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Helicobacter pylori infection

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Updated 2024 ACG guidelines for the management of Helicobacter pylori infection.

Background

Overview

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 prevalence of H. pylori infection in North America is decreasing over time but remains substantial at 30-40%. The infection is typically acquired in childhood and is more prevalent among non-White races and ethnicities, those living in crowded or poor sanitary conditions, and early-generation immigrants from countries where H. pylori is endemic. H. pylori resistance rates to antibiotics are increasing in most parts of the world.
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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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Guidelines

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 College of Gastroenterology (ACG 2024,2017,2013,2007), the American Gastroenterological Association (AGA 2024,2021,2020), the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN/NASPGHAN 2024), the American Academy of Family Physicians (AAFP 2023), the European Society for Paediatric ...
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Screening and diagnosis

Differential diagnosis: as per Maastricht V/Florence 2017 guidelines, exclude H. pylori gastritis before making a reliable diagnosis of functional dyspepsia.
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  • Indications for testing (dyspepsia)

  • Indications for testing (peptic ulcer disease)

  • 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)

Diagnostic investigations

Choice of diagnostic test: as per SIDE/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.
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  • Choice of diagnostic test (Maastricht V/Florence)

  • Culture and sensitivity

  • Culture and sensitivity (Maastricht V/Florence)

Diagnostic procedures

Biopsy, Maastricht V/Florence: as per Maastricht V/Florence 2017 guidelines, 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.
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  • Biopsy

Medical management

General principles: as per ACG 2024 guidelines, determine when to test for and treat H. pylori as a single, rather than two separate and distinct, decisions.
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  • General principles (Maastricht V/Florence)

  • First-line regimens

  • First-line regimens (Maastricht V/Florence)

  • Considerations for potassium-competitive acid blockers

  • 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

Nonpharmacologic interventions

Probiotics: as per ACG 2024 guidelines, insufficient evidence to recommend probiotic therapy to improve the efficacy or tolerability of H. pylori eradication therapy.
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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.
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  • Patients with penicillin allergy (Maastricht V/Florence)

  • Pediatric patients (indications for testing)

  • Pediatric patients (biopsy)

  • Pediatric patients (serological and molecular tests)

  • Pediatric patients (antimicrobial susceptibility testing)

  • Pediatric patients (eradication therapy)

  • Pediatric patients (probiotics)

  • Pediatric patients (confirmation of eradication)

Patient education

General counseling: as per AGA 2021 guidelines, recognize that eradication regimens for H. pylori are complex and might not be fully comprehended by patients.
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Follow-up and surveillance

Post-eradication testing: as per ACG 2024 guidelines, obtain a test of cure with an appropriately conducted urea breath test, fecal antigen test, or biopsy-based test at least 4 weeks after completion of therapy in all patients treated for H. pylori infection.
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  • Post-eradication testing (Maastricht V/Florence)

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.
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  • Local susceptibility assessment (Maastricht V/Florence)