H PYLORI is not a new bacteria. It has been studied extensively over the period 1970 to date where it is estimated that over half the world’s population is affected, according to a 2017 summary published by the NEJM Journal Watch. The prevalence of the H pylori bacterium is linked to socioeconomic and hygienic conditions, where clean water and sanitation are challenges in poorer countries. Statistically, according to 2019 UAE study, the prevalence is very high in developing countries 85 to 95 per cent compared with 30 to 50 per cent in developed countries. However in the less privileged indigenous parts of the developed countries, like in Alaska USA and Western Australia, prevalence rates spiked from 35.6 and 24.6 per cent in the urban areas of those respective countries to 74.8 and 76 per cent.

Apart from unhygienic living conditions and unclean water supply, one may also be exposed to H pylori from living in crowded areas and sharing of utensils or from direct oral contact like kissing someone who already has been infected with H pylori. It is present in saliva, vomit and feces. Eating uncooked or improperly prepared snacks or meals is a common way to acquire it. So home-cooked meals may provide a better sanitary option than buying food from entities where meal preparation may be questionable.

The incidence increases with age where 1 in 5 persons below 40 years or 1 in 2 above 60 years of age may have this stomach bug. Complications of untreated H pylori are ulcers (mostly gastric and a few duodenal) which occurs in about 10 per cent of patients, gastritis (inflammation of the stomach walls –refer to picture 1) and gastric cancer.

Signs and symptoms of H pylori are pain and or burning in the abdomen especially when empty, nausea, loss of appetite, frequent burping, bloating, morning hunger, halitosis or bad breadth and unintentional weight loss.

Sometimes persons infected with H pylori are asymptomatic so they may not be aware that they are infected. In severe cases there is more pronounced abdominal pain, difficulty in swallowing, black or tarry stool or coffee-coloured vomit.

Diagnosis of H pylori is done after the physician or the gastroenterologist screens the patient and confirms the presence of the bacteria via a laboratory test or scoping. Non-invasive diagnostic methods are urea breath test (UBT is easiest method), fecal antigen test (stool test) or serology (blood test). Other more definitive but invasive methods of enquiry are endoscopy (see Picture1 below) and or biopsy to detect the presence of this spiral-shaped bacteria in the stomach tissue (see Picture 2 below). Note that serology tests are unaffected by use of antibiotics and PPIs (treatment of the disease) hence it is not an appropriate method to determine eradication of the bacteria after treatment. A positive serology test may just indicate the presence of the H pylori bacteria but not necessarily an indication of the disease. A UBT is recommended after 4 to 12 weeks of completion of treatment to determine eradication.

Clinical presentation of peptic ulcer disease is a precursor for testing also.

The treatment protocol incorporates antibiotics and a PPI (proton pump inhibitor) to kill the bacteria and to shut down the acid production respectively. However, resistance to frequently used antibiotics cause treatment failure; hence the institution of the triple therapy where two different spectrum of antibiotics along with a PPI would do the job. Sometimes, a quadrupled therapy with the inclusion of bismuth (which has ulcer healing properties) can yield positive results when triple therapy is not fully responsive. The rational selection of antibiotics by the prescriber depends on the patient’s previous usage patterns, so disabling resistance.

In refractory H pylori (recurrence after treatment) amoxicillin, tetracycline and rifabutin are recommended by the American Gastroenterological Association (AGA) according to the 2021 guidelines. Some of the reasons for treatment failure are resistance either from patient’s history with macrolides, non-adherence to treatment (the medications were not used as prescribed) and insufficient gastric suppression.

Earlier first-line treatments may include antibiotics such as clarithromycin, metronidazole or tinidazole. In very resistant cases levofloxacin and nitroimidazole may be considered. H Pylori kits with the combination with the PPI lansoprazole for 10 to 14 days are another option.

Proper nutrition and consumption of fruits, vegetables and vitamin C help with this condition. Recommended foods for H pylori patients are yogurt with probiotics, salmon, mackerel and sardines, eggs, tofu, olive oil and carrot seed oil with omega 3 and 6, non-acidic fruits and steamed vegetables (like broccoli, cauliflower and cabbage). Moderate use of blackberry, blueberry and raspberry are encouraged to aid with bactericidal effects of meds. Only roasted or grilled white meat or fish may be tolerated in some cases. Avoid processed or fatty foods such as bacon and sausages, fries, fried chicken, spicy foods like curry and dhal, coffee, frizzy drinks and black tea.

In conclusion, awareness and education on preventative measures can assist with the eradication of this prevalent bacteria, since, as a developing country, challenges continue in accessing clean water, proper sanitation and hygiene practices.