Helicobacter pylori Infection Initial Assessment

Clinical Presentation

A thorough history and physical exam should be done to rule out other causes for dyspeptic symptoms (eg cardiac, hepatobiliary, medication- induced [eg NSAIDs], dietary indiscretion, lifestyle, etc).

Patients with dominant symptoms of heartburn or acid regurgitation without a history of peptic ulcer disease (PUD) need not be tested for Helicobacter pylori infection but should be treated for gastroesophageal reflux disease (GERD).

Please see Gastroesophageal Reflux Disease disease management chart for further information.

Screening

The eradication of H pylori leads to ulcer healing and significantly diminished incidence of recurrence as well as complications (eg bleeding, perforation). The elimination of infection reduces gastric cancer incidence; it improves gastritis and gastric atrophy but not intestinal metaplasia. A multidrug regimen, adequate duration of treatment, and adherence to therapy are needed for eradication. A “test and treat” strategy is recommended in individuals and communities at increased risk for gastric cancer.

“Test and Treat” for Helicobacter pylori

It is strongly recommended that patients with the following conditions should be tested for Helicobacter pylori and if they test positive for H pylori, treatment to eradicate the infection should be instituted: Patients on NSAID and Aspirin with a history of peptic ulcer disease (PUD) where NSAIDs increase the risk of developing complications in patients with concomitant H pylori infection; complicated and uncomplicated peptic ulcers (current or past gastric or duodenal ulcers); gastric mucosa-associated lymphoid tissue (MALT) lymphoma; previous history of lymphoma while on NSAID therapy; uninvestigated dyspepsia; immune thrombocytopenia (ITP); after resection of early gastric cancer; a family history of gastric cancer; unexplained iron-deficiency anemia; and adult household members of patients with a positive non-serological test for Helicobacter pylori.

Other Patients

Adult patients <50 years old (<40 years old in areas with high prevalence of gastric cancer) that present with persistent dyspepsia and without predominant GERD symptoms, NSAID therapy and no alarm symptoms may be approached in two different ways: By empiric therapy or may test for Helicobacter pylori prior to a trial of medication.

Empiric Therapy

Treat empirically for 2-4 weeks with an appropriate antisecretory agent and/or prokinetic agent. If symptoms do not improve with appropriate trials of proton pump inhibitor (PPI), histamine₂-receptor antagonists (H₂RAs) or prokinetic agents, consider endoscopy.

May Test for Helicobacter pylori Prior to Trial of Medication

These patients may be considered for “test and treat” but this is controversial in non-ulcer dyspepsia. It is unlikely that eradication of H pylori will reduce symptoms but it may decrease future risk of peptic ulcer disease. Endoscopy may be performed first to identify peptic ulcer disease and treat H pylori only in peptic ulcer disease patients.