The American College of Gastroenterology has published its Guideline on the Management of Helicobacter pylori Infection, the organization's first set of official recommendations since 1998. In the past decade, “a significant amount of new information…has become available,” the authors say.

Helicobacter pylori infection is widespread (U.S. prevalence is estimated at 30%-40%), and although it has no clinical manifestations in most infected individuals, the organism can be associated with significant GI pathology, notably peptic ulcer disease (PUD), chronic gastritis, and gastric malignancy.

Whom to test

The indications for testing and treatment “haven't changed much,” says author William D. Chey, MD, professor of medicine at University of Michigan, Ann Arbor. PUD is still an “absolute indication.” With regard to gastric mucosa-associated lymphoid tissue (MALT) lymphoma, evidence to support treatment of H. pylori “is much stronger than it was in 1998,” he observes; new data suggest that eradication can provide lasting remission in a substantial number of patients with high-grade as well as low-grade tumors.

A change of particular interest to primary-care physicians is the firm recommendation to test for and treat H. pylori infection in patients with uninvestigated dyspepsia who are younger than 55 years and don't have “alarm features,” such as bleeding, anemia, or unexplained weight loss.

Although the test-and-treat approach is “evidence-based,” clinicians should be mindful of its limitations. “The strategy works better than placebo, but while 30%-40% of people will get better, the majority will not,” Dr. Chey says. “Doctors' and patients' expectations need to be aligned with reality. The point is that it works better than nothing at all.”

The cost-benefit argument—this strategy reduces the number of endoscopies and office visits—depends on demographics: The advantage is clear when H. pylori prevalence is >20%, as in populations that include substantial numbers of African Americans, Asians, and Eastern European immigrants. As many as 80%-90% of such individuals are likely to be infected, compared with 10%-15% of American-born Caucasians. 

The Guideline lists other contingencies in which the benefits of eradicating H. pylori remain controversial. New data suggest an association between unexplained iron deficiency and infection, although no causal relationship has been established. The connection is biologically plausible: PUD may be accompanied by microscopic blood loss; chronic H. pylori infection may lead to acid hyposecretion, which compromises iron absorption; the organism competes with the host for iron.

“The epidemiological association is based on circumstantial evidence, and we can't make a formal recommendation,” Dr. Chey says. “But if a patient has unexplained iron deficiency, in addition to testing for celiac disease, I'll test for H. pylori.”

The utility of eradicating H. pylori to reduce gastric adenocarcinoma risk is similarly unclear. The organism is classified as a carcinogen by the World Health Organization, and there are data that its eradication is “protective” against progression of premalignant gastric lesions. Some studies from regions where gastric cancer is prevalent (but not where it is rare, such as the United States) suggest that H. pylori eradication may also lower risk in the absence of such lesions. 

H. pylori testing for an individual whose ethnic background or family history suggests a high risk of gastric cancer might be considered “on a case-by-case basis,” Dr. Chey says.

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