymptomatic despite having chronic gastritis. The infection requires prompt diagnosis and treatment to prevent complications such as peptic ulcers and gastric cancer.

Symptoms of H. pylori Infection

H. pylori infection can present with various symptoms, though many infected individuals remain asymptomatic:

• Common symptoms:

  • Epigastric pain or discomfort (predominant symptom)
  • Bloating and abdominal distension
  • Nausea
  • Belching
  • Early satiety
  • Heartburn (in some cases, though this may indicate overlap with GORD)

• Alarm symptoms requiring immediate specialist referral 1:

  • Anaemia
  • Weight loss
  • Dysphagia
  • Palpable abdominal mass
  • Malabsorption

Diagnostic Approach

The diagnostic approach depends on patient age and symptom presentation:

• For patients <45 years without alarm symptoms:

  • Non-invasive testing is recommended 1
  • 13C-urea breath test (UBT) - highly accurate and preferred
  • Laboratory serology (if validated locally)

• For patients >45 years OR those with alarm symptoms:

  • Refer for specialist evaluation and endoscopy regardless of age 1
  • Endoscopic biopsy with histology and/or rapid urease testing

Treatment Options

First-line Treatment

Triple therapy is the standard first-line treatment for H. pylori infection, consisting of:

1. Proton pump inhibitor (e.g., lansoprazole) 2
2. Amoxicillin 3
3. Clarithromycin

Treatment duration: 7-14 days (14 days preferred for higher eradication rates) 4

Alternative Regimens

For patients with penicillin allergy or in areas with high clarithromycin resistance:

• Bismuth quadruple therapy:

  • Bismuth salt
  • Proton pump inhibitor
  • Tetracycline
  • Metronidazole

• Dual therapy (for those allergic/intolerant to clarithromycin):

  • Lansoprazole
  • Amoxicillin 2

Treatment Verification

• Post-treatment testing (test of cure) is recommended at least 4 weeks after completing therapy 4
• Urea breath test or stool antigen test are preferred for confirming eradication

Clinical Pearls and Pitfalls

• Important pitfall: Many patients with H. pylori infection remain asymptomatic despite having chronic gastritis, which can progress to more serious conditions if left untreated.

• Key consideration: H. pylori infection significantly increases the risk of peptic ulcer disease and gastric cancer, making identification and eradication crucial even in minimally symptomatic patients 1.

• Treatment caution: Prior to diagnostic testing, patients should discontinue antibiotics, bismuth products, and proton pump inhibitors for at least 2 weeks to avoid false negative results 1.

• Age consideration: The prevalence of H. pylori infection varies by geographic area, age, race, ethnicity, and socioeconomic status, with higher rates in developing countries and infections typically occurring during childhood 5.

• Prevention: Adequate sanitation practices and consumption of fruits and vegetables (particularly vitamin C) appear to protect against H. pylori infection 5.

By promptly identifying and treating H. pylori infection, clinicians can significantly reduce the risk of serious complications including peptic ulcer disease and gastric cancer.