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

H. pylori Infection: Symptoms and Treatment

H. pylori infection commonly presents with dyspeptic symptoms including upper abdominal pain, bloating, nausea, and occasional vomiting, though many infected individuals remain asymptomatic. Treatment requires eradication therapy with bismuth quadruple therapy as the preferred first-line regimen.

Symptoms of H. pylori Infection

H. pylori infection can manifest with various symptoms, though many infected individuals may be asymptomatic:

Common Symptoms:

• Upper abdominal pain or discomfort (dyspepsia)
• Bloating and feeling of fullness
• Nausea
• Occasional vomiting
• Belching
• Loss of appetite

Less Common Symptoms:

• Weight loss
• Anemia (due to occult bleeding)
• Halitosis (bad breath)

Alarm Symptoms (requiring immediate referral for endoscopy):

• Weight loss
• Dysphagia (difficulty swallowing)
• Persistent vomiting
• Anemia
• Palpable abdominal mass
• Malabsorption
• Family history of gastric cancer 1

Diagnostic Approach

The diagnostic approach depends on patient age and symptoms:

• Patients <45 years without alarm symptoms: Test for H. pylori using non-invasive methods 1

  • Urea breath test (UBT) - gold standard with 95% sensitivity and 90% specificity
  • Monoclonal stool antigen test
  • Validated serological tests

• Patients >45 years or those with alarm symptoms: Refer for endoscopy with biopsy 1, 2

Treatment Recommendations

First-Line Therapy:

Bismuth quadruple therapy for 14 days is the preferred first-line treatment for H. pylori infection 2, 3, consisting of:

• PPI (standard dose) twice daily
• Bismuth subcitrate 120 mg four times daily
• Tetracycline 500 mg four times daily
• Metronidazole 500 mg three times daily

This regimen has an eradication rate of approximately 85% 2.

Alternative First-Line Options:

• Concomitant non-bismuth quadruple therapy (14 days)
• Standard triple therapy (14 days) in areas with low clarithromycin resistance

Second-Line Therapy:

If first-line therapy fails, options include:

• Levofloxacin-based therapy: PPI (standard dose) twice daily, amoxicillin 1000 mg twice daily, and levofloxacin 500 mg once daily or 250 mg twice daily for 14 days 2
• Bismuth quadruple therapy (if not used as first-line)

Special Considerations:

• For penicillin allergy: Bismuth quadruple therapy is preferred 2
• Avoid re-using antibiotics that failed previously
• For renal impairment: Adjust amoxicillin dosing according to GFR 2

Post-Treatment Follow-up

• Confirm eradication at least 4 weeks after completing treatment
• Use urea breath test or monoclonal stool antigen test
• Ensure patient has been off PPI for at least 2 weeks before testing 2

Complications of Untreated H. pylori

• Chronic gastritis
• Peptic ulcer disease
• Gastric cancer (particularly in high-risk populations)
• Gastric MALT lymphoma 4, 5

Common Pitfalls in Management

1. Failing to test for eradication: Always confirm eradication after treatment
2. Inadequate treatment duration: 14-day regimens are superior to shorter courses
3. Not considering antibiotic resistance: Local resistance patterns should guide therapy
4. Overlooking alarm symptoms: Patients with alarm symptoms require prompt endoscopy
5. Continuing PPI before diagnostic testing: Can lead to false negative results

By following these evidence-based guidelines for diagnosis and treatment of H. pylori infection, clinicians can effectively manage this common condition and prevent its potentially serious complications.