H. pylori Symptoms and Clinical Presentation
Most H. pylori infections are asymptomatic, but when symptoms occur, dyspepsia (upper abdominal discomfort, bloating, nausea) is the most common presentation. 1
Common Symptoms
- Dyspeptic symptoms including upper abdominal pain, bloating, early satiety, and nausea are the typical manifestations 1
- All infected individuals develop chronic gastritis, though most remain asymptomatic throughout their lives 2, 3
- The pattern of gastric inflammation determines clinical outcomes: antrum-predominant gastritis leads to increased acid secretion and duodenal ulcers, while corpus-predominant gastritis causes decreased acid production and increased gastric cancer risk 2
Alarm Symptoms Requiring Immediate Endoscopy
These symptoms mandate urgent specialist referral and endoscopic evaluation rather than empiric treatment: 1
- Anemia (unexplained iron deficiency) 1
- Unintentional weight loss 1
- Dysphagia (difficulty swallowing) 1
- Palpable abdominal mass 1
- Malabsorption symptoms 1
Associated Diseases and Complications
Gastrointestinal Manifestations
- Peptic ulcer disease (both gastric and duodenal ulcers) occurs in a subset of infected patients 2, 3, 4
- Gastric MALT lymphoma is directly linked to H. pylori infection, with eradication serving as first-line treatment 2
- Gastric cancer develops through progression from chronic gastritis to atrophic gastritis, intestinal metaplasia, and ultimately adenocarcinoma 2
Extragastric Manifestations
H. pylori should be tested and eradicated in patients with: 2
- Iron-deficiency anemia (unexplained) - Evidence Level 1a 2
- Idiopathic thrombocytopenic purpura (ITP) - Evidence Level 1b 2
- Vitamin B12 deficiency - Evidence Level 3b 2, 5
Drug Interactions
- H. pylori infection impairs absorption of thyroxine and L-dopa, with eradication improving bioavailability of both medications 2
High-Risk Populations Requiring Testing
Even without symptoms, testing and treatment is indicated for: 2
- First-degree relatives of gastric cancer patients (2-3x increased risk, up to 10x if multiple relatives affected) 2
- Patients with previous gastric neoplasia treated endoscopically or surgically 2
- Those with severe pan-gastritis, corpus-predominant gastritis, or severe atrophy 2
- Patients requiring chronic PPI therapy >1 year 2
- Heavy smokers or those with occupational exposure to dust, coal, quartz, or cement 2
- Chronic NSAID or low-dose aspirin users, especially with prior ulcer history 2
Key Clinical Pitfalls
False negative testing can occur when patients remain on PPIs, antibiotics, or bismuth products - these must be stopped at least 2 weeks before testing 2, 1. Conversely, false positive urea breath tests can occur in patients with achlorhydria (pernicious anemia, atrophic gastritis) due to urease-producing non-H. pylori organisms 2. When treatment appears to fail repeatedly, confirm with stool antigen test or endoscopy before retreating 2.
The "test and treat" strategy is cost-effective for patients under 45 years without alarm symptoms, while those over 45 or with alarm features require endoscopy regardless of non-invasive test results 1.