What are the typical presentations and management strategies for Helicobacter Pylori (H. Pylori) infection?

Presentation and Management of Helicobacter Pylori Infection

H. pylori infection typically presents with dyspeptic symptoms, peptic ulcer disease, or may be asymptomatic, and should be treated with bismuth quadruple therapy for 14 days as first-line treatment when antibiotic susceptibility is unknown. 1

Clinical Presentations

Common Presentations

• Dyspepsia (epigastric pain, bloating, early satiety)
• Peptic ulcer disease (gastric or duodenal ulcers)
• Asymptomatic infection
• Gastritis

Less Common Presentations

• Gastric cancer
• MALT lymphoma
• Extraintestinal manifestations

Diagnostic Testing

Non-invasive Tests (First-line in Primary Care)

• Urea Breath Test (UBT): Gold standard non-invasive test with 95% sensitivity and 90% specificity 1
• Monoclonal stool antigen test: Alternative with equivalent accuracy to UBT 1
• Serological tests: Can be used if properly validated locally, but most whole blood tests are inadequate 1

Invasive Tests (Requiring Endoscopy)

• Endoscopy with biopsy is recommended in:
  • Complicated peptic ulcer disease
  • Gastric ulcer
  • MALT lymphoma
  • When histological assessment is needed 1

Treatment Regimens

First-line Treatment

• Bismuth quadruple therapy for 14 days (preferred when antibiotic susceptibility is unknown)
  • Eradication rate: approximately 85% 1, 2

Alternative First-line Options

• Concomitant non-bismuth quadruple therapy for 14 days
  • Eradication rate: approximately 80% 1
• Triple therapy for 14 days (in areas with low clarithromycin resistance)
  • Eradication rate: approximately 85% 1

Specific Regimens

1. Triple therapy for H. pylori with clarithromycin and lansoprazole:

   • 1 gram amoxicillin
   • 500 mg clarithromycin
   • 30 mg lansoprazole
   • All given twice daily for 14 days 3

2. Dual therapy for H. pylori with lansoprazole (for patients allergic or intolerant to clarithromycin):

   • 1 gram amoxicillin
   • 30 mg lansoprazole
   • All given three times daily for 14 days 3

Second-line Treatment Options

• If bismuth quadruple therapy fails:

  • Levofloxacin-based triple therapy for 10-14 days 1

• If clarithromycin-based therapy fails:

  • Bismuth quadruple therapy for 14 days 1

• For patients who have failed two previous treatment attempts:

  • Rifabutin-based triple therapy: Rifabutin 150-300mg daily + amoxicillin 1g twice daily + PPI standard dose twice daily for 10 days 1
  • High-dose dual therapy: Amoxicillin 2-3g daily in 3-4 split doses + PPI high-dose twice daily for 14 days 1

Special Considerations

Antibiotic Resistance

• Increasing resistance to clarithromycin, levofloxacin, and metronidazole is a major cause of treatment failure 1
• Previously used antibiotics should be avoided in subsequent eradication attempts 1
• Local antibiotic resistance patterns should guide therapy selection when available 1

Penicillin Allergy

• For patients with true penicillin allergy, bismuth quadruple therapy with tetracycline instead of amoxicillin is recommended 1
• PPI-tetracycline-metronidazole is an effective alternative therapy 1

Post-Treatment Testing

• Wait at least 4 weeks after completing antibiotic therapy before testing for H. pylori eradication 1
• Use UBT or stool antigen test for confirmation of eradication 1

High-Risk Patients

• Patients with age ≥ 55 or presence of alarm symptoms should be referred for prompt endoscopy with H. pylori testing 1
• Surveillance endoscopy should be performed every 3 years in patients with risk factors for gastric cancer or atrophic gastritis 1

Dietary and Lifestyle Management

• Diet low in acidic, spicy, and fatty foods
• Regular consumption of fruits and vegetables rich in vitamin C
• Eating smaller, more frequent meals
• Avoiding eating within 3 hours of bedtime
• Staying hydrated with water throughout the day 1

Common Pitfalls to Avoid

1. Failing to test for eradication after treatment
2. Using previously failed antibiotics in subsequent treatment attempts
3. Not waiting at least 4 weeks after antibiotics before testing for eradication
4. Ignoring local antibiotic resistance patterns
5. Overlooking alarm symptoms that require endoscopy