Everything You Need to Know About H. Pylori Infection

Helicobacter pylori (H. pylori) is a corkscrew-shaped bacterium that infects the stomach. The bacterial infection can easily be passed from person to person. It is thought to affect around one-third of the U.S. population, most of whom are asymptomatic (without symptoms).

For some, H. pylori can cause symptoms of gastritis (stomach inflammation), including stomach pain, heartburn, and indigestion. H. pylori is also the primary cause of peptic ulcers and a contributing factor to stomach cancer.

While the infection can be cleared with a combination of antibiotic drugs, H. pylori is prone to antibiotic resistance and may require several attempts before all the bacteria are fully cleared.

How Is H. Pylori Transmitted?

H. pylori is one of the most transmittable types of bacteria, affecting up to two-thirds of the world's population. It's most common in developing countries where public sanitation is poor. Most infections occur during childhood, although some can develop well into adulthood.

H. pylori is easily passed through direct or indirect contact with saliva, feces, or dental plaque. Possible routes of transmission include:

• Kissing
• Sharing food
  
• Passing chewed food to a baby
• Sharing a toothbrush, dental pick, or water flosser
  
• Shaking someone's hand or touching a contaminated surface and then touching your mouth
• Consuming food prepared by soiled hands
• Drinking public or natural water contaminated with stool
• Sexual contact like "rimming" (oral-anal sex)

H. pylori has unique features that increase its contagiousness. These include its corkscrew shape, allowing the bacterium to burrow into the stomach lining. It also secretes a substance called adhesin that locks it firmly into place.

Start of Symptoms

H. pylori stays with you for a lifetime until you clear the infection with antibiotics. Even so, around 80% of people with H. pylori will be entirely asymptomatic and never realize they've been infected.

Studies suggest that around 18% of people with H. pylori will experience gastritis symptoms. The condition tends to be chronic (persistent) with episodic bouts of acute (sudden, severe) symptoms.

Symptoms of H. pylori gastritis include:

• Bloating or belching
  
• Feeling full soon during a meal (early satiation)
• Feeling overfull after eating a meal
• Gnawing or burning sensations in the upper left abdomen
• Heartburn
• Indigestion
• Loss of appetite

Nausea

Complications

Peptic Ulcer Disease

Peptic ulcer disease (PUD) is when open sores develop in the stomach lining and duodenum (the first part of the small intestine). H. pylori is the most common cause of PUD.

H. pylori causes PUD by triggering inflammation in the stomach lining. In response, the stomach releases a hormone called gastrin that helps repair tissues and stimulates hydrochloric acid secretion (HCA). Long-term exposure to excessive HCA can lead to tissue deterioration and the formation of painful, bleeding ulcers.

Among people with chronic H. pylori, between 10% and 20% will develop PUD. People with the cagA gene have an 18-fold increased risk of PUD when they have an H. pylori infection.

The symptoms of PUD are similar to chronic gastritis but may also involve:

• Blood-streaked vomit or coffee ground-like vomit
• Radiating back pain
• Stool that is dark red, black or tarry, or streaked with blood
• Symptoms of anemia caused by blood loss (including fatigue, light-headedness, shortness of breath with exercise, and pale skin color)
  

Gastric Cancer

Gastric (stomach) cancer is rare and accounts for less than 2% of all cancers and cancer deaths in the United States. H. pylori is today categorized as a class 1 carcinogen (along with things like cigarette smoke and processed meat).

H. pylori is thought to contribute to 89% of these cancers, including gastric adenocarcinoma (the main form of stomach cancer) and nearly all cases of gastric MALT lymphoma (a rare type of non-Hodgkin lymphoma).

Among people with H. pylori, those who develop stomach ulcers are 3 times more likely to get gastric cancer than those without. By contrast, duodenal ulcers (which develop in the first section of the small intestine) are not associated with gastric cancer. How H. pylori causes gastric cancer is still unknown.

Symptoms of gastric cancer mirror those of PUD but may also include:

• Swelling or fluid build-up in the abdomen (ascites)
• Unexplained weight loss
• Yellowing of the skin and whites of the eyes (jaundice)
  

Research found that eradicating H. pylori with antibiotics reduces the risk of gastric cancer by nearly 50%.

What Makes Symptoms Last Longer?

Stress

Psychological stress is known to independently increase the risk of acute gastritis in people with H. pylori. Stress may also contribute to chronic gastritis and the risk of peptic ulcer disease.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Taking NSAIDs like aspirin, Advil or Motrin (ibuprofen), or Aleve (naproxen) independently increases the risk of peptic ulcers by fourfold. If used in people with H. pylori, the risk increases to over sixfold.

Smoking

Tobacco smoke can cause the thinning (atrophy) of the stomach lining, complicating gastritis and causing precancerous changes in cells. It also increases the risk of antibiotic failure by decreasing blood flow (and distribution of antibiotics) to the stomach.

Alcohol

While alcohol does not increase the risk of H. pylori (in fact, it seems to reduce it), it can damage the lining of the stomach and make gastritis symptoms worse. As with smoking, alcohol overuse can also increase the risk of antibiotic failure in people with H. pylori.

Certain Foods

Foods known to aggravate gastritis in people with H. pylori include:

• Acidic fruits, such as pineapple
• Carbonated sodas
• Coffee
• Fatty meats
• Fried foods
• Garlic
• Mustard
• Processed meats
• Spicy foods

Do Antibiotics Clear the Infection?

H. pylori can be challenging to treat due to high rates of antibiotic resistance. The overuse of antibiotics worldwide, particularly among people who are undertreated or fail to complete treatment, has led to the emergence of drug-resistant H. pylori strains.

H. pylori treatment, described as eradication therapy, involves a combination of antibiotics that best clear most major strains of the bacterium. These antibiotics are accompanied by other drugs that reduce stomach acid and prevent H. pylori from sticking to the stomach lining.

Experts recommend a 14-day course of optimized bismuth-based quadruple therapy (BQT) for the first-line treatment of adults with H. pylori infection,

The 14-day protocol involves:

• Tetracycline 500 milligrams (mg) taken by mouth four times daily
• Metronidazole 500 mg taken by mouth three or four times daily
• Bismuth subsalicylate 240 mg or bismuth subcitrate 300 mg or taken by mouth four times daily
• A proton pump inhibitor (PPI) like esomeprazole 20 mg or lansoprazole 30 mg taken by mouth twice daily

The doses should be spaced equally over 24 hours to ensure the drugs remain at a constant therapeutic level in your blood. The medications are typically taken on an empty stomach before meals to improve absorption.

If the first-line treatment fails, other eradication protocols involving antibiotics like amoxicillin, clarithromycin, and rifabutin will be used.

Secondary Treatment for Severe Infection

Treatment of Ulcers

Smaller stomach ulcers may heal on their own or with the aid of proton pump inhibitors (PPIs) used for eradication therapy. PPIs like Nexium (esomeprazole) or Prevacid (lansoprazole) work by blocking an enzyme that stimulates acid production.

Severe ulcers may require more invasive endoscopic procedures performed under general anesthesia or with monitored anesthesia care (MAC). The procedure may involve lasers or electrocautery (uses an electric current) to stop the bleeding with heat or an injection of epinephrine to shrink local blood vessels.

In people with a history of peptic ulcers, NSAIDs should be avoided and replaced with medications like Tylenol (acetaminophen) that are less likely to promote gastric bleeding.

Periodontal Therapy

Periodontal therapy, involving the removal of dental plaque and calculus (tartar) from your teeth, has been proposed to improve cure rates for H. pylori.

It is well known that dental plaque is a reservoir for H. pylori. Some studies suggest that these reservoirs may resist oral antibiotics and can cause reinfection after treatment is completed.

Research seems to support the practice, suggesting that professional dental cleaning before eradication therapy may reduce the risk of reinfection by more than one-third.

Probiotics

One of the common reasons for the early discontinuation of eradication therapy is severe diarrhea caused by a bacteria known as Clostridioides difficile (C. difficile).

C. difficile is naturally found in the intestine but is well-controlled by other bacteria in the intestinal flora. When taking antibiotics, many of these "good" bacteria are killed, allowing C. difficile to overgrow. When this happens, the ensuing infection can cause severe diarrhea, fever, nausea, and stomach pain.

A probiotic supplement known as Saccharomyces boulardii has been shown to decrease the risk of diarrhea during eradication therapy by helping repopulate the intestinal flora. Some studies even suggest that it may improve cure rates.

Healing and Recovery  

One study showed that a 14-day course of BQT use for first-line therapy cleared the infection in 97% of cases.

Common side effects include weakness, diarrhea, constipation, loss of appetite, stomach pain, heartburn, a metallic taste in the mouth, a dry or sore mouth, and a dark tongue or stool (due to staining from bismuth). Most side effects are manageable, with only around 2% of users discontinuing treatment due to intolerance.

To better cope with H. pylori treatment and reduce the risk of side effects, here are some things you should do:

• Avoid coffee, alcohol, and spicy, fatty, or acidic foods, which can cause stomach irritation and diarrhea.
• Avoid NSAIDs and switch to Tylenol instead for pain.
• Call your healthcare provider if side effects are severe and before stopping medications.
• Eat smaller meals instead of three big meals if you are experiencing heartburn or stomach pain.
• Stop smoking, which promotes bleeding and may also reduce the efficacy of treatment. If you cannot stop, speak with your provider about smoking cessation aids.
  
• Take your medications as prescribed and to completion. Inconsistent dosing or early discontinuation can increase the risk of treatment failure and antibiotic resistance.
  

Hygiene and Contamination Prevention

As common as H. pylori is, there are a few simple ways to reduce your risk of exposure or prevent the spread of infections to others:

• Avoid pre-chewing food for children.
• Avoid sharing toothbrushes or other oral appliances.
• Clean kitchen surfaces before food preparation and eating.
• Keep bathroom surfaces clean, wearing gloves when cleaning the toilet.
• Teach your children how to avoid hand-to-mouth behaviors.
• Wash your hands for at least 20 seconds with soap and water before eating, after going to the bathroom, or whenever they are dirty.
• When traveling to parts of the world where public sanitation is poor, only drink bottled water, avoid uncooked foods in restaurants, and wash all raw fruits and vegetables with clean water before peeling and eating.

Summary

Helicobacter pylori (H. pylori) is a highly transmittable bacterium that can be passed by direct or indirect contact with saliva or stool. Most people with H. pylori have no symptoms, but those who do may experience chronic stomach pain, heartburn, bloating, and, in severe cases, stomach ulcers.

H. pylori is associated with an increased risk of peptic ulcer disease and gastric cancer. Quadruple therapy involving two antibiotics, one proton pump inhibitor (PPI), and a drug called bismuth can often clear the infection if taken as prescribed.