In a 73-year-old man with two weeks of bloating and dyspepsia and a positive Helicobacter pylori urea breath test, what is the recommended management?

Management of H. pylori-Positive Dyspepsia in a 73-Year-Old Male

This patient should receive H. pylori eradication therapy immediately, with the specific regimen chosen based on local clarithromycin resistance rates. 1

Primary Treatment Recommendation

Initiate H. pylori eradication therapy as first-line treatment. The British Society of Gastroenterology 2022 guidelines provide a strong recommendation (high-quality evidence) that all patients with dyspepsia who test positive for H. pylori should receive eradication therapy. 1

Selecting the Appropriate Eradication Regimen

The choice of first-line therapy depends on local clarithromycin resistance patterns:

In areas with high clarithromycin resistance (≥15%):

• Use 14-day concomitant therapy (PPI + amoxicillin + clarithromycin + metronidazole), OR 2
• Use 14-day bismuth quadruple therapy (PPI + bismuth + tetracycline + metronidazole) 2

In areas with low clarithromycin resistance (<15%):

• Use 14-day PPI-based triple therapy (PPI + clarithromycin + amoxicillin or metronidazole), OR 2
• Use 14-day bismuth quadruple therapy 2

Use the lowest effective PPI dose that controls symptoms, as there is no dose-response relationship for symptom control. 1

Age-Related Considerations for This 73-Year-Old Patient

While eradication therapy is the primary intervention, this patient's age warrants additional evaluation:

• Non-urgent endoscopy should be considered given his age (≥55 years) if symptoms are treatment-resistant or if he develops nausea, vomiting, or has a raised platelet count. 1
• He does not meet criteria for urgent endoscopy unless he has weight loss (which would require urgent evaluation at age ≥55) or is from a high-risk area for gastric cancer. 1

Post-Eradication Management

Confirming Eradication Success

Perform a test of cure using a non-serological test at least 4 weeks after completing therapy. 3

• Use urea breath test (sensitivity 94.7-97%, specificity 95-100%) OR monoclonal stool antigen test (sensitivity and specificity >90%). 3
• Never use serology to confirm eradication—IgG antibodies persist long after successful treatment and cannot distinguish active infection from past exposure. 3

Critical timing and medication washout requirements:

• Wait ≥4 weeks after completing therapy before testing 3
• Discontinue PPIs for 2 weeks before testing 3
• Discontinue antibiotics and bismuth for 4 weeks before testing 3
• Patient should fast for 6 hours before breath testing 3

Managing Persistent Symptoms After Confirmed Eradication

If dyspepsia persists despite confirmed H. pylori eradication:

Initiate full-dose PPI therapy (e.g., omeprazole 20 mg once daily) as first-line treatment for persistent epigastric pain or ulcer-like symptoms. 1, 3

For bloating and fullness (dysmotility-like symptoms):

• Consider a prokinetic agent, though options are limited and efficacy varies by drug class. 1
• Note that cisapride is contraindicated due to cardiac toxicity. 1

If symptoms persist despite initial therapy:

• Switch therapeutic class (PPI to prokinetic or vice versa) to address possible symptom misclassification 1, 3
• If still refractory, trial high-dose PPI therapy 1
• Refer for endoscopy if symptoms remain refractory after therapeutic switches 1

Critical Pitfalls to Avoid

Do not interpret persistent antibody positivity as treatment failure—this is the most common error and leads to unnecessary repeat treatment. 3

Do not test for eradication too early (before 4 weeks)—this yields false-negative results from temporary bacterial suppression rather than true eradication. 3

Set realistic expectations: Many patients with functional dyspepsia will not experience symptom relief from H. pylori eradication alone, though eradication eliminates peptic ulcer mortality risk. 1, 3

If Eradication Fails

Never repeat the same antibiotic regimen—use a completely different combination to avoid increasing antibiotic resistance. 3

Second-line options:

• If first-line was clarithromycin-based: Use 14-day bismuth quadruple therapy or 14-day levofloxacin triple therapy 3, 2
• If first-line was bismuth quadruple therapy: Use 14-day levofloxacin triple therapy 3, 2

After two treatment failures: Pursue antibiotic susceptibility testing to guide third-line therapy. 3, 2

Adjunctive Measures

Recommend regular aerobic exercise to all patients with dyspepsia (strong recommendation). 1

Probiotics may be used as adjuvant treatment to reduce antibiotic side effects and potentially enhance eradication rates. 2