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 symptoms of dyspepsia, epigastric pain, and nausea, and should be treated with 14-day bismuth quadruple therapy or triple therapy with a proton pump inhibitor, amoxicillin, and clarithromycin for optimal eradication rates. 1, 2

Clinical Presentation

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

• Common symptoms:

  • Epigastric pain (significantly associated with active infection) 3
  • Nausea 3
  • Dyspepsia (indigestion)
  • Bloating
  • Early satiety
  • Belching

• Less common symptoms:

  • Halitosis (bad breath)
  • Weight loss
  • Loss of appetite

• Complications-related symptoms:

  • Hematemesis (vomiting blood) or melena (black, tarry stools) from bleeding ulcers
  • Severe, persistent abdominal pain from perforated ulcers

Diagnostic Approach

The American Gastroenterological Association recommends testing for H. pylori in patients with erythematous gastropathy using: 1

1. Non-invasive tests:

   • Urea breath test (UBT) - Gold standard with 95% sensitivity and 90% specificity
   • Monoclonal stool antigen test
   • Serology - Particularly useful if patient has recently taken proton pump inhibitors

2. Invasive tests (requiring endoscopy):

   • Rapid urease test (RUT)
   • Histopathology
   • Bacterial culture

Important caveat: Proton pump inhibitors should be stopped 2 weeks before testing (except for serology) to avoid false negatives 1

Treatment Recommendations

First-line Treatment Options

The American College of Gastroenterology recommends the following regimens: 1, 2

1. Bismuth quadruple therapy (preferred when antibiotic susceptibility is unknown):

   • 14-day regimen
   • 85% eradication rate

2. Triple therapy:

   • Proton pump inhibitor (e.g., omeprazole) + amoxicillin + clarithromycin
   • All medications taken twice daily
   • 14-day regimen strongly recommended over 10-day or 7-day regimens (provides ~5% better eradication rates)
   • 85% eradication rate

3. Concomitant non-bismuth quadruple therapy:

   • 14-day regimen
   • 80% eradication rate

Special Populations

• Clarithromycin allergy or resistance: 4

  • Dual therapy with amoxicillin and lansoprazole is indicated

• Pregnancy: 1

  • Defer treatment until after pregnancy unless severe symptoms or complications are present
  • Focus on symptomatic relief with dietary modifications and antacids
  • Avoid NSAIDs

• Renal impairment: 1

  • Requires adjusted amoxicillin dosing

Post-Treatment Follow-up

• Confirmation of H. pylori eradication should be performed 4 weeks after completing treatment 1
• Use urea breath test or stool antigen test (stop PPIs 2 weeks before testing)
• If symptoms persist after eradication or H. pylori testing is negative, continue PPIs for an additional 4-8 weeks and consider alternative diagnoses like functional dyspepsia 1

Referral Criteria

• Immediate specialist referral for endoscopy is recommended for: 1

  • Patients >45 years with severe symptoms
  • Any patient with alarm symptoms:
    • Dysphagia
    • Palpable abdominal mass
    • Malabsorption
    • Weight loss
    • Anemia

• Primary care management appropriate for: 1

  • Younger patients (<45 years) without alarm symptoms

Prevention of Complications

Eradication of H. pylori provides important benefits: 1

• Prevents progression to atrophic gastritis
• Reduces risk of gastric cancer
• Prevents peptic ulcer disease recurrence

Clinical pearl: Surveillance endoscopy should be performed every 3 years in patients with risk factors for gastric cancer or atrophic gastritis 1