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Condition · Food pipe and stomach
H. pylori infection
Helicobacter pylori (H. pylori) is a bacterium that lives in the lining of the stomach. More than half the world’s population carries it, and most carriers never have symptoms. In some people it causes gastritis and ulcers, and over many years it raises the risk of stomach cancer. It is found with a breath, stool or biopsy test, treated with a 14-day course of an acid-blocker and antibiotics, and then tested again to confirm that it has gone.
At a glance
What it is
A bacterial infection of the stomach lining, usually picked up in childhood and carried for life unless it is treated.
Common signs
Often none. Otherwise upper abdominal burning, early fullness, nausea and belching.
How it is confirmed
A urea breath test, a stool antigen test, or a biopsy taken at endoscopy.
How it is treated
An acid-blocker with antibiotics for 14 days, followed by a test of clearance four weeks or more later.
What are the signs of H. pylori infection?
Most people have no symptoms
The infection is usually picked up in childhood and carried silently for decades. Many people learn of it only when a test is done for another reason.
When it does cause symptoms
- Burning or gnawing pain in the upper middle abdomen
- Pain on an empty stomach or at night that eases with food, which suggests an ulcer
- Feeling full after a few mouthfuls
- Nausea, bloating and frequent belching
- Tiredness from a low iron or vitamin B12 level
See a doctor promptly if you have
- Vomiting blood, or black, tarry stools
- Weight loss you cannot explain
- Food sticking when you swallow
- Vomiting that will not stop
- A low blood count (anaemia)
Sudden, severe abdominal pain with a hard abdomen is an emergency. Go to the nearest emergency department.
What it is
What is happening inside?
The stomach is acidic enough to kill most bacteria. H. pylori survives by burrowing into the mucus layer that protects the stomach lining and by making an enzyme, urease, that neutralises the acid immediately around it.
How it survives in acid. H. pylori burrows into the mucus layer that protects the stomach lining and makes an enzyme, urease, that neutralises the acid immediately around it.
Its presence inflames the lining. Doctors call this H. pylori gastritis, and an international consensus classes it as an infectious disease whether or not it causes symptoms. In most people the inflammation stays mild. In some it leads to:
- Ulcers in the stomach or in the duodenum, the first part of the small intestine.
- Thinning of the stomach lining over many years, which lowers vitamin B12 and iron absorption
- A higher risk of stomach cancer. Most people with the infection never develop cancer, but clearing the infection lowers the risk.
See gastritis for how an inflamed stomach is assessed.
Why it happens
How do people catch it, and who should be tested?
H. pylori passes from person to person, mostly within families and mostly in childhood, through saliva and through food or water contaminated with stool. It is commoner where homes are crowded and clean water is harder to come by. Adults rarely catch it afresh.
Testing is worthwhile when the result will lead to treatment.
An ulcer, now or in the past
H. pylori is the commonest cause of ulcers. Clearing it prevents most of them from returning.
Upper abdominal symptoms without warning signs
In a younger adult with indigestion, a breath or stool test followed by treatment is a recognised first step, before an endoscopy.
Low iron or vitamin B12 without another cause
The infection can interfere with the absorption of both.
Long-term painkillers or aspirin
Anti-inflammatory painkillers and H. pylori each cause ulcers, and together the risk is higher.
Family and household
A close relative with stomach cancer is a reason to test. Recent American guidance also suggests testing adults who live with someone who has tested positive.
What it does not explain
H. pylori does not cause acid reflux. Heartburn alone is not a reason to test for it. See GERD.
How I find out
Which test answers which question?
Urea breath test
It tells us: Whether the infection is active now. You swallow a test drink and breathe into a bag or tube about 20 minutes later.
When I use it: As a first test in people without warning signs, and to confirm clearance after treatment.
Stool antigen test
It tells us: Whether proteins from the bacterium are present in the stool, which also means active infection.
When I use it: As an alternative to the breath test, before and after treatment.
Endoscopy with biopsy
It tells us: Whether H. pylori is present, how inflamed the lining is, and whether there is an ulcer or a change that needs follow-up. A sample can also be tested for antibiotic resistance.
When I use it: Warning signs, symptoms that begin later in life, or an infection that has survived two courses of treatment.
Blood antibody test
It tells us: Whether you have ever had the infection. It stays positive for years after successful treatment.
When I use it: Rarely. It cannot show whether the infection is present now, so it is not used to check clearance.
Acid-blockers and antibiotics can make the breath, stool and biopsy tests falsely negative. Guidelines advise stopping proton pump inhibitors for two weeks, and antibiotics for four weeks, before testing. Do not stop a prescribed medicine without asking.
Treatment
How is H. pylori treated?
International guidelines advise treating everyone who tests positive, because the infection does not clear without treatment.
A 14-day combination course
An acid-blocker is taken with two or three antibiotics, often with a bismuth compound, for 14 days. The combination is chosen from the antibiotics you have taken in the past, because resistance to some common antibiotics is widespread.
Take every dose
Courses fail for two main reasons: antibiotic resistance and missed doses. The second is in your hands. A metallic taste, loose stools and nausea are common and usually mild. Bismuth turns the stool black, which is harmless. Tell me about side effects before you stop anything.
Test that it has gone
A breath or stool test is done four weeks or more after the last antibiotic, with acid-blockers stopped for two weeks. Feeling better is not proof of clearance, so this step is not skipped.
If the first course fails
A second course uses different antibiotics. After two failures, a biopsy is tested to find out which antibiotics the bacterium is still sensitive to.
If there was an ulcer
The acid-blocker is continued for some weeks so that the ulcer closes. A stomach ulcer is usually checked again by endoscopy to confirm that it has closed.
A newer group of acid-blockers, called potassium-competitive acid blockers, is being used in some treatment courses.
Root-cause care
The integrative view: what else I look at
Antibiotics are the treatment. No food, herb or supplement has been shown to clear H. pylori without them. Alongside the course, I pay attention to:
- Getting through the course. A probiotic taken during treatment can reduce side effects such as loose stools, which helps people to finish every dose. It does not clear the infection.
- The gut afterwards. Two weeks of antibiotics disturb gut bacteria for a while. Fibre and fermented foods help them to return. See how to restore gut bacteria after antibiotics.
- Nutrient levels. I check vitamin B12 and iron when the infection has been long-standing, and correct them if they are low.
- Other irritants. Painkillers, alcohol and tobacco slow the recovery of the lining.
Recovery
What should I expect?
| When | What happens |
|---|---|
| Days 1 to 14 | The combination course. Pain from gastritis or an ulcer usually eases within the first week. |
| Week 6 or later | The breath or stool test of clearance, at least four weeks after the last antibiotic. |
| After clearance | Most people remain free of the infection. Catching it again as an adult is uncommon. |
| If symptoms continue | The infection may not have been the cause. We look for functional dyspepsia and other reasons. |
Questions patients ask me about H. pylori
Is H. pylori contagious?
Yes, within households, mainly in childhood. It spreads through saliva and through food or water contaminated with stool. Ordinary adult contact carries a low risk.
Should my family be tested if I have H. pylori?
Family members with symptoms, or with a close relative who had stomach cancer, should be tested. Recent American guidance suggests testing adults in the same household as well. I decide this with each family.
Can H. pylori go away with home remedies?
No. Honey, garlic, turmeric and probiotics have not been shown to clear the infection. They may ease symptoms, but only a course of antibiotics with an acid-blocker removes the bacterium.
Does everyone with H. pylori need treatment?
Current guidelines advise treatment for everyone with a positive test, even without symptoms, because the infection inflames the stomach and persists for life.
Can H. pylori come back after treatment?
It can, but in adults this is uncommon once a test has confirmed clearance. An early return usually means that the first course did not fully clear it.
Does H. pylori cause stomach cancer?
It raises the risk, and it is the main known cause of stomach cancer worldwide. Most people with the infection never develop cancer, and clearing the infection lowers the risk.
Can I do the test while I am taking acidity tablets?
The result may be falsely negative. Proton pump inhibitors are stopped for two weeks before the breath or stool test. Ask before stopping, because some people need an alternative in the meantime.
Sources
This page is written for patients and is based on the guidelines and studies below. It is for education and does not replace a consultation.
- Maastricht VI/Florence consensus on Helicobacter pylori infection. Malfertheiner P et al. Gut. 2022. PubMed 35944925
- American College of Gastroenterology guideline on the treatment of Helicobacter pylori infection. Chey WD et al. Am J Gastroenterol. 2024. PubMed 39626064
- Kyoto global consensus on Helicobacter pylori gastritis. Sugano K et al. Gut. 2015. PubMed 26187502
- Systematic review and meta-analysis of the global prevalence of Helicobacter pylori infection. Hooi JKY et al. Gastroenterology. 2017. doi:10.1053/j.gastro.2017.04.022
- American and Canadian guideline on the management of dyspepsia. Moayyedi P et al. Am J Gastroenterol. 2017. PubMed 28631728
- American Gastroenterological Association update on potassium-competitive acid blockers. Patel A et al. Gastroenterology. 2024. doi:10.1053/j.gastro.2024.06.038