Snapshot A 54-year-old man presents to his primary care physician for an annual checkup. He reports having intermittent epigastric discomfort. He reports that the symptoms often improve after eating and that he has some bloating after big meals. He denies any fevers, chills, nausea or vomiting. He also denies having any blood in his stools. His physical exam is unremarkable. A urea breath test is arranged and the results are positive. He is started on triple therapy for eradication of the infection. Introduction Classification Helicobacter pylori gram-negative, spiral-shaped (comma-shaped), catalase-positive, urease-positive, oxidase-positive rod with motile flagella transmission oral to oral fecal to oral causes chronic gastritis, which can lead to peptic ulcer disease, particularly in the duodenum mucosa-associated lymphoid tissue (MALT) lymphoma gastric adenocarcinoma Epidemiology incidence very common demographics infections are often acquired during childhood risk factors smoking nonsteroidal anti-inflammatory drug (NSAID) use Pathogenesis the bacteria produces urease, which produces ammonia and results in an alkaline environment the ammonia allows the bacteria to survive in the acidic gastric environment the bacteria colonize the antrum of the stomach mucosal inflammation leads to atrophy hypochloridia causes ↑ gastrin ↑ gastrin from G cells in the stomach and duodenum ↑ gastric acid secretion and growth of gastric mucosa Prognosis very good prognosis with treatment recurrence may occur Presentation Symptoms dyspepsia belching postprandial bloating heartburn epigastric pain may cause nighttime awakening relief with food or antacids fullness Studies Labs urea breath test administer 13C urea test for ammonia + 13C-CO2 exhaled may have false negatives when patients are exposed to H. pylori treatments such as proton pump inhibitors, histamine-2 (H2) blockers, bismuth, and antibiotics that either reduce bacterial load or are anti-secretory, reducing the amount of urea produced most accurate testing stool antigen test Endoscopy with gastric biopsy histology with silver stain or immunohistochemical staining H. pylori infection inflammation intestinal metaplasia atrophy Making the diagnosis based on clinical presentation and noninvasive tests such as urea breath test or stool antigen test endoscopy can also be used to diagnose Differential Peptic ulcer disease from other causes distinguishing factors associated with NSAIDs use may also have Zollinger-Ellison syndrome Treatment Management approach eradication therapy is beneficial for patients with peptic ulcer disease, chronic gastritis, Medical triple therapy indications no history of previous macrolide exposure no local resistance of H. pylori clarithromycin resistance drugs proton pump inhibitor clarithromycin amoxicillin or metronidazole quadruple therapy indication history of macrolide exposure or penicillin allergy drugs proton pump inhibitor bismuth subcitrate metronidazole tetracycline Complications Malignancies gastric adenocarcinoma MALT lymphoma Iron deficiency anemia Immune thrombocytopenia