When I did my general surgery residency in the 1990s, it wasn’t uncommon to see patients with bleeding or perforated ulcers of the stomach or the duodenum (first part of the small intestine.) It was around that time that the bacteria called Helicobacter pylori was identified as the major cause of ulcers. Once identified in patients and treated, ulcer disease in the US requiring surgery has nearly become a thing of the past.
Helicobacter pylori (H. pylori) is a type of bacteria that lives in the stomach. H. pylori is very common; some data suggest that it is present in approximately 50 percent of the world population. The vast majority of people infected with H. pylori has no symptoms and will never develop problems. However, H. pylori is capable of causing a number of digestive problems, including ulcers and, much less commonly, stomach cancer. It is not clear why some people with H. pylori get these conditions and others do not.
H. pylori is probably spread by consuming food or water contaminated with the organism that is excreted in fecal matter of infected individuals. H. pylori causes changes to the stomach and duodenum. The bacteria infect the protective tissue that lines the stomach. This leads to the release of certain enzymes and toxins and activation of the immune system. Together, these factors may directly or indirectly injure the cells of the stomach or duodenum. This causes chronic inflammation in the walls of the stomach (gastritis) or duodenum (duodenitis). As a result of these changes, the stomach and duodenum are more vulnerable to damage from digestive juices such as stomach acid. In the United States and other developed countries, infection with H. pylori is unusual during childhood but becomes more common during adulthood. However, in resource-limited countries, most children are infected with H. pylori before age 10.
Most individuals with chronic gastritis or duodenitis caused by H. pylori have no symptoms. However, approximately 5 to 10 percent of people develop more serious problems, including stomach or duodenal ulcers and, rarely, tumors of the stomach.
Ulcers can cause a variety of symptoms or no symptoms at all, with the most common ulcer symptoms including:
Pain or discomfort (usually in the upper abdomen)
Bloating
Feeling full after eating a small amount of food
Lack of appetite
Nausea or vomiting
Dark or tar-colored stools
Ulcers that bleed can cause a low blood count and fatigue
Less commonly, chronic gastritis causes abnormal changes in the stomach lining, which can lead to certain forms of cancer. It is uncommon to develop cancer as a result of H. pylori infection. Nevertheless, because so many people in the world are infected with H. pylori, it is considered to be an important cause of stomach cancer. People who live in countries in which H. pylori infection occurs at an early age are at greatest risk of stomach cancer.
There are several ways to diagnose H. pylori. The most commonly used tests include the following:
Breath tests — Breath tests (known as urea breath tests) require that you drink a specialized solution containing a substance that is broken down by the H. pylori bacterium. The breakdown products can be detected in your breath.
Stool tests — Tests are available that detect H. pylori proteins in stool.
Blood tests — Blood tests can detect specific antibodies (proteins) that the body's immune system develops in response to the H. pylori bacterium. However, concerns over its accuracy have limited its use.
WHO SHOULD BE TESTED FOR H. PYLORI?
If you have symptoms, diagnostic testing for H. pylori infection is recommended if you have chronic stomach pain, nausea, active gastric/duodenal ulcers, or if you have a past history of ulcers. Although H. pylori infection is the most common cause of ulcers, not all patients with ulcers have H. pylori. Certain medications such as aspirin, ibuprofen [Motrin, Advil], naproxen [Aleve]) can also cause peptic ulcers. If you do not have symptoms, H. pylori testing is usually not recommended if you have no symptoms and no past history of peptic ulcer disease. However, it may be considered for selected people, such as those with a family history or concern about stomach cancer, particularly individuals of Chinese, Korean, Japanese, or Central American descent; these groups have a higher incidence of stomach cancer.
People with a history of peptic ulcer disease, active gastric ulcer, or active duodenal ulcer associated with H. pylori infection should be treated. Successful treatment of H. pylori can help the ulcer to heal, prevent ulcers from coming back, and reduce the risk of ulcer complications (like bleeding). Guidelines in the United States and other countries recommend that patients who require long-term anti-inflammatory medications such as aspirin, ibuprofen, naproxen, and similar drugs treatment for arthritis and other medical conditions should be tested for H. pylori and if infected undergo treatment to eradicate the H. pylori infection.
No single drug cures H. pylori infection. Most treatment regimens involve taking several medications for 14 days.
Most of the treatment regimens include a medication called a proton pump inhibitor. This medication decreases the stomach's production of acid, which allows the tissues damaged by the infection to heal. Examples of proton pump inhibitors include lansoprazole (Prevacid), omeprazole (Prilosec), pantoprazole (Protonix), rabeprazole (AcipHex), dexlansoprazole (Dexilant), and esomeprazole (Nexium). Two antibiotics are also generally recommended; this reduces the risk of treatment failure and antibiotic resistance. There are increasing numbers of patients with H. pylori infection that is resistant to antibiotics, so it is important to take all the medications prescribed for the entire course, typically 10 to 14 days, and then have a test that confirms that the infection has been cleared.
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