10 responses to “Management of Helicobacter pylori in 2023: who should be tested, treated, and how”

  1. In Ontario h.pylori breath test and fecal testing is private pay rendering it inaccessible to the majority of newcomers especially the refugee population.
    We are left with serology which as pointed out will always remain positive.
    The proposed strategy of retesting for cure after treatment renders this even more challenging to use this approach.
    Otherwise a good overview and review.

  2. Thank you for this excellent TCMP! You specify that the PPI should not be stopped in patients with H Pylori confirmed PUD (and especially bleeding ulcers) until the infection is confirmed eradicated – but I presume one must stop the PPI for 14 days in order to completed a UBT or HpSAT to confirm successful treatment? i.e. continue a PPI for 8-12 weeks after the 14 day eradication period, and then stop it for 2 weeks prior to testing the patient again?

  3. I agree with the change to quad therapy as first line treatment.
    In Sask as well I believe it is not easy access to get the urea breath test, however, stool antigen is much more accessible.

    I am curious about the need to hold a PPI prior to the stool antigen or endoscopy as to what the percentage of equivocal results would be?

    For Joanne in Ontario, I do hope the province moves to cover at least stool antigen as a much less invasive way than endoscopy for getting results that are not private pay.

    If someone has ulcers confirmed by endoscopy my referral centre will treat empirically and after treatment will continue minimum 3 months of PPI

    I think as well telling patients the pill burden before they pick up the prescription is important to increase compliance as it is a lot of medications for two weeks to take, and I have had some people say they didn’t finish the course as it was to many pills!

    Very relevant TCMP, thank you!

  4. While I was practicing as a GP Anesthetist, and taking an NSAID for shoulder pain, I had a GI bleed. I was H Pylori positive on gastroscopy. I had the multi pill regime.

    Since then, if I have spicy pizza and/or a beer, I get some indigestion, and will take a PPI for a few days. Likely about 7 tablets per month, on average.
    Is being an anesthetist still considered a risk factor for IPylori infections?
    Begs the question of whether I should be worked up again.? Gastroduodenosopy. Or, whatever.

    KP born 1945.
    BSc (Hons. Chem) MD CCFP FCFP LM
    Clinical Associate Professor, Retired
    Department of Family Practice,
    Faculty of Medicine, University of BC

  5. Thank you- good update for current treatment approach – also should mention diet and eliminating caffeine – esp the AM caffeine – on empty stomachs

  6. Great presentation on current approach to treatment of H.pylori ; still dispense a lot of HP-PAC combos and occasionally get the Bi-QUAD therapy dispensed.

  7. Thanks for a great review of H Pylori testing and treatment. Will use the blister packs! I anticipate it will still be a challenge for me to differentiate patients with dyspepsia vs GERD. Any further tips on this?

  8. Thanks for coming up with this amazing piece on the subject. Can you please advise on which foods to take and avoid while treating H. Pylori?

  9. @ Mairead Keady: Yes that is correct. I would continue to treat with PPI for at least 3 months if indeed an ulcer was seen. After that one can usually hold the PPI for 2. Weeks. This assumes the patient does not have any ongoing dyspepsia symptoms. Sometimes if the patient has heartburn symptoms that are troublesome one can give antacids temporarily

    @ Evan M: The issue is false negative or equivocal results. If an endoscopy is done there is no need to hold the PPI as histology generally will detect Hp if the infection is persistent. Importantly biopsies need to be taken from both the antrum AND the body part of the stomach to avoid false negative results.
    For UBT and stool antigen test the recommendation is to hold PPIs for 14 days prior to the test. The stool test has more equivocal results than the UBT. Not much data have been published on the rates of equivocal or false negative results.

    @ R Keith Phillips: Endoscopists and possibly anesthesiologists were reported to have a higher risk of Hp infection but there are no recent data on this. It is recommended to repeat testing to determine whether Hp was cured after Hp treatment is given. This is especially true if one had a bleeding ulcer. In this case was there indeed a bleeding ulcer seen as the cause of the GI bleed? In this case the NSAID may have triggered the GI bleed but test for cure of Hp is still recommended. I do not think it likely that the spicy food is the cause of the upper GI symptoms. More likely this is due to underlying GERD (heartburn dominant symptom) or dyspepsia (epigastric discomfort dominant symptom). In this case given there is frequent recurrence of symptoms I would consider taking a PPI every day. And this even more so since there is a history of a previous upper GI bleed.

    @Dr. Cynthia L. Clark: Any further tips on to differentiate patients with dyspepsia vs GERD? Not really. Importantly PPIs are effective in both conditions. There is a lot of overlap between GERD and Dyspepsia. In GERD heartburn is often the dominant symptom. In dyspepsia epigastric pain or discomfort is the dominant symptom. If gastroscopy is done in patients with dyspepsia reflux esophagitis is more commonly seen than gastric or duodenal ulcers. So GERD is more common.

    @Ron Abraham A healthy diet is very important. And so is quitting smoking as this is a risk factor for GERD, peptic ulcers and upper GI bleeding. I never take people off a good cup of coffee! (I myself love a cappuccino in the morning and would not comply with stopping having them) But excessive intake of coffee can cause indigestion.

  10. Does the quad-pack come prepacked like H-pak or would it be better to get the pharmacist to bubble pack for better adherence?

    Mary Obstfeld, NP
    Cold Lake First Nations, Alberta

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