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Helicobacter pylori infection

Definition
H. pylori is a Gram-negative bacterium that causes chronic infection and inflammation of the stomach and duodenum.
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Pathophysiology
H. pylori infection is transmitted via the fecal-oral and oral-oral routes; horizontal transmission, and environmental transmission through contaminated water also occurs.
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Epidemiology
The overall prevalence of H. pylori infection is estimated at 30.7% in the US. However, the distribution is heterogeneous with a higher prevalence in immigrants from high-risk areas (Latin America, Asia).
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Disease course
H. pylori infection is associated with an increased risk of various gastrointestinal diseases including functional dyspepsia, gastritis, peptic ulcer disease, gastric intestinal metaplasia, and gastric cancer.
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Prognosis and risk of recurrence
Although successful eradication of H. pylori infection prevents the development and progression of H. pylori-associated diseases, the efficacy of treatment regimens has decreased due to increased antibiotic resistance. Globally, the annual recurrence, reinfection, and recrudescence rate of H. pylori is 4.3%, 3.1%, and 2.2%, respectively.
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Key sources
The following summarized guidelines for the evaluation and management of Helicobacter pylori infection are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2023), the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN 2023), the Italian Society of Digestive Endoscopy (SIDE/SIGE 2022), the American Gastroenterological Association (AGA 2021; 2020), the World Society of Emergency Surgery (WSES 2020), the American Society for Clinical Pathology (ASCP 2019), the European Society for the Study of Coeliac Disease (ESsCD 2019), the Maastricht V/Florence Consensus Report (Maastricht V/Florence 2017), the American College of Gastroenterology (ACG 2017; 2013; 2007), the American College of Gastroenterology (ACG/CAG 2017), the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN/NASPGHAN 2017), the Canadian Association of Gastroenterologists (CAG 2016), and the American Society for Gastrointestinal Endoscopy (ASGE 2010).
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Guidelines

1.Screening and diagnosis

Epidemiology
As per ACG 2017 guidelines:
Recognize that H. pylori is a chronic condition and is usually acquired in childhood.
B
Recognize that the incidence and prevalence of H. pylori infection are generally higher among people born outside North America. Recognize that the prevalence of the infection within North America is higher in certain racial and ethnic groups, the socially disadvantaged, and people who have immigrated to North America.
B
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  • Epidemiology (Maastricht V/Florence)

  • Differential diagnosis

  • Indications for testing (dyspepsia)

  • Indications for testing (PUD)

  • Indications for testing (NSAID use)

  • Indications for testing (lymphocytic gastritis)

  • Indications for testing (GERD)

  • Indications for testing (neoplasia)

  • Indications for testing (celiac disease)

  • Indications for testing (hyperemesis gravidarum)

  • Indications for testing (hematological conditions)

2.Diagnostic investigations

Choice of diagnostic test: as per SIGE 2022 guidelines, obtain urea breath test or monoclonal ELISA stool antigen test for noninvasive diagnosis of H. pylori infection, both in pre- and post-therapy settings.
A
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  • Choice of diagnostic test (Maastricht V/Florence)

  • Culture and sensitivity

  • Culture and sensitivity (Maastricht V/Florence)

3.Diagnostic procedures

Biopsy, Maastricht V/Florence: take two biopsies from the antrum (greater and lesser curvature 3 cm proximal to the pyloric region) and two biopsies from the middle of the body as a minimum standard for the assessment of H. pylori gastritis. Consider taking an additional biopsy from the incisura for the detection of precancerous lesions.
B
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  • Biopsy

4.Medical management

General principles, Maastricht V/Florence: consider employing a test-and-treat strategy for uninvestigated dyspepsia taking into account the regional H. pylori prevalence and cost-benefit considerations. Do not use this strategy in patients with alarm symptoms or older patients.
B
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  • General principles

  • First-line regimens

  • First-line regimens (Maastricht V/Florence)

  • Management of treatment failure (evaluation)

  • Management of treatment failure (decision to treat)

  • Management of treatment failure (choice of regimen)

  • Management of treatment failure (adjunctive therapies)

  • Management of persistent dyspepsia

5.Nonpharmacologic interventions

Probiotics: as per SIGE 2022 guidelines, consider offering probiotics in addition to eradication therapy to reduce the rate of side effects associated with the eradication therapy.
C

6.Specific circumstances

Patients with penicillin allergy: as per AGA 2021 guidelines, consider obtaining penicillin allergy testing in patients labeled as having this allergy, in the absence of a history of anaphylaxis, in order to delist penicillin as an allergy and potentially enable its use.
C

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  • Patients with penicillin allergy (Maastricht V/Florence)

  • Pediatric patients (diagnosis)

  • Pediatric patients (testing)

  • Pediatric patients (counseling)

  • Pediatric patients (management)

  • Pediatric patients (follow-up)

  • Pediatric patients (treatment failure)

7.Patient education

General counseling: recognize that eradication regimens for H. pylori are complex and might not be fully comprehended by patients.
B
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8.Follow-up and surveillance

Post-eradication testing: as per SIGE 2022 guidelines, obtain urea breath test or monoclonal ELISA stool antigen test in the post-therapy setting.
A
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  • Post-eradication testing (Maastricht V/Florence)

9.Quality improvement

Local susceptibility assessment: as per AGA 2021 guidelines, compile local data on H. pylori eradication success rates for each regimen, along with patient demographic and clinical factors (including prior non-H. pylori antibiotic exposure). Make aggregated data publicly available to guide the local selection of H. pylori eradication therapy.
B

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  • Local susceptibility assessment (Maastricht V/Florence)