Helicobacter pylori, better known as H. pylori, is a type of bacteria that infects the stomach. It is one of the most common infections worldwide, with around 50% of people infected globally. For most people, H. pylori does not cause any symptoms or problems. However, for some, it can lead to peptic ulcers and stomach cancer. This raises the question – can you live with H. pylori forever, or does it need to be treated?
What is H. pylori?
H. pylori are spiral-shaped bacteria that live in the mucosal lining of the stomach. They were first discovered in 1982 by Australian scientists Barry Marshall and Robin Warren, who went on to win the Nobel Prize for their discovery. Here are some key facts about H. pylori:
- It is very common – around 50% of the world’s population are infected.
- Infection often occurs in childhood and can persist lifelong if not treated.
- In developing countries, >80% of the population may be infected.
- It is spread from person to person, likely through the fecal-oral route.
- Good hygiene and sanitation can help prevent infection.
- H. pylori infection almost always causes some inflammation in the stomach.
Despite being so common, H. pylori can be difficult to diagnose. There are several tests available:
- Blood test – Looks for antibodies to H. pylori in the blood. Cannot tell if current infection or past exposure.
- Stool antigen test – Checks for presence of H. pylori proteins in a stool sample.
- Breath test – The patient swallows radioactive carbon molecules which the bacteria metabolize. The byproducts are detected in the breath if H. pylori is present.
- Endoscopy – A small tissue sample (biopsy) can be taken during endoscopy to check for H. pylori.
H. pylori infection – benign or malignant?
For the majority of infected people, H. pylori causes no problems and leads to no symptoms. However, in around 15-20% of cases, it results in disease such as:
- Peptic ulcers – Ulcers in the stomach or duodenum. H. pylori weakens the protective mucous layer and stimulates acid secretion.
- Gastritis – Inflammation and irritation of the stomach lining.
- Duodenitis – Inflammation of the duodenum.
- Stomach cancer – Having H. pylori increases stomach cancer risk up to 6-fold.
- Gastric MALT lymphoma – A rare tumor that is strongly linked to H. pylori infection.
Overall, H. pylori满足s the criteria for a carcinogen – a substance capable of causing cancer. The exact mechanism by which it causes stomach cancer is not fully understood but likely involves chronic inflammation and cell changes over many years.
Should H. pylori infection be treated?
Given the potential complications, should we treat all cases of H. pylori infection, or can it be left alone? Current expert guidelines recommend:
- Treat all symptomatic cases (e.g. peptic ulcer)
- Treat if there is a family history of gastric cancer
- Consider treating cases with precancerous stomach lesions
- May treat asymptomatic cases in certain higher risk groups e.g. first degree relatives of stomach cancer patients, certain ethnic groups
- No need to treat low-risk asymptomatic children or adults
So in summary – mild, asymptomatic cases often do not need treatment. But cases at higher risk of complications should have eradication therapy.
H. pylori treatment
Treatment involves a 1-2 week course of antibiotics as well as acid-suppressing medications. Common combinations include:
| Antibiotics | + | Other medications |
|---|---|---|
| Amoxicillin | + | Clarithromycin |
| Metronidazole | + | Proton pump inhibitor e.g. omeprazole |
| Tetracycline | + | Bismuth compounds |
Successful eradication of H. pylori is confirmed with a urea breath test or stool antigen test at least 4 weeks after finishing treatment. Eradication rates with standard triple therapy (amoxicillin + clarithromycin + PPI) are now unacceptable at less than 80% due to rising antibiotic resistance. So, quadruple therapy and non-antibiotic combinations may be recommended, especially after a failed treatment attempt.
What if H. pylori is not treated?
For the majority of people with mild, asymptomatic H. pylori infections, no treatment is needed and there are likely no long-term consequences. However, around 10-15% may develop peptic ulcer disease during their lifetime. The bacteria can persist for life unless specifically treated with antibiotics.
For those at higher risk of complications (e.g. family history of stomach cancer), lack of treatment does increase the risk of problems in the future. However, H. pylori treatment only reduces, not eliminates, the risk of stomach cancer. Other risk factors like smoking, diet, alcohol also play a role.
Can H. pylori come back after treatment?
In most cases, H. pylori eradication is permanent and the bacteria do not recur. However, in a small number of cases, the infection can come back after apparently successful treatment. This occurs in around 1-10% of people.
Reasons for H. pylori recurrence include:
- Reinfection from a spouse or family member
- Treatment failure – antibiotics did not completely eliminate the bacteria
- Recrudescence – some bacteria went dormant then revived after treatment
To reduce the risk of recurrence, retesting is advised at least 4 weeks after treatment. Retreatment is recommended if H. pylori is still present. For people at higher risk of stomach cancer, regular retesting may be advised.
Can I be completely cured of H. pylori?
The majority of people who receive antibiotic treatment for H. pylori are permanently cured of the infection. First treatment success rates range from 70-90% depending on the regimen used. After a failed first attempt, second line “rescue” therapy can boost the overall eradication rate to 90-95%.
In a small proportion, H. pylori proves difficult to eradicate despite multiple courses of antibiotics. This is more likely if the bacteria are resistant to key antibiotics like clarithromycin. culture and susceptibility testing may help guide optimal antibiotic choice in these difficult cases.
Living with H. pylori long-term
For the majority infected with H. pylori, a long-term “balance” is achieved where the infection persists but causes no harm. Our stomach immune responses adapt to keep the bacteria under control and prevent damage. Maintaining a healthy lifestyle supports this balance:
- Avoid smoking and excess alcohol which both exacerbate H. pylori-induced inflammation.
- Eat more fruits and vegetables which help regulate stomach acidity and boost antioxidant levels.
- Manage stress levels which affect stomach acid secretion and gut immunity.
- Consider probiotic supplements to support healthy gut bacteria.
Monitoring for any concerning symptoms is wise, even if H. pylori treatment is not undertaken immediately. Ulcers, persistent pain, unexplained weight loss, vomiting or family history of stomach cancer all warrant medical review.
Conclusion
For many people infected with H. pylori, the bacteria cause no problems at all and can be left untreated. However, for around 10-20% H. pylori leads to stomach ulcers or cancer, so treatment is recommended. Successful eradication is possible in most cases but recrudescence can occasionally occur. Even without treatment, a healthy lifestyle can help maintain the natural balance between H. pylori and the stomach immune defenses.