Helicobacter pylori associated dyspepsia/duodenal/gastric ulcer

[Helicobacter Pylori (H. pylori) Primary Care Pathway (specialistlink.ca); Gut 2022;71:1724–62; Am J Gastroenterol 2017;112:988-1013]


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- Indications for investigation of H. pylori by stool antigen test (SAT) or urea breath test (UBT):

  • uninvestigated dyspepsia (epigastric pain dominant symptom) in patients < 60 years of age without alarm features
  • active, or past history of, peptic ulcer disease (PUD)
  • personal or first-degree relative history of gastric cancer
  • long term  ASA or NSAID use with history of PUD

  • unexplained iron deficiency anemia

  • idiopathic thrombocytopenia (ITP)

  • low-grade MALT lymphoma
  • First Nations individuals and first generation immigrants from Asia, Africa, and Central and South America.

      NB: H. pylori serology is not recommended as it does not differentiate acute from past infections.


- Indications for endoscopy:

  • new onset persistent dyspepsia in patients > 60 years of age

  • no or limited response to acid-suppression therapy

  • dyspepsia with alarm features

- Investigation and treatment of H. pylori is not recommended for patients with gastroesophageal reflux disease (GERD) symptoms (dominant symptoms of heartburn and/or regurgitation).

- Compliance is essential to achieve expected eradication rates of >80% and to decrease development of antimicrobial resistance.

- Triple therapy [PPI + (clarithromycin or metronidazole) + amoxicillin] is no longer recommended.

- H. pylori eradication should be confirmed by SAT, UBT, or rarely gastric biopsy in all patients ≥ 4 weeks after treatment completed. When a patient is tested by SAT or UBT, PPl therapy should be withheld for 2 weeks as use of PPIs can lead to false negative results. The patient should be off antibiotics and bismuth compounds for 4 weeks prior to testing. 

- Subsequent courses of H. pylori treatment should only be given if repeat testing (stool antigen test, UBT, gastric biopsies) shows persistent H. pylori.

- Reinfection of H. pylori is infrequent (< 2%/patient year).  Most recurrences of H. pylori are in fact recrudescence of the original infection.

- Need for post H. pylori therapy acid suppression:

   - In the case of PUD, do not stop PPI until the patient has a confirmed negative H. pylori test after H. pylori treatment

  • uncomplicated ulcers - usually at least 8-16 weeks of PPI therapy is needed to ensure healing of the ulcer. If the patient is asymptomatic after this 8-16 week PPI course and has no other risk factors for ulcers (e.g. anticoagulation and/or anti-platelet therapy), the PPI can be stopped as long as the patient is proven H. pylori negative.

  • complicated ulcers (bleeding, perforation, obstruction) – if there was a clear risk factor for the ulcer (e.g. NSAID use), the PPI can possibly be stopped after the patient’s H. pylori is cured. Many of these patients will need long term PPI for ulcer prevention however because of other risk factors (age, anticoagulation and/or anti-platelet therapy). In that case a PPI, usually given once daily, should be given indefinitely.

NB: PPIs are generally safe. There is a slight increased risk of enteric infections including Clostridioides difficile infection, microscopic colitis (presents with watery diarrhea), low magnesium levels (rare), or interstitial nephritis (rare).