Helicobacter pylori is a bacterium that resides in the lining of the stomach that causes H. pylori infection a bacterial stomach ulcer. “Helico” means spiral, which indicates that the bacteria are spiral in shape.

H. pylori infection may cause no symptoms initially and usually come to medical attention when the disease has progressed to a chronic stage.

However, H. pylori infection may cause heartburn, belching, bloating, nausea, vomiting and, weight loss.

H. pylori also cause Peptic Ulcer Disease (PUD) and cancers of the stomach. PUD can further lead to complications like bleeding, perforation, and obstruction.

The infection spread either through fecal-oral (food-borne) or even through saliva. Therefore, it is more common in areas that lack clean water and sanitation or a good sewage system.

Diagnosis is made through noninvasive tests, including detection of antibodies against H. pylori, fecal bacterial detection and Urea breath test, and invasive test which includes gastric biopsy. After that the specimens are analyzed by tests to detect bacterial presence.

Treatment regimens include combinations of antibiotics and proton pump inhibitors, this is given as triple or quadruple therapy. Other drugs that reduces acid production can also be used, these include H2-receptor antagonist, antacids, etc.

Surgery can also be performed. Individuals improve after treatment although relapses are common.

Infection can be prevented if one takes care of hygiene, eating clean, drinking boiled or filtered water, washing hands before eating.

Symptoms of Helicobacter H Pylori Infection

Most people with H. pylori infection usually have no symptoms for years. Therefore, when patients come to clinical attention, they mostly have reached the chronic phase.

When signs or symptoms do occur, they may include:

• Dull or burning pain in the upper abdomen may worsen when the stomach is empty such as in between meals or in the middle of the night. The pain is usually relieved by food or taking an antacid.

• Nausea
• Vomiting
• Bloating
• Belching
• Weight loss
• Anemia

These are typically seen when one develops ulcers.

Ulcers can also bleed in the stomach or intestine, and present with either of the following symptoms:

• Bloody stools
• Dizziness
• Trouble breathing
• Pale skin
• Tiredness
• Sharp and excruciating stomach pain

Uncommonly, H. pylori infection can lead to the development of stomach cancer which has the following manifestations:

• Heartburn
• Nausea
• Bellyache or swelling
• Vomiting
• Weight loss

Causes of Helicobacter Pylori Infection

The exact way of transmission is yet unknown, but it is proposed that H. pylori can spread via the fecal-oral route, or it may be passed from one person to another through direct contact with saliva.

So, eating with dirty hands or consuming unclean food and water, or eating in contaminated utensils can cause H. pylori infection.

Risk factors

There are risk factors associated with H. pylori infection which depend on one’s environment and living conditions. These include:

• Age

Children are more likely to develop the infection because they lack proper hygiene practices. H. pylori is also prevalent among the elderly above the age of 50 years.

• Ethnicity

African Americans or Mexican Americans are more prone to the development of H. pylori infection.

• Living Conditio

Living in a crowded place or living with someone who is infected with H. pylori or even drinking unreliable and unclean water exposes one to the risk of getting H. pylori infection.

Those people who live in developing countries, where unsanitary conditions and crowded living space is more common, have a higher risk of developing H. pylori infection.

Complications

The complication associated with H. pylori infection are:

• Gastritis

Inflammation of the stomach lining is called gastritis which is usually caused by H. pylori, or it may occur due to autoimmunity. Gastritis tends to further transform into PUD or cancers like adenocarcinoma or MALToma.

• Ulcers

More than 90% of peptic ulcers are associated with H. pylori. The bacteria destroys the protective lining of the stomach and intestine which allows acid produced by the stomach to create open sores or ulcers.

Peptic ulcers are further complicated by:

Bleeding: it occurs most frequently and may be life-threatening. It is associated with iron deficiency anemia.

Perforation: an ulcer can break through the wall of the stomach or intestine. This could also lead to peritonitis.

Obstruction: mostly occurs in chronic ulcers. It is secondary to the development of edema and scarring. It causes extreme crampy abdominal pain.

• Cancer:

H. pylori is also associated with an increased risk of stomach cancer, most commonly adenocarcinoma, and MALToma. The H. pylori-induced inflammation may trigger certain pathways that contribute to transform into cancers.

When To See A Doctor for Helicobacter Pylori Infection ?

One should consult their doctor if they have symptoms like heartburn, indigestion or if the symptoms get worse or they observe new symptoms. If blood is seen in either vomit or stool, immediate consultation is required, as this could be life-threatening.

Diagnosis of Helicobacter Pylori Infection

The first step in diagnosing H. pylori infection is taking a detailed history from the patient. This helps exclude NSAIDs induce peptic ulcers, evaluate the living condition of the patient and also helps in the assessment of the risk factors and if the patient is more likely to have H. pylori infection or some other infection or disease.

To confirm the diagnosis, tests can be performed. These include non-invasive and invasive procedures.

Noninvasive Tests

Physical exam

During a physical exam, a doctor examines the stomach of the patient to check if they have any signs of bloating or tenderness. A doctor will also listen to sounds within the gut.

Blood Test

• Antibodies Against H. pylori

Blood is drawn from the patient's hand and then sent to a laboratory for further analysis. The blood samples are used to look for antibodies against H. pylori.

It should be kept in mind that this is only helpful in diagnosing an infection if the person has not previously been infected with H. pylori because if that's the case tests will come back positive even if they don't have an active infection.

• Iron Deficiency

The blood test is also used to check if the patient has iron deficiency, which will occur if they have ulcers that have started to bleed.

Stool Test

Patients are asked for stool samples which are needed to detect H. pylori bacteria. This, along with the urea breath test accounts for confirmation that the infection has been eradicated.

This also gives clue that H. pylori have a fecal-oral mode of transmission.

Feces is also tested to check if occult blood is present, yet again to evaluate if there is any bleeding happening in the GI tract.

Urea Breath Test

H. pylori convert urea into carbon dioxide. During the Urea breath test, patients are given a solution that contains urea which they swallow.

Once swallowed, urea is then broken down by enzymes, released by H. pylori, into carbon dioxide. This carbon dioxide is then detected by special devices.

If normal amount of Carbon dioxide is detected this indicates that the infection has been eradicated. Urea breath test has 95% accuracy.

Upper GI Exam

If patients develop ulcers, these can be seen on X-rays or barium swallows. Though not commonly used as Urea breath test and stool test are usually sufficient for diagnosis of H. pylori, X-rays can help diagnose perforation or benign or malignant ulcers.

CT Scan:

It provides detailed images of the inside of the body. Supposedly missed ulcers can be seen on CT scans.

Invasive Test

Endoscope

An endoscope is a tube with a camera on it. An endoscope is inserted to look down the throat, in the stomach, and upper parts of the small intestine.

During this procedure, a sample of tissue can be excised (biopsy) which can then later be analyzed.

The specimen collected is analyzed by:

• Rapid urease test
• Bacterial culture
• Bacterial DNA detection by PCR

During the procedure, the patient is either asleep or awake but on certain medication to make them feel comfortable.

Treatment for Helicobacter Pylori Infection ?

The treatment option includes medication and surgery.

• Medication for

The treatment goal of H. pylori infection is a rapid relief of symptoms, healing of ulcers, reduction recurrence, and reducing mortality and morbidity.

There are different classes of drugs that are used to treat H. pylori infection including the following:

1. Antibiotic

Antibiotic kills bacteria residing in the body. They have a different mode of action. The three main antibiotics that are important in treating H. pylori infection are Clarithromycin, Metronidazole, and Amoxicillin.

Clarithromycin is a semisynthetic macrolide, which is derived from erythromycin, it inhibits protein synthesis by binding to the ribosome of the bacteria.

Metronidazole also inhibits protein synthesis by binding to the DNA which causes loss of DNA structure and strand breakage.

Amoxicillin belongs to beta-lactams. These work by binding to a protein that is responsible for the synthesis of the cell wall.

Other classes of antibiotics can also be used depending on bacterial resistance and if the patient is allergic to a certain drug.

Side effects commonly observed are:

• Nausea
• Vomiting
• Diarrhea
• Metallic taste in the mouth (associated with clarithromycin)
• Loss of appetite

• Proton Pump Inhibitors

These drugs inhibit gastric H,K-ATPase which results in inhibition of gastric acid secretion. PPIs are used in combination with antibiotics as triple therapy to treat H. pylori-induced peptic ulcer disease.

Following agents are used:

• Omeprazole
• Lansoprazole
• Pantoprazole

     The side effects of PPI include:

• Nausea and vomiting
• Diarrhea
• Headache
• Osteoporosis
• Vitamin B12 deficiency

• H2-Receptor Antagonists

The mechanism of action of H2-receptor antagonists is by binding to histamine H2 receptors that are located on gastric parietal cells. This is binding is reversible.

These drugs also reduce gastric acid secretion.

Drugs that act as H2-receptor antagonists are:

• Cimetidine
• Ranitidine
• Nizatidine

     The side effects include the following:

• Dizziness
• Diarrhea
• Headache
• Hepatotoxicity (with Ranitidine)
• Gynecomastia, galactorrhea, and reduced sperm count

• Antacids

Antacids are a combination of various compounds and contain:

• Sodium bicarbonate
• Aluminum hydroxide
• Magnesium hydroxide

These are weak bases that react with gastric acid and neutralize it.

The side effects of antacids are:

• Constipation (with Aluminum hydroxide)
• Diarrhea (with Magnesium hydroxide)
• Calcinuria (with Calcium carbonate)

• Cytoprotective Agents

Sucralfate is a combination of Aluminum hydroxide and sulfated sucrose and is used as a cytoprotective agent.

In acidic media, these agents dissolve and coat the ulcerative tissue. Because of this reason, these should not be given with antacids, PPI, and H2-receptor antagonists.

These drugs have the following side effects:

• Constipation
• Dry mouth
• Black stools

• Anti-Muscarinic Agents

Anti-muscarinic drugs reversibly bind to M1 receptors and reduce acid production and gastrointestinal spasms.

Drugs include:

• Pirenzepine
• Telenzepine

     Side effects are as follows:

• Dry mouth
• Blurred vision

For the complete eradication and prevention of reoccurrence, triple therapy is used. The best among all triple therapy regimens is:

• Omeprazole/Lansoprazole
• Clarithromycin
• Amoxicillin/Metronidazole

Some other triple therapy regimens are:

• Bismuth subsalicylate
• Metronidazole
• Tetracycline

Sometimes, Quadruple therapy may be given if triple therapy fails:

• Omeprazole/Lansoprazole
• Metronidazole
• Tetracycline

• Surgery

Even though medical intervention is usually enough to eradicate H. pylori and H. pylori-induced complications, sometimes a surgical approach may be required in patients to obtain hemostasis.

1. Antrectomy

Antrectomy is the surgical removal of antrum where gastrin-producing cells are present. It is usually performed in combination with a bilateral truncal vagotomy.

This may have the following complications:

• Dysphagia
• Diarrhea
• Malabsorption
• Recurrence of gastric ulcers

• Vagotomy

In this procedure, one or more branches of the Vagus nerve are cut. By doing so, the rate of gastric acid secretion is reduced.

Vagotomy has side effects as well which includes:

• Bleeding
• Gallstones
• Dumping syndrome
• Delayed gastric emptying
• Injury to the adjacent structure during surgery

Preventions of Helicobacter Pylori Infection

H. pylori infection can be prevented if one takes necessary precautionary measures which include:

• Washing hands after using bathrooms and before eating or preparing food
• Avoiding food or water that is not clean
• Avoiding consumption of food that is not properly cooked
• Keeping a safe distance from people who are infected with H. pylori
• Avoiding living in crowded areas

Even though nutrition has no role in preventing or causing peptic ulcer disease in people who are infected with H. pylori, however, spicy food, alcohol, and smoking may worsen an already present ulcer and prevent its healing.