A Functional Medicine H. Pylori Treatment Protocol

Though the mysteries surrounding H. pylori infection persist, its association with heightened rates of peptic ulcers and stomach cancer underscores the necessity of effectively diagnosing and managing this prevalent bacterial infection that affects approximately half of the world's population. This article will explore the intricacies of diagnosing and managing H. pylori infection, exploring the latest advancements and strategies to address this elusive pathogen.

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What Is H. pylori?

Helicobacter pylori (H. pylori) is a spiral-shaped bacterium that can infect and grow in the mucus layer of the stomach and duodenum (the first segment of the small intestine). Australian scientists Barry Marshall and Robin Warren first discovered it in 1982. Now, H. pylori is recognized as one of the most common bacterial infections globally, affecting 50-75% of the world's population. 

H. pylori Signs & Symptoms

Up to 90% of people with H. pylori are asymptomatic. When symptoms occur, it generally is a sign that the infection has contributed to gastritis (inflammation of the stomach lining) or a peptic ulcer (a sore within the lining of the stomach or small intestine). These symptoms may include: 

• Dull or burning stomach pain
• Nausea and vomiting
• Burping
• Loss of appetite
• Bloating 
• Heartburn or reflux
• Unintentional weight loss
• Dark stools (caused by bleeding ulcers)

Root Causes of H. pylori

H. pylori bacteria are found in saliva, teeth plaque, and feces. Infection is primarily transmitted through oral-oral and fecal-oral routes and is most commonly acquired during childhood. (15, 17) 

Once H. pylori has entered the gastrointestinal (GI) tract, it survives the stomach's acidic environment by binding tightly to the stomach lining, neutralizing stomach acid, and directly contributing to tissue damage and inflammation. These virulence factors interfere with the host's immune responses and help the bacteria survive. (1) 

Risk factors for H. pylori infection include:

• Living in crowded conditions
• Living without a reliable supply of clean water
• Living in a developing country
• Living with someone who has H. pylori
• Having hypochlorhydria (low stomach acid)

How to Diagnose H. pylori

Per the American College of Gastroenterology (ACG) guidelines, screening for H. pylori infection should be performed in patients with an active or past history of peptic ulcer disease (PUD), gastric mucosa-associated lymphoid tissue (MALT) lymphoma, gastric cancer, and indigestion.

Step 1: H. pylori Testing

Once the decision has been made to test for H. pylori infection, several diagnostic tests are available. 

• Endoscopic Biopsy: Endoscopy is recommended for patients who are at least 55 years old or those with alarm symptoms. During endoscopy, a flexible tube with a camera is inserted through the mouth and into the upper portion of the digestive tract to visualize the stomach lining directly. Biopsy samples can be taken and sent to the laboratory for analysis via rapid urease testing, histology, and culture. (11) 
• Urea Breath Test: This is the most accurate non-invasive testing method for diagnosing H. pylori. Patients should discontinue antimicrobial agents, proton pump inhibitors (PPIs), and bismuth compounds at least two weeks before testing to prevent false negative results. 
• Stool Antigen Test: This testing method is slightly less accurate than the urea breath test, but it is cheaper. Patients should discontinue antimicrobial agents, PPIs, and bismuth preparations at least two weeks before testing to prevent false negative results. 
• Antibody Test: This is the least preferred testing method because it is the least accurate and cannot distinguish between an active and past infection. However, it can be recommended as an alternative testing method for patients who may not be able to stop taking PPIs or antibiotic medications.

The following are examples of H. pylori tests available to order through Rupa Health: 

• H. Pylori Antigen by Doctor's Data
• H. Pylori (IgG) by Alletess Medical Laboratory
• Helicobacter Pylori Antibodies (H. Pylori) by Access Med Labs

Step 2: Order Additional Labs to Individualize Treatment

Specialty labs can help providers thoroughly assess GI health, rule out factors contributing to digestive inflammation and symptoms, and customize H. pylori management protocols for maximum efficacy. 

Stool Tests

Comprehensive stool testing can holistically assess gastrointestinal health and function to adjunctively support gut health and a balanced gut microbiome as needed and indicated by results. Several specialty stool tests also include virulence factors and antibiotic-resistant genes as part of their H. pylori panels to assist in the timely and successful management of infection:

• GI-MAP by Diagnostic Solutions
• H. Pylori by Diagnostic Solutions

Blood Tests

If hypochlorhydria is suspected or determined to be a cause or effect of H. pylori infection, additional investigation is warranted to screen for the causes and consequences of low stomach acid. 

Atrophic gastritis, pernicious anemia, and hypothyroidism are conditions that can cause hypochlorhydria in addition to aging. Hypochlorhydria can cause protein, vitamin B12, iron, and calcium deficiencies. (23) 

As such, the following blood tests could be appropriate: 

• Complete blood count (CBC)
• Comprehensive metabolic profile (CMP)
• Thyroid panel
• Intrinsic factor antibodies
• Anti-parietal cell antibodies
• Micronutrient panel

Food Sensitivity Tests

While food sensitivities do not cause H. pylori infection, their presence can exacerbate GI inflammation and H. pylori-related symptoms. Antibody testing identifies foods to which an individual is sensitive so that they can be temporarily removed from the diet to help manage digestive symptoms and support GI health. 

Testing options include:

• 96 IgG Food Sensitivity Panel by Alletess Medical Laboratory
• foodANALYZER IgG Food Sensitivity by Access Med Labs
• 144 Food Panel: IgA/IgG by US BioTek

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Management Plan for H. pylori

Medical guidelines proposed by the ACG suggest that antimicrobial therapy should be initiated for all patients who test positive for active H. pylori infection to manage the bacterial overgrowth (2). 

1. Manage Infection

Here's Why This Is Important: 

Untreated H. pylori infection is associated with adverse health complications (discussed in more detail later in this article). Managing the infection may help improve digestive symptoms in symptomatic individuals and is associated with improved long-term health outcomes. 

How Do You Do This?

Standard-of-care medical guidelines recommend antibiotic therapy for managing H. pylori. Several first-line protocols can be implemented (outlined below). The choice between one over another should consider the patient's history of penicillin allergy and macrolide exposure, the patient's ability to adhere to a multi-drug regimen, and the sensitivity of the regional H. pylori strain to the combination of antibiotics administered. (2)

• Clarithromycin Triple Therapy: PPI, clarithromycin, and amoxicillin or metronidazole for 14 days
• Bismuth Quadruple Therapy: PPI, bismuth, tetracycline, and metronidazole or tinidazole for 10-14 days
• Concomitant Therapy: PPI, clarithromycin, amoxicillin, and metronidazole or tinidazole for 10-14 days
• Sequential Therapy: PPI and amoxicillin for 5-7 days followed by a PPI, clarithromycin, and nitroimidazole for 5-7 days
• Hybrid Therapy: PPI and amoxicillin for seven days followed by a PPI, amoxicillin, clarithromycin, and nitroimidazole for seven days 
• Levofloxacin Triple Therapy: PPI, levofloxacin, and amoxicillin for 10-14 days
• Fluoroquinolone Sequential Therapy: PPI and amoxicillin for 5-7 days followed by a PPI, fluoroquinolone, and nitroimidazole for 5-7 days

Many natural antimicrobial agents are considered safe and may be effective in managing H. pylori. Natural formulas use a combination of the following ingredients and can be used instead of or in combination with antibiotics, but it is important to consult with a healthcare provider before starting any new treatment: 

• Mastic Gum 350 mg three times daily
• Berberine 500 mg twice daily 
• Licorice 380 mg twice daily
• Lactoferrin 200 mg twice daily

2. Support Inflammation Management

Here's Why This Is Important:

Addressing inflammation in the management of H. pylori infection is essential for symptom relief and reducing the risk of long-term complications, including peptic ulcers and gastric cancer.

How Do You Do This?

The following therapies have evidence to support their antioxidant, anti-inflammatory, and healing properties. Doctors may recommend their patients start supplementing during antimicrobial therapy to help manage inflammation-related symptoms and then continue once H. pylori has been managed to ensure inflammation has been resolved post-infection. 

• Curcumin 30 mg twice daily 
• Licorice 250 mg three times daily, taken 30 minutes before meals
• N-Acetylcysteine (NAC) 600 mg three times daily 
• Probiotics: Lactobacillus and Bifidobacterium spp., Saccharomyces boulardii, and soil-based probiotics (12, 30)

Some patients may benefit from a 4-8 week elimination diet to remove triggers that commonly exacerbate upper GI inflammation, peptic ulcers, and gastritis. In addition to individual food sensitivities, consider eliminating these triggering foods:

• Coffee
• Acidic foods
• Spicy foods
• Alcohol
• Ultra-processed packaged foods

Adding foods to the diet can be just as, if not more, important than an elimination. Eating a well-balanced, whole-food diet that includes foods rich in fiber, antioxidants, and flavonoids may support protective effects on the GI mucosal lining and help prevent nutrient deficiencies. (3, 26)  

Broccoli sprouts, rich in sulforaphane, have also been shown to exert positive anti-inflammatory, anti-cancer, and bactericidal effects in patients with H. pylori infection. Research supports eating 70 grams of broccoli sprouts daily for eight weeks during an H. pylori management protocol. (26)

3. Retesting

Here's Why This Is Important:

H. pylori's resistance to standard management regimens is rapidly developing, contributing to management challenges. Therefore, post-management retesting is routine to confirm the status of the infection. A positive follow-up test may indicate the need for continued antimicrobial therapy. (24) 

How Do You Do This?

Patients with a history of ulcer complications, MALT, or early gastric cancer should perform a repeat urea breath test or undergo a follow-up endoscopy. For all other patients, repeat breath or stool testing is appropriate. 

It is important to note that serological antibody tests cannot be used as a test for cure. Additionally, retesting should be performed at least four weeks after the completion of antibiotic therapy and 1-2 weeks after discontinuing a PPI. (2) 

The Risks of Untreated H. pylori

The link between H. pylori and PUD is well-established; H. pylori is associated with up to 95% of duodenal and 80% of gastric ulcers. Managing H. pylori infection in patients with PUD may lead to faster ulcer healing and lower reoccurrence rates. (24)

Patients with H. pylori infection also have a two-to-six-fold increased risk of gastric (stomach) cancer and MALT lymphoma. 

H. pylori Case Study

You can read about how one patient's H. pylori infection was successfully diagnosed and managed here:

How Mary Completely Resolved Her Acid Reflux With An Integrative Medicine Approach: A Case Study

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Key Takeaways:

• Diagnosing and effectively managing Helicobacter pylori may help mitigate its associated risks, including peptic ulcer disease and gastric cancer. 
• To accurately identify H. pylori infection, diagnostic methods such as breath tests, blood tests, stool tests, and endoscopic biopsy must be utilized. 
• Once diagnosed, conventional management strategies involve a combination of antibiotics, PPIs, and bismuth-containing compounds to address the bacteria and alleviate symptoms. However, antibiotic resistance poses a growing challenge, necessitating careful consideration of management regimens and follow-up testing.