What H. pylori Does

H. pylori is a spiral bacterium that lives in the stomach lining. It survives the acidic environment by producing urease, an enzyme that neutralizes acid in a thin layer around it. Once established, it can sit there for decades.

Common symptoms when it causes trouble:

• Upper abdominal pain or burning, often worse on an empty stomach
• Nausea
• Bloating and frequent burping
• Loss of appetite
• Unintended weight loss

Long-standing infection can cause:

• Chronic gastritis. Inflammation of the stomach lining.
• Peptic ulcers. Open sores in the stomach or duodenum. Can bleed.
• Gastric cancer and MALT lymphoma. Uncommon but real long-term risks that drop substantially after eradication.

Worth noting: most people infected with H. pylori never have symptoms. Testing is usually triggered by ongoing dyspepsia, ulcers found on endoscopy, or specific risk factors.

How It's Diagnosed

Four tests are available in Canada, in descending order of how often they're used:

1. Urea breath test (UBT). Non-invasive, very accurate, and used both for diagnosis and to confirm cure after treatment.
2. Stool antigen test. Equally good. Convenient if a breath test isn't available locally.
3. Endoscopy with biopsy. Done if there's bleeding, alarm symptoms, or a need to look directly at the stomach lining. The biopsy can be tested for H. pylori with high accuracy.
4. Blood antibody test. Cheap and widely available, but it can stay positive long after an infection clears, so it can't tell active from old infection. Rarely used today.

Both the breath test and the stool antigen test can be falsely negative if you've recently taken PPIs (2 weeks), antibiotics (4 weeks), or bismuth (4 weeks). Stop those first if your doctor agrees.

The Treatment Regimens

Most H. pylori eradication uses a combination of two antibiotics, a PPI, and often bismuth, for 10 to 14 days. The two main first-line regimens in Canada:

Bismuth quadruple therapy (BQT), 14 days. Now the preferred first-line option in most of Canada, given rising clarithromycin resistance:

• PPI twice daily
• Bismuth subsalicylate four times daily
• Tetracycline 500 mg four times daily
• Metronidazole 500 mg three or four times daily

Concomitant therapy (PAMC), 14 days. Used when bismuth-based therapy isn't tolerated:

• PPI twice daily
• Amoxicillin 1 g twice daily
• Clarithromycin 500 mg twice daily
• Metronidazole 500 mg twice daily

That's a lot of pills (sometimes 18 to 20 a day). Many people set phone alarms for each dose.

The shorter 10-day triple therapy (PPI + amoxicillin + clarithromycin) used to be standard but eradication rates have dropped below 80% because of clarithromycin resistance. It's still used when local resistance is known to be low.

What the Two Weeks Look Like

Most people feel worse on treatment than they did with the infection itself, which is the main reason patients quit early. Common side effects:

• Metallic or bitter taste, especially from metronidazole. Strong-flavoured drinks (mint, ginger) help.
• Black stools and a darkened tongue from bismuth. Harmless. They go away after treatment.
• Nausea in the first 2 to 3 days. Taking pills with a small meal helps.
• Diarrhea, sometimes mild, sometimes more. Probiotics (Bio-K, Florastor) may reduce it; the evidence is mixed but it doesn't hurt to try.
• Headaches and fatigue.
• Strict alcohol avoidance while taking metronidazole. The combination causes intense nausea and flushing.

The most important thing is finishing all 14 days. Stopping early is the single biggest reason eradication fails and resistance builds. If side effects become unbearable, call your doctor rather than just quitting.

Confirming It Worked

A test-of-cure is recommended for everyone, not just those with persistent symptoms. About 20 to 30% of first-line treatments fail, and you can't tell from symptoms alone.

Timing matters:

• Wait at least 4 weeks after finishing antibiotics and bismuth.
• Stop PPI at least 2 weeks before the test.
• Use a breath test or stool antigen test. Don't use blood antibodies (still positive even after cure).

If the test is negative, you're done. Symptoms that were caused by H. pylori usually settle within 1 to 3 months.

If treatment failed, your doctor will switch to a second-line regimen using different antibiotics, often levofloxacin-based or extending bismuth quadruple therapy. About 90% of patients are eradicated by their second course.

Eating and Living Through Treatment

Simple things that help most patients get through the 14 days:

• Eat small, bland meals before each dose. An empty stomach plus four antibiotics often equals nausea.
• Add plain yogurt or a probiotic (Bio-K, Florastor) once a day to reduce diarrhea risk.
• Skip alcohol entirely, especially if metronidazole is in the regimen.
• Cut back on coffee, spicy food, and acidic drinks (orange juice, tomato sauce) until your stomach calms down.
• Don't smoke. It interferes with stomach healing and lowers eradication rates.
• Sleep more than usual. Your body is dealing with a lot.

You don't need to change your diet long-term to "prevent" H. pylori from coming back. Reinfection rates in Canada are very low (well under 2% per year once you've been cured).

The Bottom Line

H. pylori eradication is a 10 to 14 day commitment of taking multiple medications on a strict schedule, often with unpleasant side effects. About 70 to 90% of first-line treatments cure the infection. The 4-week follow-up test is non-negotiable; otherwise you won't know whether you're done. If your first round fails, second-line therapy works for most people who try it.

FAQ

1. What if I don't treat it? Most people with H. pylori never develop a problem. Of those who do, the main risks are chronic gastritis, ulcers, and, much less commonly, gastric cancer or MALT lymphoma. Treatment is recommended if you've had ulcers, ongoing dyspepsia, or other specific risk factors.
2. How do I know it worked? A breath test or stool antigen test at least 4 weeks after finishing antibiotics. You need to be off PPIs for at least 2 weeks before that test.
3. Can it come back? Reinfection is rare in Canada, well under 2% per year once eradicated. If symptoms come back later, it's more often something else (reflux, NSAIDs, functional dyspepsia).
4. Are there natural treatments? Some research suggests probiotics, broccoli sprouts (sulforaphane), and certain plant extracts have activity against H. pylori, but none reliably cure the infection on their own. They can complement antibiotic therapy but not replace it.
5. What if the side effects are too much? Call your prescriber. Sometimes a small dose change, anti-nausea medication, or a switch in antibiotic makes the difference. Don't just stop the course.
6. Does diet matter? During treatment, bland and low-irritant foods help with nausea. After eradication, you don't need a special diet to "prevent" recurrence.
7. Is the treatment safe for everyone? Most adults tolerate it. People with severe penicillin or sulfa allergies, kidney disease, or pregnancy will need an adjusted regimen. Tell your prescriber about all medications, including supplements.

Disclaimer: This blog post is intended for educational purposes only and should not be taken as medical advice. Always consult your healthcare provider for personal health concerns.