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

Symptoms and Treatment of Helicobacter pylori Infection

H. pylori infection commonly presents with dyspeptic symptoms including epigastric pain and nausea, and while many infections are asymptomatic, treatment is strongly recommended using bismuth quadruple therapy for 14 days as first-line therapy to prevent complications such as peptic ulcer disease and gastric cancer.

Common Symptoms of H. pylori Infection

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

• Primary symptoms:

  • Dyspepsia (indigestion)
  • Epigastric pain (significantly associated with active infection) 1
  • Nausea 1
  • Weight loss (alarm symptom)
  • Anemia (alarm symptom)

• Alarm symptoms requiring immediate specialist referral:

  • Dysphagia
  • Palpable abdominal mass
  • Malabsorption
  • Weight loss
  • Anemia 2

Diagnostic Approach

The diagnostic approach depends on patient age and presence of alarm symptoms:

• Patients <45 years without alarm symptoms:

  • Test for H. pylori using non-invasive methods
  • Recommended tests:
    • 13C-urea breath test (UBT) - gold standard with excellent sensitivity (95%) and specificity (90%) 2, 3
    • Laboratory serology (validated locally) 2
    • Monoclonal stool antigen test (comparable accuracy to UBT) 3

• Patients >45 years with severe symptoms OR any patient with alarm symptoms:

  • Immediate referral to specialist for endoscopy 2
  • Biopsy for histology, culture, and rapid urease test 4

Treatment Recommendations

First-Line Treatment

For treatment-naïve patients:

• Bismuth quadruple therapy (preferred regimen when antibiotic susceptibility is unknown) 3, 5:

  • PPI (high-dose) twice daily
  • Bismuth subcitrate ~300mg four times daily
  • Metronidazole 500mg three times daily
  • Tetracycline 500mg four times daily
  • Duration: 14 days (85% eradication rate) 3

• Alternative regimens:

  • Triple therapy with clarithromycin and lansoprazole 6:
    • Amoxicillin 1g twice daily
    • Clarithromycin 500mg twice daily
    • PPI (lansoprazole) twice daily
    • Duration: 14 days

Treatment for Refractory Infection

For patients who fail initial treatment:

• If bismuth quadruple therapy failed:

  • Levofloxacin-based triple therapy OR
  • Rifabutin-based triple therapy 3

• If clarithromycin-based triple therapy failed:

  • Bismuth quadruple therapy 3

Optimizing Treatment Success

• Maximize acid suppression:

  • Use high-dose PPIs (increases eradication rates by 6-10%)
  • Administer PPI 30 minutes before meals on empty stomach 3

• Optimize antibiotic dosing:

  • Amoxicillin: at least 2g daily in 3-4 divided doses
  • Metronidazole: 1.5-2g daily in divided doses 3

• Treatment duration:

  • 14-day regimens are strongly recommended over 7-day regimens (approximately 5% better eradication rates) 3

Post-Treatment Follow-up

• Confirm eradication at least 4 weeks after completing treatment 3
• Use urea breath test or monoclonal stool antigen test
• Ensure patient has been off PPI for at least 2 weeks before testing 3

Common Pitfalls to Avoid

• Reusing failed antibiotics, particularly clarithromycin and levofloxacin 3
• Inadequate PPI dosing, which significantly reduces eradication rates 3
• Short treatment duration (7-day regimens have lower success rates) 3
• Ignoring prior antibiotic exposure 3
• Failing to refer patients with alarm symptoms for endoscopy 2

Special Considerations

• Penicillin allergy: Use bismuth-based quadruple therapy with tetracycline and metronidazole 3
• Renal impairment: Adjust amoxicillin dosing based on GFR 3
• Bleeding ulcers: Start treatment when oral feeding is resumed 3

H. pylori eradication has been shown to prevent relapse of duodenal ulcers and reduce the risk of gastric cancer, making proper diagnosis and treatment essential for improving long-term outcomes 1, 3.