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

Symptoms and Treatment of Helicobacter pylori Infection

H. pylori infection primarily manifests as dyspeptic symptoms, with more severe cases potentially presenting with alarm symptoms such as anemia, weight loss, dysphagia, palpable mass, or malabsorption. 1

Symptoms of H. pylori Infection

• Dyspeptic symptoms are the most common presentation of H. pylori infection 1
• H. pylori infection always implies gastritis, which is a risk factor for further gastrointestinal disease 2
• Alarm symptoms that require immediate specialist referral include:
  • Anemia
  • Weight loss
  • Dysphagia
  • Palpable abdominal mass
  • Malabsorption 1
• H. pylori can increase or decrease acid secretion depending on the intragastric distribution of inflammation 1
• Most infected individuals remain asymptomatic, but some develop significant mucosal inflammation leading to peptic ulcers 3

Diagnostic Approach

• Non-invasive testing is recommended for initial diagnosis in primary care for patients under 45 years without alarm symptoms 1
• Recommended non-invasive tests include:
  • 13C-urea breath test (UBT) - strongly recommended with high accuracy 1
  • Stool antigen test - acceptable alternative with 90-95% accuracy 1
  • Laboratory serology - acceptable if locally validated 1
• Endoscopy with biopsy is indicated for:
  • Patients over 45 years with severe dyspeptic symptoms
  • Any patient with alarm symptoms
  • Patients with a known history of gastric ulcer 1

Treatment Algorithm

1. First-line treatment should be given for 14 days due to increasing failure rates 4, 5:

   • In areas with low clarithromycin resistance (<15%):
     • Triple therapy: PPI + clarithromycin + amoxicillin/metronidazole 4, 6
   • In areas with high clarithromycin resistance (≥15%):
     • Concomitant quadruple therapy: PPI + amoxicillin + metronidazole + clarithromycin (PAMC)
     • Bismuth quadruple therapy: PPI + bismuth + metronidazole + tetracycline (PBMT) 4, 6

2. Second-line treatment options:

   • Bismuth quadruple therapy (if not used as first-line)
   • Levofloxacin-containing therapy: PPI + amoxicillin + levofloxacin 4, 6

3. Third-line treatment:

   • Should be guided by antimicrobial susceptibility testing when available
   • Rifabutin-containing regimens should be restricted to patients who have failed at least 3 prior options 4, 5

Post-Treatment Follow-up

• Confirmation of H. pylori eradication is strongly recommended in:
  • Complicated peptic ulcer disease
  • Gastric ulcer
  • Low-grade gastric MALT lymphoma 2
• Follow-up testing should be performed no earlier than 4 weeks after treatment cessation 2
• Stop antibiotics, bismuth, or PPIs at least 2 weeks before testing to avoid false negative results 2

Common Pitfalls to Avoid

• Mono-antibiotic therapy increases the risk of antibiotic resistance and should be avoided 2
• Poor patient compliance can lead to treatment failure; patients should be educated on completing the full course 2
• Failure to confirm eradication in high-risk cases 2
• Using rapid "office" serological tests which have shown disappointing sensitivity and specificity (63-97% and 68-92% respectively) 1

Special Considerations

• H. pylori eradication produces long-term relief of dyspepsia in one of 12 patients with functional dyspepsia 1
• H. pylori eradication has been shown to have a prophylactic effect against gastric cancer 7
• The "test and treat" strategy is cost-effective compared to prompt endoscopy in managing dyspeptic patients under 45 years without alarm symptoms 1