Can you provide a concise, patient‑friendly explanation of Helicobacter pylori infection, its symptoms, treatment regimen, and follow‑up care?

Understanding Helicobacter pylori Infection: Patient Information

What is Helicobacter pylori?

Helicobacter pylori (H. pylori) is a common bacterial infection that lives in your stomach and affects approximately half of the world's population. 1 This bacterium is typically acquired during childhood and, if left untreated, persists for life. 1 H. pylori has unique properties that allow it to survive in the acidic environment of your stomach by producing an enzyme called urease. 2

How Do You Get It?

• H. pylori spreads from person to person, primarily through oral-oral contact (such as kissing or sharing utensils) and fecal-oral routes (through contaminated food or water). 2
• The infection is more common in areas with poor sanitation, affecting 70-90% of people in developing countries versus lower rates in developed nations. 2
• There is no substantial reservoir of H. pylori outside the human stomach. 2

What Problems Can It Cause?

While many infected people never develop symptoms, H. pylori can lead to serious conditions:

• Chronic gastritis (stomach inflammation) occurs in all infected individuals 1
• Peptic ulcers in the stomach and duodenum 3, 1
• Gastric cancer - H. pylori is recognized as a major risk factor 4
• MALT lymphoma (a type of stomach lymphoma) that can be cured in 60-80% of early cases by treating the infection 4
• Iron deficiency anemia, vitamin B12 deficiency, and idiopathic thrombocytopenic purpura (ITP) 4

Common Symptoms

Many people have no symptoms, but when present, they may include:

• Upper abdominal pain or discomfort 3
• Bloating and nausea 3
• Loss of appetite 3
• In severe cases: bleeding, weight loss, or persistent vomiting (these require immediate medical attention) 4

How Is It Diagnosed?

Your doctor will choose between non-invasive tests (for most patients) or endoscopy-based tests (for those with concerning symptoms). 4

Non-invasive tests (no endoscopy needed):

• Urea breath test - highly accurate and easy to perform 4
• Stool antigen test using validated laboratory-based monoclonal antibodies - equally accurate to breath test 4
• Blood antibody tests - useful for initial screening but cannot confirm eradication 4

Invasive tests (require endoscopy):

• Tissue biopsy with special staining 4
• Rapid urease test during endoscopy 4
• Culture for antibiotic sensitivity testing 4

Important: You must stop taking proton pump inhibitors (PPIs like omeprazole) for at least 2 weeks, antibiotics for at least 4 weeks, and bismuth products or sucralfate for at least 4 weeks before testing to avoid false-negative results. 5, 6

Treatment Regimen

The standard treatment is bismuth quadruple therapy for 14 days, which is the preferred first-line treatment in most areas. 5, 6

First-line treatment consists of four medications taken together:

• Bismuth subsalicylate - 2 tablets or capsules four times daily, 30 minutes before meals 5
• Tetracycline 500 mg four times daily, 30 minutes after meals 5
• Metronidazole 500 mg four times daily, 30 minutes after meals 5
• High-dose proton pump inhibitor (esomeprazole or rabeprazole 40 mg) twice daily, 30 minutes before meals 5

Critical points about treatment:

• The full 14-day course must be completed even if you feel better 6
• Treatment duration of 14 days is significantly more effective than 7 days 5, 6
• Using high-dose PPIs twice daily increases success rates by approximately 5% 5, 6
• Esomeprazole or rabeprazole are preferred over pantoprazole due to superior potency 5

If first treatment fails:

• Your doctor will prescribe alternative antibiotics not previously used 5, 3
• Levofloxacin-containing therapy may be used, though resistance is increasing 5, 6
• After multiple failures, antibiotic susceptibility testing should guide treatment 5, 3

Common side effects and management:

• Nausea, metallic taste, and diarrhea are common with antibiotics 3
• Probiotics can be added to reduce side effects and may improve eradication rates 3
• Most side effects are temporary and resolve after completing treatment 3

Follow-Up Care

You must have a test to confirm the bacteria is gone at least 4 weeks after finishing treatment. 5, 6

• The urea breath test or stool antigen test are the preferred methods for confirmation 5, 6
• Remember to stop PPIs for at least 2 weeks before this follow-up test 6
• If you had a gastric ulcer, MALT lymphoma, or complicated peptic ulcer disease, endoscopy-based testing is necessary 5

Special follow-up situations:

• Patients with severe gastritis, atrophy, or precancerous changes need endoscopic surveillance every 2-3 years 4
• First-degree relatives of gastric cancer patients should be tested and treated 4, 5
• Those with previous gastric surgery or gastric neoplasia require ongoing monitoring 4

Why Treatment Is Important

Eradicating H. pylori cures over 90% of peptic ulcers and prevents their recurrence. 4 More importantly:

• Treatment halts the progression toward gastric cancer by healing gastritis and preventing atrophy 4
• Early-stage MALT lymphoma can be cured in 60-80% of cases with H. pylori eradication alone 4
• Treatment resolves iron deficiency anemia and ITP in many patients 4
• Eradication improves absorption of thyroid medication and levodopa in affected patients 4

Important Warnings

Antibiotic resistance is the main reason treatment fails, so completing the full course exactly as prescribed is critical. 4

• Never use antibiotics you've been exposed to recently, as resistance is likely 6
• Avoid taking medications that suppress the bacteria without killing it (like PPIs alone), as this can lead to false-negative tests 5, 6
• If you're under 45 years old without alarm symptoms (bleeding, weight loss, difficulty swallowing), you can be tested and treated without endoscopy 6
• If you're over 45 years old with new stomach symptoms, or have any alarm symptoms at any age, you need endoscopy first 6

Special Populations

For patients with penicillin allergy:

• Bismuth quadruple therapy is safe and effective since it doesn't contain penicillin 5, 6

For children:

• Treatment must be supervised by pediatric specialists in specialized centers 6
• Tetracycline cannot be used in children under 8 years due to risk of permanent tooth discoloration 6
• Weight-based dosing is mandatory and differs from adult regimens 6

For patients on long-term medications:

• Those taking NSAIDs or aspirin long-term should be tested and treated to prevent ulcers 4
• Patients requiring long-term PPI therapy for more than 1 year should be tested and treated to prevent progression to atrophic gastritis 4