What are the symptoms and treatment options for Helicobacter pylori infection?

Helicobacter pylori Symptoms and Treatment

Clinical Presentation

Most patients with H. pylori infection present with dyspeptic symptoms including upper abdominal pain or discomfort, though many remain asymptomatic despite having chronic gastritis. 1

Common Symptoms

• Dyspepsia (central upper abdominal pain or discomfort) is the predominant presentation 1
• Indigestion, belching, heartburn, and abdominal fullness 2
• Nausea and vomiting 2
• Some patients present with atypical symptoms including headache, fatigue/weakness, anxiety, and bloating 2

Alarm Symptoms Requiring Immediate Specialist Referral

• Anemia 1
• Unintentional weight loss 1
• Dysphagia 1
• Palpable abdominal mass 1
• Malabsorption 1

Important caveat: H. pylori can increase or decrease acid secretion depending on the intragastric distribution of inflammation—antral-predominant gastritis increases acid production (associated with duodenal ulcers), while body-predominant atrophic gastritis decreases acid production (associated with gastric cancer risk). 3

Diagnostic Approach

For Patients Under 45 Years Without Alarm Symptoms

Non-invasive testing is recommended as the initial diagnostic approach in primary care. 1

Recommended non-invasive tests include:

• 13C-urea breath test (UBT) with highest accuracy 1
• Stool antigen test using validated laboratory-based monoclonal test with 90-95% accuracy 3, 1
• Laboratory serology only if locally validated 1

Critical pitfall: Patients must stop antibiotics, bismuth products, or PPIs at least 2 weeks before testing to avoid false negative results. 3, 4

For Patients Over 45 Years or With Alarm Symptoms

Endoscopy with biopsy is mandatory for patients over 45 years with severe dyspeptic symptoms, any patient with alarm symptoms, and patients with a known history of gastric ulcer. 1

Treatment Recommendations

First-Line Eradication Therapy

All patients with confirmed H. pylori infection should receive eradication therapy regardless of symptoms, as H. pylori infection always implies gastritis, which is a risk factor for peptic ulcer disease, gastric cancer, and other complications. 4

The standard regimen consists of:

• A proton pump inhibitor (PPI) plus two antibiotics for 14 days 4
• In areas with high clarithromycin resistance (≥15%): 14-day concomitant therapy or 14-day bismuth quadruple therapy (BQT) as first-line regimen 5
• In areas with low clarithromycin resistance (<15%): 14-day triple therapy or 14-day BQT 5

For treatment-naive patients in North America: Bismuth quadruple therapy for 14 days is the preferred regimen when antibiotic susceptibility is unknown. 6

Second-Line Therapy

For treatment-experienced patients: 14-day levofloxacin triple therapy or 14-day BQT if BQT was not previously used 5

For multiple treatment failures: Antimicrobial susceptibility testing should be performed, or use antibiotics not previously used such as amoxicillin, tetracycline, bismuth, or furazolidone. 5

Common Side Effects

Gastrointestinal abnormal responses are major pitfalls during eradication therapy:

• Diarrhea is the most common side effect, occurring in 41% of patients during week 1 of treatment 7
• Flatulence and abdominal distention are also common (31-33% of patients) 7
• Most symptoms are mild and decrease after treatment completion 7

Post-Treatment Follow-Up

Confirmation of H. pylori eradication is strongly recommended in complicated peptic ulcer disease, gastric ulcer, and low-grade gastric MALT lymphoma. 1, 4

Follow-up testing protocol:

• Perform testing no earlier than 4 weeks after cessation of treatment 1, 4
• Stop antibiotics, bismuth, or PPIs at least 2 weeks before testing to avoid false negative results 4
• Use 13C-urea breath test, stool antigen test, or endoscopy with biopsy for confirmation 4

Special Clinical Contexts

Functional Dyspepsia

H. pylori eradication produces long-term relief of dyspepsia in one of 12 patients with functional dyspepsia, which is better than any other treatment. 3, 1

Gastric Cancer Prevention

Gastric cancer is the most dreaded outcome of H. pylori infection. All infected individuals develop gastritis and are at risk for progression to atrophic gastritis, metaplasia, and ultimately gastric cancer. 3 Eradication halts the progression and reduces overall gastric cancer risk, though it does not eliminate risk entirely. 3

Associated Conditions Requiring Testing and Treatment

• Iron-deficiency anemia (Evidence level 1a) 3
• Idiopathic thrombocytopenic purpura (ITP) (Evidence level 1b) 3
• Vitamin B12 deficiency (Evidence level 3b) 3
• Gastric MALT lymphoma: H. pylori eradication is first-line treatment for low-grade gastric MALT lymphoma, achieving cure in 60-80% of early-stage cases 3