Helicobacter pylori Fact Sheet for Health Care Providers Updated: July 1998 What is H. pylori?

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Helicobacter pylori

Fact Sheet for Health Care Providers

Updated: July 1998

What is H. pylori?

Helicobacter pylori (H. pylori) is a spiral-shaped

bacterium that is found in the gastric mucous layer

or adherent to the epithelial lining of the stomach.

H. pylori causes more than 90% of duodenal ulcers

and up to 80% of gastric ulcers. 

Before 1982, when this bacterium was discovered,

spicy food, acid, stress, and lifestyle were

considered the major causes of ulcers. The

majority of patients were given long-term

medications, such as H

2

 blockers, and more

recently, proton pump inhibitors, without a chance

for permanent cure. These medications relieve

ulcer-related symptoms, heal gastric mucosal

inflammation, and may heal the ulcer, but they do

NOT treat the infection.  When acid suppression is

removed, the majority of ulcers, particularly those

caused by H. pylori, recur. Since we now know

that most ulcers are caused by H. pylori,

appropriate antibiotic regimens can successfully

eradicate the infection in most patients, with

complete resolution of mucosal inflammation and a

minimal chance for recurrence of ulcers.

How common is H. pylori infection?

   

Approximately two-thirds of the world’s

population is infected with H. pylori. In the United

States, H. pylori is more prevalent among older

adults, African Americans, Hispanics, and lower

socioeconomic groups.

What illnesses does H. pylori cause?

Most persons who are infected with H. pylori

never suffer any symptoms related to the infection;

however, H. pylori causes chronic active, chronic

persistent, and atrophic gastritis in adults and

children. Infection with H. pylori also causes

duodenal and gastric ulcers. 

Infected persons have a 2- to 6-fold increased risk

of developing gastric cancer and mucosal-

associated-lymphoid-type (MALT) lymphoma

compared with their uninfected counterparts. The

role of H. pylori in non-ulcer dyspepsia remains

unclear. 

What are the symptoms of ulcers?

Approximately 25 million Americans suffer from

peptic ulcer disease at some point in their lifetime.

Each year there are 500,000 to 850,000 new cases

of peptic ulcer disease and more than one million

ulcer-related hospitalizations. 

The most common ulcer symptom is gnawing or

burning pain in the epigastrium. This pain typically

occurs when the stomach is empty, between meals

and in the early morning hours, but it can also

occur at other times. It may last from minutes to

hours and may be relieved by eating or by taking

antacids. 

Less common ulcer symptoms include nausea,

vomiting, and loss of appetite. Bleeding can also 

occur; prolonged bleeding may cause anemia

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leading to weakness and fatigue. If bleeding is

heavy, hematemesis, hematochezia, or melena may

occur. 

Who should be tested and treated for 

H. pylori ?

Persons with active gastric or duodenal ulcers or

documented history of ulcers should be tested for

H. pylori, and if found to be infected, they should

be treated.  To date, there has been no conclusive

evidence that treatment of H. pylori infection in

patients with non-ulcer dyspepsia is warranted. 

Testing for and treatment of H. pylori infection are

recommended following resection of early gastric

cancer and for low-grade gastric MALT lymphoma.

Retesting after treatment may be prudent for

patients with bleeding or otherwise complicated

peptic ulcer disease. 

Treatment recommendations for children have not

been formulated. Pediatric patients who require

extensive diagnostic work-ups for abdominal

symptoms should be evaluated by a specialist. 

How is H. pylori infection diagnosed?

Several methods may be used to diagnose H. pylori

infection. Serological tests that measure specific 

H. pylori IgG antibodies can determine if a person

has been infected. The sensitivity and specificity of

these assays range from 80% to 95% depending

upon the assay used. 

Another diagnostic method is the breath test. In this

test, the patient is given either 

13

C- or 

1 4

C-labeled

urea to drink. H. pylori metabolizes the urea

rapidly, and the labeled carbon is absorbed. This

labeled carbon can then be measured as CO

2 

in the

patient’s expired breath to determine whether 

H. pylori is present. The sensitivity and specificity

of the breath test ranges from 94% to 98%.

Upper esophagogastroduodenal endoscopy is

considered the reference method of diagnosis.

During endoscopy, biopsy specimens of the

stomach and duodenum are obtained and the

diagnosis of H. pylori can be made by several

methods:

•

The biopsy urease test - a colorimetric test

based on the ability of H. pylori to produce

urease; it provides rapid testing at the time of

biopsy. 

•

Histologic identification of organisms -

considered the gold standard of diagnostic

tests. 

•

Culture of biopsy specimens for H. pylori,

which requires an experienced laboratory and is

necessary when antimicrobial susceptibility

testing is desired.

What are the treatment regimens

used for H. pylori eradication?

Therapy for H. pylori infection consists of 10 days

to 2 weeks of one or two effective antibiotics, such

as amoxicillin, tetracycline (not to be used for

children <12 yrs.), metronidazole, or

clarithromycin, plus either ranitidine bismuth

citrate, bismuth subsalicylate, or a proton pump

inhibitor.  Acid suppression by the H

2

 blocker or

proton pump inhibitor in conjunction with the

antibiotics helps alleviate ulcer-related symptoms

(i.e., abdominal pain, nausea), helps heal gastric

mucosal inflammation, and may enhance efficacy of

the antibiotics against H. pylori at the gastric

mucosal surface.

Currently, eight H. pylori treatment regimens are

approved by the Food and Drug Administration

(FDA) (Table 1); however, several other

combinations have been used successfully.

Antibiotic resistance and patient noncompliance

are the two major reasons for treatment failure.

Eradication rates of the eight FDA-approved

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regimens range from 61% to 94% depending on the

regimen used. Overall, triple therapy regimens have

shown better eradication rates than dual therapy.

Longer length of treatment (14 days versus 10

days) results in better eradication rates.

Are there any long-term consequences

of H. pylori infection?

Recent studies have shown an association between

long-term infection with H. pylori and the

development of gastric cancer. Gastric cancer is the

second most common cancer worldwide; it is most

common in countries such as Colombia and China,

where H. pylori infects over half the population in

early childhood. In the United States, where 

H. pylori is less common in young people, gastric

cancer rates have decreased since the 1930s.

How do people get infected with 

H. pylori?

It is not known how H. pylori is transmitted or why

some patients become symptomatic while others do

not. The bacteria are most likely spread from

person to person through fecal-oral or oral-oral

routes. Possible environmental reservoirs include

contaminated water sources. Iatrogenic spread

through contaminated endoscopes has been

documented but can be prevented by proper

cleaning of equipment. 

What can people do to prevent 

H. pylori infection?

Since the source of H. pylori is not yet known,

recommendations for avoiding infection have not

been made. In general, it is always wise for persons

to wash hands thoroughly, to eat food that has been

properly prepared, and to drink water from a safe,

clean source.

Table 1. FDA-approved treatment options 

(as of July 98

)

Omeprazole 40 mg QD + clarithromycin 500 mg

TID x 2 wks, then omeprazole 20 mg QD x 2 wks

                                               -OR-

Ranitidine bismuth citrate (RBC) 400 mg BID +

clarithromycin 500 mg TID x 2 wks, then RBC 400

mg BID x 2 wks

-OR-

Bismuth subsalicylate (Pepto Bismol

®

) 525 mg

QID + metronidazole 250 mg QID + tetracycline

500 mg QID* x 2 wks + H

2

 receptor antagonist

therapy as directed x 4 wks

-OR-

Lansoprazole 30 mg BID + amoxicillin 1 g BID +

clarithromycin 500 mg TID x 10 days

-OR-

Lansoprazole 30 mg TID + amoxicillin 1 g TID x 2

wks**    

-OR-

Rantidine bismuth citrate 400 mg BID  +

clarithromycin 500 mg BID x 2 wks, then RBC 400

mg BID x 2 wks

-OR-

Omeprazole 20 mg BID  + clarithromycin 500 mg

BID  + amoxicillin 1 g BID x 10 days

-OR-

Lansoprazole 30 mg BID + clarithromycin 500 mg

BID  +  amoxicillin 1 g BID x 10 days

*Although not FDA approved, amoxicillin has been substituted for

tetracycline for patients for whom tetracycline is not recommended.

**This dual therapy regimen has restrictive labeling. It is indicated

for patients who are either allergic or intolerant to clarithromycin or

for infections with known or suspected resistance to clarithromycin.

What is the Centers for Disease

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Control and Prevention (CDC) doing

to prevent H. pylori infection?

CDC, with partners in other government agencies,

academic institutions, and industry, is conducting a

national education campaign to inform health care

providers and consumers of the link between 

H. pylori and stomach and duodenal ulcers. CDC is

also working with partners to study routes of

transmission and possible prevention measures, and

to establish an antimicrobial resistance surveillance

system to monitor the changes in resistance among

H. pylori strains in the United States. 

How can I get more

information about H. pylori?  

1. NIH Consensus Development Conference.

Helicobacter pylori in peptic ulcer disease. JAMA

272:65-69, 1994. 

2. Soll, AH. Medical treatment of peptic ulcer

disease. Practice guidelines. [Review]. JAMA

275:622-629, 1996. [published erratum appears in

JAMA 1996 May 1;275:1314].

3. Hunt, RH. Helicobacter pylori: from theory to

practice. Proceedings of a symposium. Am J Med

1996; 100 (5A) supplement.

4. The American Gastroenterological Association,

American Digestive Health Foundation, 7910

Woodmont Avenue, 7th floor, Bethesda, MD

20814, [phone] telephone, [phone]

fax.

5. The National Digestive Diseases Information

Clearinghouse, National Institute of Diabetes and

Digestive and Kidney Diseases, National Institutes

of Health, 2 Information Way, Bethesda, MD

20892-3570, [phone] telephone. 

6. Hunt RH,  Thompson ABR. Canadian

Helicobacter pylori Consensus Conference. Can J.

Gastroenterol 1998, 12(1):31-41.

7. European Helicobacter pylori Study Group.

Current European concepts in the management of

H. pylori information. The Maastricht Consensus.

Gut 1997; 41, 8-13.

For further information, contact:

Health Communications Activity

Division of Bacterial and Mycotic Diseases

National Center for Infectious Diseases

Centers for Disease Control and Prevention

1600 Clifton Road, MS C09

Atlanta, GA 30333

CDC also has established an H. pylori web site and

information line for health care providers and

patients.  The Internet address is

www.cdc.gov/ncidod/dbmd/hpylori.htm

The toll free number is 

1-888-MY ULCER

(1-888-698-5237)