Symptoms of H. pylori Infection
The most common presentation of H. pylori infection is dyspeptic symptoms, characterized by pain or discomfort in the central upper abdomen as the predominant symptom. 1
Clinical Presentation
Primary Symptoms
Dyspeptic symptoms are the hallmark presentation, manifesting as central upper abdominal pain or discomfort. 1
Many patients with H. pylori infection remain asymptomatic despite having chronic gastritis, as the infection exhibits a wide disease spectrum. 2, 3
The symptom pattern often overlaps significantly with gastroesophageal reflux disease (GERD), making it difficult to distinguish based on symptoms alone. 4
Alarm Symptoms Requiring Immediate Specialist Referral
These symptoms mandate urgent endoscopy regardless of age:
- Anemia 1
- Unintentional weight loss 1
- Dysphagia (difficulty swallowing) 1
- Palpable abdominal mass 1
- Malabsorption 1
- Evidence of gastrointestinal bleeding 4
Associated Conditions and Complications
H. pylori infection can lead to several serious complications beyond simple dyspepsia:
Peptic ulcer disease (both gastric and duodenal ulcers) is a major complication that can be cured by eradication of the bacterium. 4, 2
Gastric adenocarcinoma risk is increased with chronic infection. 2, 3
Mucosa-associated lymphoid tissue (MALT) lymphoma can develop, though eradication may lead to lymphoma regression. 5, 2
Chronic atrophic gastritis and precancerous gastric lesions may develop over time. 2, 6
Diagnostic Approach Based on Age and Symptoms
For Patients Under 45 Years Without Alarm Symptoms
Non-invasive testing is the recommended initial approach using 13C-urea breath test (most accurate), stool antigen test, or validated laboratory serology. 1
The "test and treat" strategy is cost-effective and appropriate for this population in primary care. 4, 1, 5
These patients can be managed without endoscopy if they test positive for H. pylori and receive eradication therapy. 4
For Patients Over 45 Years or With Alarm Symptoms
Immediate endoscopy with biopsy is strongly recommended, as the risk of gastric malignancy increases significantly after age 45 (standardized incidence rate of 19 per 100,000 for men and 9 per 100,000 for women in the European Community). 4, 1
The age cutoff may be lower than 45 years depending on regional differences in gastric cancer incidence. 4
Biopsy specimens should be obtained for H. pylori testing at the time of endoscopy. 4
Treatment Considerations
First-Line Eradication Therapy
Bismuth quadruple therapy for 14 days is the preferred empiric regimen when antibiotic susceptibility is unknown. 7
Triple therapy (PPI + amoxicillin + clarithromycin) for 14 days is appropriate in areas with low clarithromycin resistance (<15%). 2, 6
Medications should be taken at the start of meals to minimize gastrointestinal intolerance. 1, 8
Confirmation of Eradication
Test-of-cure is strongly recommended in complicated peptic ulcer disease, gastric ulcer, and gastric MALT lymphoma. 1
Follow-up testing should be performed no earlier than 4 weeks after treatment cessation. 1
Stop antibiotics, bismuth, or PPIs at least 2 weeks before testing to avoid false-negative results. 1
Important Clinical Pitfalls
Symptom overlap is common: Many patients have overlapping symptoms between functional dyspepsia, GERD, and H. pylori-related disease, making symptom-based diagnosis unreliable. 4
Serology limitations: Rapid office serological tests have variable sensitivity and specificity and cannot distinguish active infection from past exposure. 1, 5
Limited benefit in functional dyspepsia: H. pylori eradication provides long-term symptom relief in only 1 out of 12 patients with functional dyspepsia, though it should still be pursued as preventive medicine. 1
Family history matters: Patients with a family history of gastric cancer should be referred for endoscopy even if under 45 years old, as this represents a significant risk factor. 4, 5