• What is Helicobacter pylori?
• How is H. pylori infection diagnosed?
• Why treat H. pylori?
• How is H. pylori treated?
• Who should receive treatment?

What is Helicobacter pylori?

Helicobacter pylori (H. pylori) is a bacterium that causes chronic inflammation (gastritis) of the inner lining of the stomach in humans. This bacteria also is the most common cause of ulcers worldwide. H. pylori infection is most likely acquired by ingesting contaminated food and water and through person to person contact. In the United States, 30% of the adult population is infected. (50% of infected persons are infected by the age of 60.) The infection is more common in crowded living conditions with poor sanitation. In countries with poor sanitation, 90% of the adult population can be infected. Infected individuals usually carry the infection indefinitely unless they are treated with medications to eradicate the bacterium. One out of every six patients with H. pylori infection will develop ulcers of the duodenum or stomach. H. pylori also is associated with stomach cancer and a rare type of lymphocytic tumor of the stomach called MALT lymphoma.

How is H. pylori infection diagnosed?

Accurate tests for the detection of H. pylori infection are available. They include blood antibody tests, urea breath tests, stool antigen tests and endoscopic biopsies.

Blood tests for the presence of antibodies to H. pylori can be performed easily and rapidly. However, blood antibodies can persist for years after complete eradication of H. pylori with antibiotics. Therefore, blood antibody tests may be good for diagnosing infection, but they are not good for determining if antibiotics have successfully eradicated the bacterium.

The urea breath test (UBT) is a safe, easy, and accurate test for the presence of H. pylori in the stomach. The breath test relies on the ability of H. pylori to break down urea into carbon dioxide which is eliminated from the body in the breath. Ten to 20 minutes after swallowing a capsule containing "labeled" urea, a breath sample is collected and analyzed for labeled carbon dioxide. The presence of labeled carbon dioxide in the breath (a positive test) means that there is active infection. The test becomes negative shortly after eradication of the bacteria from the stomach with antibiotics.

Endoscopy is an accurate test for diagnosing H. pylori as well as the inflammation and ulcers that it causes. For endoscopy, the doctor inserts a flexible viewing tube (endoscope) through the mouth and through the esophagus into the stomach, and duodenum. During endoscopy, small tissue samples (biopsies) from the stomach lining can be obtained. These tissue samples are placed on special slides containing urea (e.g., CLO test slides). If the urea is broken down by H. pylori in the biopsy, there is a simple color change around the biopsy sample on the slide. This means that there is active infection with H. pylorin the stomach.

Why treat H. pylori?

Chronic infection with H. pylori weakens the natural defenses of the lining of the stomach against the ulcerating action of acid. Medications that neutralize stomach acid (antacids), and medications that decrease stomach acid output (H2-blockers and proton pump inhibitors or PPIs) have been used effectively for many years to treat ulcers. (H2-blockers, include ranitidine (Zantac) , famotidine (Pepcid) , cimetidine (Tagamet) , and nizatidine (Axid) . PPIs include omeprazole (Prilosec) , lansoprazole (Prevacid) , rabeprazole (Aciphex) , pantoprazole (Protonix) , and esomeprazole (Nexium). ) Antacids, H2-blockers and PPIs, however, do not eradicate H. pylori from the stomach, and ulcers frequently return promptly after these medications are discontinued. Hence, antacids, H2-blockers or PPIs have to be taken daily for many years to prevent the return and the complications of ulcers such as bleeding, perforation, and obstruction of the stomach. Eradication of H. pylori prevents the return of ulcers and ulcer complications once the medications are stopped. Eradication of H. pylori also is important in the treatment of the rare condition MALT lymphoma of the stomach.

How is H. pylori treated?

H. pylori is difficult to eradicate from the stomach because it is capable of developing resistance to commonly used antibiotics. Therefore, two or more antibiotics usually are given together with a PPI and/or bismuth containing compounds to eradicate the bacterium. (Bismuth and PPIs have anti-H.pylori effects.) Examples of combinations of medications that are effective are:

• a PPI, amoxicillin(Amoxil) and clarithromycin (Biaxin)
• a PPI, metronidazole (Flagyl), tetracycline and bismuth subsalicylate

These combinations of medications can be expected to cure 70%-90% of infections. Some doctors may evaluate patients for eradication of H. pylori after treatment with a urea breath test or a stool antigen test, particularly if there have been serious complications of the infection. Endoscopic biopsies to determine eradication of the bacteria are not necessary. Blood tests are not good for determining eradication since it takes many months for the antibodies to H. pylori to decrease. Patients who fail a course of treatment are retreated, often with a different combination of medications.

Who should receive treatment?

There is a general consensus among doctors that patients should be treated if they are infected with H.pylori and have ulcers. The goal of treatment is to eradicate the bacteria, heal the ulcers, and prevent the ulcers' return. Patients with MALT lymphoma of the stomach also should be treated. MALT lymphoma is rare, but the tumor often quickly regresses upon successful eradication of H. pylori. There currently is no recommendation to treat patients infected with H. pylori without ulcer disease or MALT lymphoma. Since antibiotic combinations can have side effects and stomach cancers are infrequent in the United States, it is felt that the risks of treatment to eradicate H. pylori in patients without symptoms or ulcers may not justify the unproven benefits of treatment for the purpose of preventing stomach cancer .

Many physicians believe that dyspepsia may be associated with infection with H. pylori. Although it is not clear if H. pylori causes the dyspepsia, many physicians will test patients with dyspepsia for infection with H. pylori and treat them if infection is present.

Scientists studying the genetics of H. pylori have found different strains (types) of the bacterium. Some strains of H. pylori appear to be more prone to cause ulcers and stomach cancer. Further research in this area may help doctors to intelligently select those patients who need treatment. Vaccination against H. pylori is unlikely to be available in the near future.

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