In a 57-year-old patient with erosive gastritis and a positive rapid urease test who presents with increased non-infective loose stools, can we initiate Helicobacter pylori eradication therapy (HP kit)?

Can We Start H. pylori Eradication Therapy in This Patient?

Yes, initiate H. pylori eradication therapy immediately in this 57-year-old patient with erosive gastritis and a positive rapid urease test, despite the presence of loose stools. The positive RUT confirms active H. pylori infection requiring treatment, and the non-infectious diarrhea is likely a manifestation of H. pylori-associated gastritis that will resolve after successful eradication 1.

Why Treatment Should Be Started Now

The Positive RUT Is Reliable

• A positive rapid urease test can be trusted even in the presence of factors that might cause false negatives (such as recent PPI use), because these factors reduce bacterial load but do not produce false positive results 2.
• The RUT has high specificity (99-100%) when properly performed, making false positives extremely rare 3, 4.
• The patient's erosive gastritis provides endoscopic confirmation of active gastric pathology consistent with H. pylori infection 5.

The Diarrhea Is Expected and Will Likely Improve

• Loose stools in H. pylori-infected patients are typically a manifestation of H. pylori-associated gastritis rather than a separate disorder, and these symptoms characteristically resolve after successful eradication 1, 6.
• Diarrhea occurs in 21-41% of patients during the first week of eradication therapy due to antibiotic-induced microbiota disruption, but this transient worsening does not indicate treatment failure 1.
• The current non-infectious diarrhea is not a contraindication to starting therapy; delaying treatment risks progression to more serious complications including atrophic gastritis, intestinal metaplasia, and gastric cancer 2, 1.

Recommended First-Line Regimen

Bismuth quadruple therapy for 14 days is the optimal first-line treatment 1:

• High-dose PPI twice daily (esomeprazole or rabeprazole 40 mg preferred) taken 30 minutes before meals 1
• Bismuth subsalicylate 262 mg (2 tablets) four times daily 1
• Metronidazole 500 mg three to four times daily 1
• Tetracycline 500 mg four times daily 1

This regimen achieves 80-90% eradication rates even in areas with high clarithromycin and metronidazole resistance 1.

Critical Optimization Factors

• The 14-day duration is mandatory—extending from 7 to 14 days improves eradication by approximately 5% 1.
• Use esomeprazole or rabeprazole 40 mg twice daily rather than standard-dose PPIs, as this increases cure rates by an additional 8-12% 1.
• Counsel the patient that diarrhea may temporarily worsen during the first week but should improve after completing therapy 1.
• Emphasize completing the full 14-day course despite gastrointestinal side effects, as poor compliance is a leading cause of treatment failure 1.

Confirming Eradication

• Test for eradication success at least 4 weeks after completing therapy using urea breath test or validated monoclonal stool antigen test 1, 6.
• Discontinue PPIs at least 2 weeks before testing to avoid false-negative results 1, 6.
• Never use serology for test-of-cure, as antibodies persist long after successful eradication 1.

Common Pitfalls to Avoid

• Do not delay treatment waiting for diarrhea to resolve—the loose stools are likely H. pylori-related and will improve with eradication 1, 6.
• Do not use standard-dose PPI once daily—this markedly increases failure risk 1.
• Do not shorten therapy below 14 days to minimize side effects—this significantly reduces eradication success 1.
• Do not assume the diarrhea represents a contraindication—it is an expected manifestation that typically resolves after cure 1, 6.