Helicobacter Pylori (H. PYLORI) Infection, signs and Treatments || Pharmacyteach.com

  

HELICOBACTER PYLORI (H. PYLORI) INFECTION

 

What Is Helicobacter pylori Infection?

Helicobacter pylori is a spiral-shaped bacterium that can live in the stomach's protective mucus layer. Unlike many microorganisms that cannot tolerate highly acidic conditions, H. pylori has specialized mechanisms that help it survive in the stomach. Once established, it can interact with the stomach lining and trigger inflammation that may persist for years if the infection is not eradicated. Some infected people remain symptom-free, whereas others experience indigestion, upper abdominal discomfort, or peptic ulcer disease. The infection is medically important because it is associated with chronic gastritis, gastric and duodenal ulcers, and an increased risk of certain stomach cancers. 

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MECHANISMS OF PHYSIOLOGICAL DISRUPTION OF H. PYLORI

Gastric ulcers:

» Helicobacter pylori: Secretes urease → conversion of urea to NH3 → alkalinization of acidic environment → survival of bacteria in gastric lumen

» Bacterial colonization and attachment to epithelial cells → release of cytotoxins (e.g., CagA toxin) → disruption of the mucosal barrier and damage to underlying cells

Duodenal ulcers:

» Helicobacter pylori: Inhibits somatostatin secretion → increased gastrin secretion → increased hydrogen (H+) secretion → excess hydrogen (H+) delivery to the duodenum

» Direct spread of H. pylori to the duodenum → inhibition of duodenal HCO3- secretion → acidification and insufficient neutralization of duodenal contents

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DIAGNOSTIC APPROACH FOR SUSPECTED PUD/H.PYLORI

Initial evaluation for all patient groups

» Screen for common etiologies on history, e.g., NSAID use, smoking, steroids, caffeine, alcohol, diet

» Consider the following investigations if there is suspicion for occult bleeding: CBC, BUN/Urea, creatinine, stool occult blood test

» Patients ≤ 60 years of age without red flags for dyspepsia

    - Begin with noninvasive testing for H. pylori infection: A positive result indicates exposure to H. pylori, but cannot distinguish between a past and current infection. Antibodies may still be detected after eradication.

    - Urea breath test: Detects a labeled carbon isotope in a breath sample. Can be used for initial diagnosis or confirmation of eradication. Sensitivity increases if PPIs have been discontinued for at least 2 weeks before testing.

    - H. pylori stool antigen test: Can be used for initial diagnosis or confirmation of eradication

    - Serum IgG antibodies against H. pylori

» Refer directly for EGD

    - Patients > 60 years of age, or > 45 years of age in areas with high gastric cancer prevalence

    - Patients with red flags for dyspepsia: on a case-by-case basis

    - Patients unresponsive to H. pylori eradication therapy, PPI trial therapy

Further evaluation:

» All patients with persistently uncertain etiology → Consider secretin stimulation test for gastrinoma (specialized laboratory studies).

» Esophagogastroduodenoscopy (EGD): The most accurate test to confirm the diagnosis.

Other clinical applications of EGD include:

    - Malignancy screening: to differentiate PUD from gastric cancer

        - Visualization of the lesions

        - Biopsy sampling

        - Invasive H. pylori testing

    - Simultaneous therapeutic measures: hemostasis treatment with Electrocautery for active bleeding

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CLASSIC ENDOSCOPIC APPEARANCE OF PEPTIC ULCERS

	Benign	Malignant
Base	Smooth	Ulcerated mass protruding into the lumen
Edges	Rounded, regular	Irregular, overhanging
Surrounding mucosa	Regular	Nodular, Irregular
Location	Gastric ulcers: lesser curvature of the stomach, b/w the corpus and antrum. Duodenal ulcers: anterior or posterior wall of the duodenal bulb	Atypical
Histopathology	Chronic inflammatory changes and active granulation	Dysplasia, invasion of deeper layers
❖ Gastrinoma: multiple ulcers and thick gastric folds

 

TREATMENT GUIDELINES FOR H. PYLORI ASSOCIATED ULCER (H. PYLORI ERADICATION THERAPY)

 Bismuth quadruple therapy is not the only available option. Depending on the clinical situation, a clinician may consider rifabutin-based triple therapy or dual therapy combining a potassium-competitive acid blocker, such as vonoprazan, with amoxicillin. Other regimens may be suitable when antibiotic susceptibility is known. The availability and suitability of these treatments vary by country, and prescribing decisions should reflect local guidance and the patient's medical history.

1. STANDARD BISMUTH-BASED QUADRUPLE THERAPY (14 DAYS)

Best option - Preferred in areas with high levels ≥ 15% of clarithromycin resistance

Non-pharmacological management in H.Pylori

- Dietary recommendations

    » Reduce portion size

    » Avoid eating at least 3 hours before lying down (e.g., before going to sleep).

    » Avoid foods and beverages that appear to trigger symptoms (dietary products, lussi, excessive intake of tea/coffee, heavy food like Paya, Liver/Kaliji, Paratha, Chole, which make the patient uncomfortable)

- Physical recommendations

    » Patients with obesity should be encouraged to lose weight & should also receive advice on the best approach.

    » Elevate the head-end of the bed (10-20 cm) for patients who experience symptoms while sleeping.

- Reduce or avoid triggers

    » Reduce or avoid stress.

    » Avoid nicotine, alcohol, and caffeine (especially if they appear to trigger symptoms).

    » If possible, avoid medications that may worsen symptoms: For example, NSAIDs, Aspirin, corticosteroids, calcium channel blockers (CCBs), benzodiazepines (diazepam).

1. PPIs: Cap. Omeprazole 20mg - 40mg (Ruling, Omezol) OR Cap. Esomeprazole 20mg - 40mg (Eskem, Esso) x Twice daily (1---0---1) x on empty stomach 30 minutes before meal (کھانے سے 30 منٹ پہلے)

2. Tab. Bismuthsubsalicylate 265mg (Bismol) x Two tablets orally four times daily (2--2--2--2)

3. Cap. Tetracycline 500mg x one capsule orally four times daily (QID) (1--1--1--1)

4. Tab. Metronidazole 400mg (Klint, Merozine, Flagyl) x three times a day (1---1---1)

Medicine	Main role
Proton pump inhibitor (PPI)	Suppresses stomach acid and supports healing
Bismuth compound	Contributes to antimicrobial activity and mucosal protection
Tetracycline	Antibiotic that helps eradicate H. pylori
Metronidazole	Antibiotic that acts against susceptible bacteria

2. RIFABUTIN-BASED TRIPLE THERAPY (TALICIA)

1. PPIs: Cap. Omeprazole 40mg (Ruling, Omezol) OR Cap. Esomeprazole 40mg (Eskem, Esso) x every 8 hours

2. Tab. Rifabutin 50mg x every 8 hours (three times a day)

3. Tab. Amoxicillin 1g (Zeemox, Ospomox) x BD OR Cap. Amoxicillin 500mg (Amoxil, Zeemox) x 2 capsules x BD

OR Cap. Talicia: Four capsules three times a day; each capsule contains omeprazole 10 mg/rifabutin 12.5 mg/amoxicillin 250 mg, orally every 8 hours; thus, total dosages are.

 

3. VONOPRAZAN-BASED TRIPLE THERAPY (14 DAYS)

1. Tab. Clarithromycin 500mg (Klaricid, Claritek, Ultima) x Twice daily (1---0---1)

2. Tab. Amoxicillin 1g (Zeemox, Ospomox) x BD OR Cap. Amoxicillin 500mg (Amoxil, Zeemox) x 2 capsules x BD

3. Tab. Vonoprazan 20mg (Vonozan, Voniza, Vocinti) x Twice daily (1---0---1)

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4. VONOPRAZAN BASED DUAL THERAPY (14 DAYS)

1. Tab. Amoxicillin 1g (Zeemox, Ospomox) x TDS OR Cap. Amoxicillin 500mg (Amoxil, Zeemox) x 2 capsules x TDS

2. Tab. Vonoprazan 20mg (Vonozan, Voniza, Vocinti) x Twice daily (1---0---1)

 

5. STANDARD TRIPLE THERAPY (14 DAYS)

No longer recommended, except in locales where clarithromycin resistance is < 15%

1. Tab. Clarithromycin 500mg (Klaricid, Claritek, Ultima) x Twice daily (1---0---1)

2. Tab. Amoxicillin 1g (Zeemox, Ospomox) x BD OR Cap. Amoxicillin 500mg (Amoxil, Zeemox) x 2 capsules x BD OR Tab. Metronidazole 400mg (Klint, Metrozine, Flagyl) x Three times a day (1---1---1)

PPIs: Cap. Omeprazole 20-40mg (Ruling, Omezol) OR Cap. Esomeprazole 20mg-40mg (Eskem, Esso) 1--0--1(BD) Twice daily on empty stomach 30 minutes before meal (کھانے سے 30 منٹ پہلے)

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H. PYLORI FOLLOW-UP TREATMENT (AFTER 14 DAYS)

- After completion of the course of H. Pylori eradication therapy, continue treatment with PPI (Esomeprazole, Pantoprazole) 40 mg once daily for 4 – 6 weeks if the ulcer is large (> 1cm) or complicated.

- Confirm successful eradication of H.pylori with urea breath test, stool antigen test, or PCR test, or endoscopy with biopsy at least 4 weeks after completion of antibiotic treatment and 2 weeks after completion of PPI treatment

    » Stop PPIs at least 2 weeks before the urea breath test is performed for accurate results.

    » SEROLOGY IS NOT RECOMMENDED TO CONFIRM ERADICATION, AS H. PYLORI ANTIBODIES MAY STILL BE PRESENT FOR WEEKS OR MONTHS AFTER ERADICATION.

    » Acid suppression medication can be discontinued once eradication is confirmed.

Frequently Asked Questions (FAQs)

1. What are the first signs of H. pylori infection?

Many people have no symptoms. When symptoms occur, they may include burning or aching in the upper abdomen, bloating, nausea, frequent burping, and feeling full quickly after eating. These symptoms are not specific to H. pylori, so a diagnostic test is needed to confirm an active infection.

2. Can H. pylori infection be cured permanently?

Yes, H. pylori can often be eradicated successfully with an appropriate combination of antibiotics and acid-suppressing medication. A test of cure is recommended at least four weeks after completing treatment, with appropriate medication washout periods. Reinfection is possible, so successful treatment does not guarantee lifelong protection.

3. Which test is best for detecting H. pylori?

The urea breath test and stool antigen test are widely used noninvasive methods for detecting active infection. Endoscopy with biopsy may be appropriate when a patient has alarm symptoms or needs further examination. Blood antibody tests are generally less useful for confirming active infection or successful eradication because antibodies can remain positive after the bacteria have been eliminated.

4. What foods should I avoid if I have H. pylori?

There is no universal H. pylori diet. If certain foods worsen your symptoms, consider limiting them while maintaining a balanced diet. Very spicy meals, coffee, acidic drinks, and fatty foods may trigger discomfort in some individuals but not others. Food changes can help manage symptoms, but they cannot replace prescribed eradication treatment.

5. Is H. pylori infection dangerous?

H. pylori is not dangerous for everyone, but untreated infection can cause peptic ulcers and is associated with an increased risk of gastric cancer and gastric MALT lymphoma. A positive result should be discussed with a healthcare professional so that appropriate treatment can be arranged. Vomiting blood, passing black tarry stools, or experiencing sudden severe abdominal pain requires urgent medical assessment.

References and Further Reading

1. American College of Gastroenterology. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. The American Journal of Gastroenterology, 2024.

2. American College of Gastroenterology. H. pylori Treatment Guideline Highlights.

3. National Cancer Institute. Helicobacter pylori (H. pylori) and Cancer.

4. American Family Physician. ACG Guideline for Treatment of Helicobacter pylori Infection in Adults