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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 is spread by consuming food or water contaminated with the bacteria. Both children and adults can become infected with H. pylori bacteria; however, children are at a greater risk of getting an H. pylori infection.

Individuals who live in crowded conditions, lack clean water, or have unsanitary living conditions are at a greater risk for getting H. pylori

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


A wide variety of methods are available to detect H. pylori infection.  Your healthcare provider will help you decide which one is the best for you.

Endoscopy-based testing

One common option is  a simple procedure called an endoscopy that investigates the stomach.  A long flexible tube called an 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 tract during the test.  

Tissue samples can then be collected for H. pylori testing.

  • Histology – The sample is examined under a microscope by a pathologist to look for H. pylori bacteria.
  • Rapid urease test – A chemical-based test is applied to the sample.
  • Culture – The sample is put in a special culture dish. If H. pylori bacteria are present in the sample, they may grow. The problem is that H. pylori is not easy to grow in the lab, so this test is only used in those with cases that are resistant to treatment.

Non-invasive testing

Many healthcare providers will recommend a non-invasive test that does not require an endoscopy.

  • Urea breath test – You will drink a specialized solution containing a substance that is broken down by the H. pylori bacteria. The breakdown products can then be detected in your breath.
  • Stool test – A sample of the individual’s 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

If you have symptoms

Testing is recommended if you have any of the listed symptoms. 

If you don’t have symptoms

Testing can be considered if you have the following risk factors.

  • Family history of peptic ulcer or gastric cancer.
  • Family members living in your household who have been diagnosed with an H. pylori infection.
  • Regular use of nonsteroidal anti-inflammatory drugs (NSAIDs).
  • You belong to a high-risk group (e.g., in the United States, Latino and African American, and other racial or ethnic groups).
  • You are a first-generation immigrant from a country where H. pylori is common.

Testing should be considered if you have the following risk factors.

  • Sensation of indigestion
  • Gastric or duodenal ulcers
  • Gastric mucosa-associated lymphoid tissue (MALT) lymphoma – A rare type of stomach cancer
  • Idiopathic thrombocytopenia (ITP) – A blood disease that leads to low platelet count in the blood


No single drug cures an H. pylori infection. Most treatment regimens involve taking 2-4 medications at the same time for 14 days.  They can be prescribed separately or in prepackaged combinations to make it easier for you to take. Your healthcare provider will help you decide which one is the best for you.

Medications used in these combinations can include:


  • Proton pump inhibitors (PPI)

Proton pump inhibitors (PPIs) are the most commonly prescribed class of medication for the treatment of heartburn and acid-related disorders. They work by blocking the site of acid production in the parietal cell of the stomach. Examples: omeprazole, esomeprazole, lansoprazole, rabeprazole, pantoprazole, dexlansoprazole

  • Bismuth subsalicylate or bismuth subcitrate is an antidiarrheal and anti-inflammatory agent used to treat nausea, heartburn, indigestion, upset stomach, diarrhea. Example: Pepto-Bismol™
  • Potassium-competitive acid blockers block acid secretion in the stomach. Example: Vonoprazan


  • One to three different antibiotics: Antibiotics are medicines that fight infections caused by bacteria in humans and animals by either killing the bacteria or making it difficult for the bacteria to grow and multiply. Examples: amoxicillin, clarithromycin, tetracycline, metronidazole, levofloxacin, rifabutin

**Side effects during treatment**

Up to half of all patients will report side effects while taking H. pylori treatment.

Side effects are usually mild, and fewer than 10 percent of patients stop treatment because of side effects.

For those who do experience side effects, it may be possible to adjust the dose or timing of medication, so you should immediately contact your healthcare provider if that happens.

Follow up

After finishing treatment, it is important to follow up with a breath or stool test to make sure the H. pylori is cured.  Up to 20 percent of patients are not cured after completing their first course of treatment.  Retreatment with alternative medications may be required.

Combination Therapy Treatment:

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

Prepackaged Treatment Combinations
Helidac® is a combination package of bismuth subsalicylate and two antibiotics (metronidazole and tetracycline), taken together with a PPI.    

Pylera® contains bisimuth 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 requiring no additional pills.

Voquenza™ Dual Pak™ contains Vonoprazan and one antibiotic (amoxicillin).

Voquenza™ Triple Pack™ is a combination of Vonoprazan and two antibiotics (amoxicillin, clarithromycin).

Recrudescence or Reinfection

The same individual can have an H. pylori infection more than once.  This generally occurs as either recurrence of the initial infection (recrudescence) or infection with a completely new type of H. pylori (reinfection).

Recrudescence is the recolonization of the same strain within 12 months after effective treatment.

Reinfection is the colonization with a new strain, more than 12 months after effective treatment.

In more affluent countries, recrudescence is more common than reinfection.  In developing countries, reinfection is more common, with a significant chance of infection that continues for the rest of the individual’s life.


H. pylori is one of the most common human infections.  It is a common cause of inflammation in the stomach (gastritis), peptic ulcers, 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 up to 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
This Fact Sheet is being provided in part by bioMérieux and Seres Therapeutics and donors of IFFGD.

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IFFGD is a nonprofit education and research organization. Our mission is to inform, assist, and support people affected by gastrointestinal disorders.

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