Helicobacter Pylori (H. pylori) Infection


Watch Dr. Chey’s presentation on Helicobacter Pylori Infection during our virtual 2022 30th Anniversary NES Event

H. pylori

What is H. pylori?

Helicobacter Pylori (H. Pylori) is a spiral shaped bacteria that lives in the mucous lining of the stomach to protect itself from the harsh acid environment. It is one of the most common infections worldwide affecting more than half the world. It can cause peptic ulcers and several other potentially serious conditions, such as:

  • Inflammation of the stomach (gastritis)
  • Stomach and duodenal ulcers – About 10-15% of patients who have H. pylori will develop an ulcer.
  • Stomach cancer – While only a small percentage of patients with H. pylori will develop gastric cancer, one of the most common causes of gastric cancer is H.pylori infection.

How does it spread?

H. pylori infection occurs when H. pylori bacteria infect the stomach. This bacteria can be spread from person to person via bowel movements, through infected surfaces or contaminated food and water. Individuals who live in crowded conditions, lack clean water, or have unsanitary living conditions are at a greater risk for getting H. pylori. Both children and adults can become infected with H. pylori bacteria; however, children are at a greater risk of getting an H. pylori infection.

Symptoms of H. pylori

Most people with H. pylori infection will not experience any signs or symptoms. Why certain individuals do so remain uncertain. If an individual does have symptoms, they may include:

  • An ache or burning pain in the upper abdomen
  • Abdominal pain that becomes worse on an empty stomach
  • Nausea
  • Loss of appetite
  • Frequent burping
  • Bloating
  • Unintentional weight loss

Symptoms that are cause for alarm and require an immediate appointment with your healthcare provider include:

  • Severe abdominal pain
  • Difficulty swallowing
  • Bloody or black tarry stools
  • Bloody, or grainy black vomit

Diagnosis

There are a range of diagnostic tests which can identify the H. pylori infection. In the past, the most common was a simple procedure called an endoscopy that investigates the stomach using a long flexible tube called an endoscope. The endoscope is placed into the mouth, down the esophagus, and into the stomach and beginning of the small intestine. This tube has a camera and light on the end which allows your healthcare provider to see inside your gastrointestinal (GI) tract during the test. Endoscopic tests for H. pylori can include a histology, rapid urease test (RUT), or a culture.

  • Histology – The study of tissues and cells under a microscope.
  • Rapid urease test (RUT) – A biopsy of tissue from the stomach that is mixed with urea to detect the level of ammonia (an H. pylori product)
  • A culture test is when the healthcare provider removes a tissue sample from the body (in this case, the stomach) and puts it in a special dish. If H. pylori bacteria are present in the sample, they will grow until they can be seen under a microscope or in a liquid solution.

Currently, most healthcare providers are beginning to use non-endoscopic procedures. This includes the urea breath test and stool testing (fecal antigen tests). These are currently the most recommended tests to detect an H. pylori infection.

  • Urea Breath Test- non-invasive test where the patient will drink urea and breathe into a bag to test the level of CO2. Urea produces exhaled CO2 only when H. pylori is present in the stomach,
  • Stool Test – A sample of the individuals bowel movement is collected and tested for excreted H. pylori proteins. This can be done at home, in the healthcare provider’s office, at a medical clinic or hospital.

When to test for an H. pylori Infection

Your healthcare provider should test for an H. pylori infection if you have:

  • Either active peptic ulcer disease OR a history of documented, untreated peptic ulcer disease. Peptic ulcers are open sores that develop on the inside lining of your stomach and the upper portion of your small intestine.
  • Gastric mucosa-associated lymphoid tissue (MALT) lymphoma is a rare disease which is often associated with Helicobacter pylori (H. pylori) infection. It occurs when there is an abnormal and excessive growth of tissue within lymphoid tissue in the stomach. It is usually the result of chronic immune stimulation due to infections, such as H. pylori.
  • After endoscopic resection of early gastric cancer. Gastrointestinal endoscopic mucosal resection (EMR) is a procedure to remove pre-cancerous, early-stage cancer or other abnormal tissues (lesions) from the digestive tract.
  • Dyspepsia. Pain or discomfort centered in the upper abdomen, often referred to as dyspepsia, is a common disorder that affects up to 30% of the general population. Symptoms of dyspepsia include upper abdominal pain or discomfort, early feeling of fullness (satiety), nausea, belching, and bloating. Patients can also experience symptoms of burning, pressure, or fullness often, but not necessarily, related to meals.
    • Uninvestigated dyspepsia. Uninvestigated dyspepsia means that these symptoms have not been addressed and no diagnostic testing has occurred. H.pylori has many of the same symptoms as dyspepsia, so the healthcare provider will want to rule out this infection as the cause of the symptoms.
    • Functional dyspepsia (with a normal upper endoscopy). Functional Dyspepsia is a disorder where a group of dyspeptic symptoms exist and after diagnostic testing for possible causes has occurred, but no structural or metabolic disease is present to explain them.
  • Unexplained iron deficiency anemia. Iron-deficiency anemia is a lack of healthy red blood cells in blood that develops if you do not have enough iron in your body. It is the most common type of anemia.
  • Idiopathic thrombocytopenic purpura. Thrombocytopenic purpura is a blood disorder where there is abnormal decrease in the number of platelets in the blood. It is considered idiopathic if it occurs suddenly with no identifiable cause.

Treatments

H.pylori is often treated using 2-4 drugs at the same time. This can include Proton Pump Inhibitors (PPIs) along with 1-3 antibiotics.

Proton Pump Inhibitors (PPIs) Antibiotics
Omeprazole
Esomeprazole
Lansoprazole
Rabeprazole
Pantoprazole
Dexlansoprazole
Amoxicillin
Clarithromycin
Tetracycline
Metronidazole
Levofloxacin
Rifabutin

*It’s important to avoid antibiotics that you have previously received as your body may become resistant to that antibiotic. *

Generally, treatment lasts 14 days (should not be less than 10). It is critically important that you take the medications as prescribed for the proper duration of therapy. The best chance to get rid of the infection is the first try. If you are not able to get rid of the infection on the first try, it becomes harder to get rid of with subsequent forms of therapy. After finishing treatment, it is important to follow up with a breath or stool test to make sure the H. pylori is cured.

Combination Therapy Treatment:

Several treatments have been developed as a prepackaged combination to make it easier for patients to take these complex regimens.

  • Helidac® is a combination package of an antidiarrheal agent (bismuth subsalicylate), and two antibiotics (metronidazole and tetracycline), taken together with a PPI.
  • Pylera™ contains a combination of minerals (Bismuth, potassium and citrate also known as bismuth subcitrate) and two antibiotics (metronidazole and tetracycline) in the same capsules, again taken with a PPI.
  • Talicia® is a combination of two antibiotics (rifabutin and amoxicillin) and a PPI (omeprazole) requiring no additional pills.

In May 2022, the FDA approved two novel combination therapy treatments for H. pylori infection.

  • Voquenza™ Triple Pak™
  • Voquenza™ Dual Pack™

In both of these FDA approved treatments, vonoprazan is co-packaged with either one or two antibiotic(s). Vonoprazan is an oral small molecule potassiumcompetitive acid blocker (PCAB). This therapy helps suppress acid secretion in the stomach while increasing the effectiveness of the antibiotic(s).

Summary

H. pylori is one of the most common human infections. It is a common cause of inflammation in the stomach (gastritis), peptic ulcers, and gastric cancer, and unexplained upper gastrointestinal symptoms. There are blood, breath, stool, and endoscopic tests to identify this infection. Treatments consist of a 2-4 drug regimen given for 14 days. Patients treated for H. pylori should undergo a follow up test 4 weeks after the course of treatment to determine if it was successful.

Adapted from IFFGD Publication #166 Helicobacter Pylori (H. pylori) Infection by Alyssa Sutton, Program Coordinator, IFFGD and William D. Chey, MD, FACG, AGAF, FACP, RFF, Professor of Gastroenterology & Nutrition Sciences, Chief, Division of Gastroenterology Michigan Medicine. Edited by Steven Moss, MD Professor of Medicine, Brown University

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