What are the symptoms and treatment of Helicobacter pylori infection?

Helicobacter pylori Symptoms and Treatment

Clinical Presentation

Most H. pylori-infected individuals remain asymptomatic, but when symptoms occur, dyspepsia is the most common presentation, including indigestion, belching, heartburn, abdominal fullness, nausea, and vomiting. 1, 2

Common Symptoms

• Dyspeptic symptoms: Upper abdominal discomfort, bloating, early satiety, and postprandial fullness 1, 2
• Recurrent abdominal pain: Particularly in children, where H. pylori-associated gastritis may manifest as chronic recurrent abdominal pain 3
• Atypical presentations: Some patients present with non-specific symptoms including headache, fatigue/weakness, anxiety, and generalized bloating 2

Alarm Symptoms Requiring Immediate Specialist Referral

The following red flags mandate urgent endoscopic evaluation regardless of age: 1

• Anemia (unexplained iron deficiency)
• Unintentional weight loss
• Dysphagia (difficulty swallowing)
• Palpable abdominal mass
• Malabsorption symptoms

Disease Spectrum and Complications

H. pylori infection causes a wide spectrum of disease severity 4:

• Chronic active gastritis: Present in all infected individuals, though often asymptomatic 5, 4
• Peptic ulcer disease: Both gastric and duodenal ulcers occur in a subset of infected patients 5, 6
• Gastric cancer: H. pylori is the primary risk factor for gastric adenocarcinoma, with risk increasing exponentially with age 5
• MALT lymphoma: Low-grade gastric marginal zone lymphoma is directly linked to H. pylori infection 5

Effect on Acid Secretion

H. pylori can paradoxically increase or decrease gastric acid secretion depending on the pattern of gastritis distribution. 5

• Antral-predominant gastritis: Leads to increased acid production, commonly associated with duodenal ulcer disease 5
• Body-predominant atrophic gastritis: Results in decreased acid secretion and is associated with increased gastric cancer risk 5

Diagnostic Approach

Non-Invasive Testing (Primary Care Setting)

For patients under 45 years without alarm symptoms, non-invasive testing is the recommended initial approach. 1

Preferred non-invasive tests include: 5, 1

• 13C-urea breath test (UBT): Gold standard non-invasive test with highest accuracy
• Monoclonal stool antigen test: 90-95% accuracy when using validated laboratory-based tests
• Serology (IgG ELISA): Only if locally validated tests with >90% accuracy are available

Critical Testing Considerations

Stop proton pump inhibitors (PPIs) for at least 2 weeks before testing with UBT, stool antigen, or biopsy-based tests to prevent false-negative results. 5, 1

Serology is the only test unaffected by PPIs, antibiotics, or bismuth, as IgG antibodies remain elevated despite transient decreases in bacterial load. 5 However, serology cannot distinguish active from past infection and should not be used to confirm eradication 5.

Endoscopic Evaluation

Endoscopy with biopsy is indicated for: 1

• Patients over 45 years with new-onset dyspeptic symptoms
• Any patient with alarm symptoms regardless of age
• Patients with known history of gastric ulcer
• When histological assessment of mucosal abnormalities is needed

Treatment Indications

H. pylori eradication is strongly recommended in the following conditions: 5, 4

Mandatory Eradication

• Peptic ulcer disease: Both active and history of gastric or duodenal ulcer (>90% cure rate with eradication) 5
• Gastric MALT lymphoma: First-line treatment for low-grade gastric marginal zone lymphoma (60-80% cure rate in early stage) 5
• History of gastric cancer or gastric cancer surgery 5
• Family history of gastric cancer 5, 4

Strongly Recommended Eradication

• Functional dyspepsia: Provides long-term symptom relief in 1 of 12 patients (number needed to treat = 12) 5, 1
• Before initiating NSAID therapy: Mandatory in patients with peptic ulcer history 5
• Low-dose aspirin users with history of gastroduodenal ulcer: Reduces long-term risk of peptic ulcer bleeding 5
• Long-term PPI therapy: Eradication prevents progression to atrophic gastritis 5

Additional Indications

• Iron deficiency anemia (unexplained) 5, 4
• Idiopathic thrombocytopenic purpura (ITP) 5, 4
• Vitamin B12 deficiency 5, 4
• Household family member with active H. pylori infection 4

Treatment Regimens

First-Line Therapy in High Clarithromycin Resistance Areas (≥15%)

14-day bismuth quadruple therapy (BQT) or 14-day concomitant therapy is the preferred first-line regimen when antibiotic susceptibility is unknown. 4, 6

Alternative first-line options include: 6

• Rifabutin triple therapy for 14 days (if no penicillin allergy)
• Potassium-competitive acid blocker dual therapy for 14 days

First-Line Therapy in Low Clarithromycin Resistance Areas (<15%)

14-day triple therapy (PPI + clarithromycin + amoxicillin) or 14-day BQT is recommended. 4

Second-Line (Salvage) Therapy

For treatment-experienced patients, optimized 14-day BQT is preferred if not previously used. 6

If BQT was previously used, rifabutin triple therapy for 14 days is the suitable alternative. 6

Salvage regimens containing clarithromycin or levofloxacin should only be used if antibiotic susceptibility is confirmed. 6

Multiple Treatment Failures

Antimicrobial susceptibility testing should be performed after multiple treatment failures. 4 If unavailable, use antibiotics not previously administered or for which resistance is unlikely (amoxicillin, tetracycline, bismuth, or furazolidone) 4.

Confirmation of Eradication

Post-treatment test-of-cure is strongly recommended in: 1

• Complicated peptic ulcer disease
• Gastric ulcer (all cases)
• Low-grade gastric MALT lymphoma

Testing should be performed no earlier than 4 weeks after treatment cessation, with PPIs, antibiotics, and bismuth stopped at least 2 weeks before testing. 1

The 13C-urea breath test is the gold standard for confirming eradication. 5 Stool antigen testing is an acceptable alternative 5.

Common Pitfalls

• False-negative testing: Occurs when patients continue PPIs, antibiotics, or bismuth during diagnostic testing 5
• Using serology for eradication confirmation: Antibodies remain elevated for months to years after successful eradication, making serology unsuitable for test-of-cure 5
• Inadequate treatment duration: Regimens shorter than 14 days have significantly lower eradication rates 4, 6
• Testing too early after treatment: Testing before 4 weeks post-treatment may yield false results 1