What symptoms do patients with Helicobacter pylori (H. pylori) infection present with?

Symptoms of Helicobacter pylori Infection

Patients with H. pylori infection commonly present with dyspeptic symptoms, including epigastric pain, fullness, bloating, and early satiety, though many infections remain clinically silent. 1

Common Symptoms

• Epigastric pain (ulcer-like dyspepsia) - Often the most bothersome symptom, typically acid-related 2
• Fullness, bloating, or satiety (dysmotility-like dyspepsia) 2
• Heartburn - May become apparent as the predominant symptom after eradication of H. pylori 2

Symptom Patterns

H. pylori infection presents with a wide disease spectrum that can be categorized as follows:

Asymptomatic Infection

• Many patients with H. pylori have no symptoms despite having chronic gastritis 3
• These silent infections are particularly concerning as they can progress to more serious conditions without detection 4

Symptomatic Infection

• Peptic Ulcer Disease

  • Epigastric pain that may be relieved by food or antacids
  • Pain that worsens at night or when stomach is empty
  • Possible nausea, vomiting, or loss of appetite 3

• Non-ulcer Dyspepsia

  • Persistent upper abdominal discomfort
  • Feeling of fullness after eating small amounts
  • Early satiety and bloating 2, 1

Alarm Symptoms

Certain symptoms warrant immediate referral to a specialist for endoscopy, regardless of age:

• Weight loss
• Progressive dysphagia
• Recurrent vomiting
• Evidence of gastrointestinal bleeding
• Anemia
• Palpable mass
• Malabsorption 2

Clinical Significance

H. pylori infection is clinically significant as it:

• Is the most consistent risk factor for gastric cancer 1
• Significantly increases risk of both gastric and duodenal ulcers 1
• Is strongly linked to iron-deficiency anemia, idiopathic thrombocytopenic purpura, and vitamin B12 deficiency 1
• Can cause chronic gastritis that may progress to atrophy, intestinal metaplasia, and eventually cancer 1

Age Considerations

• Patients under 45 years without alarm symptoms may be tested and treated for H. pylori in primary care without endoscopy 2
• Patients over 45 years with dyspeptic symptoms should be referred for endoscopy due to increased risk of gastric cancer 2
• The standardized incidence rate of gastric cancer in Europeans over 45 is 19 per 100,000 for men and 9 per 100,000 for women 2

Diagnostic Approach

When evaluating patients with suspected H. pylori infection:

1. For patients <45 years without alarm symptoms:

   • Test for H. pylori using urea breath test or laboratory serology
   • If positive, treat the infection 2

2. For patients ≥45 years or those with alarm symptoms:

   • Refer for endoscopy
   • Test for H. pylori during endoscopy
   • Treat based on findings 2

Treatment Considerations

After successful H. pylori eradication, some patients may continue to have residual symptoms that require targeted treatment:

• For persistent epigastric pain: PPI therapy (e.g., omeprazole 20 mg daily)
• For persistent fullness/bloating: Consider prokinetic agents 2

Common Pitfalls

1. Missing silent infections - Many H. pylori infections remain clinically silent but still increase risk for serious complications 4

2. Overlooking alarm symptoms - Failing to recognize alarm symptoms that require immediate endoscopy can delay diagnosis of serious conditions 2

3. Assuming symptom resolution means cure - Some patients may have persistent H. pylori infection despite symptom improvement 2

4. Treating without testing - Empiric treatment without confirming H. pylori status can lead to unnecessary antibiotic use and resistance 1

5. Inadequate follow-up - Not confirming eradication can allow persistent infection to continue causing damage 1

H. pylori infection should be considered in any patient presenting with dyspeptic symptoms, particularly those with epigastric pain, fullness, or bloating, while recognizing that many infections may be asymptomatic.