H. pylori Symptoms: Diagnosis and Treatment
Clinical Presentation
H. pylori infection commonly presents with abdominal pain, bloating, nausea, and dyspepsia, but most infected individuals remain asymptomatic despite chronic gastritis being universally present. 1 The infection can lead to peptic ulcer disease, gastric cancer, and MALT lymphoma in a subset of patients. 2, 3
Diagnostic Approach
Age-Based Algorithm
For patients under 45-55 years without alarm symptoms, use the "test and treat" strategy with non-invasive testing; for those 55 years or older or with alarm symptoms, proceed directly to endoscopy. 1
Young Patients (<45-55 years) Without Alarm Symptoms:
First-line diagnostic test: Urea Breath Test (UBT) or stool antigen test 1, 4
Avoid serology as primary diagnostic method 4
Older Patients (≥55 years) or Those With Alarm Symptoms:
- Proceed directly to endoscopy with biopsy-based testing 1, 4
- Alarm symptoms requiring endoscopy include: 1
- Weight loss
- Progressive dysphagia
- Recurrent vomiting
- Evidence of gastrointestinal bleeding (anemia, melena)
- Family history of gastric cancer
- Palpable abdominal mass
Critical Testing Considerations
Stop proton pump inhibitors (PPIs) for at least 2 weeks before testing with UBT, stool antigen, rapid urease test, histology, or culture to avoid false-negative results. 1, 4 Antibiotics and bismuth products should be discontinued for at least 4 weeks before testing. 1, 4
Serology is the only test unaffected by PPIs and may be used when patients cannot stop acid suppression or have recently used antibiotics, though it cannot confirm active infection. 4
Treatment Approach
First-Line Therapy
For treatment-naive patients, bismuth quadruple therapy (BQT) for 14 days is the preferred empiric regimen when antibiotic susceptibility is unknown. 3 This recommendation is based on high clarithromycin resistance rates (≥15%) in North America. 2, 3
Alternative first-line regimens include: 2, 3
- 14-day concomitant therapy (PPI + amoxicillin + clarithromycin + metronidazole)
- 14-day rifabutin triple therapy (for penicillin-allergic patients)
Treatment regimens should achieve >80% eradication rate on an intention-to-treat basis. 1
Confirmation of Eradication
Test-of-cure is mandatory and should be performed at least 4 weeks after completion of treatment using UBT or stool antigen test, not serology. 1, 4 This timing allows for bacterial clearance and reduces false-negative results. 4
Confirmation is particularly critical in patients with: 4
- Complicated peptic ulcer disease
- Gastric ulcer
- Low-grade gastric MALT lymphoma
- Family history of gastric cancer
Second-Line Therapy for Treatment Failure
For patients with persistent infection after first-line therapy, use optimized BQT for 14 days if not previously used, or rifabutin triple therapy for 14 days if BQT was the initial regimen. 3
Avoid clarithromycin or levofloxacin-containing regimens unless antibiotic susceptibility is confirmed. 3
Common Pitfalls to Avoid
- Do not use rapid in-office serological tests - they have limited accuracy and should be avoided 4
- Do not use serology to confirm eradication - antibodies remain elevated after successful treatment 1, 4
- Do not test patients currently taking PPIs - wait at least 2 weeks after discontinuation to avoid false-negative results 1, 4
- Do not use treatment regimens shorter than 14 days - inadequate duration leads to treatment failure 2, 3
- Do not assume young patients without alarm symptoms need endoscopy - this is not cost-effective compared to test-and-treat strategy 1
Long-Term Implications
Eradication of H. pylori reduces the risk of peptic ulcer recurrence and halts progression to gastric cancer, though it does not eliminate cancer risk entirely in those with established atrophic gastritis. 1 All infected individuals develop chronic gastritis and remain at risk for serious complications including gastric adenocarcinoma, which represents the most dreaded outcome of chronic infection. 1