Helicobacter pylori Infection

in Children:
Recommendations for
Diagnosis and Treatment

Jennifer A. Olay, MD
Pediatric Gastroenterology,
Hepatology and Nutrition
Helicobacter pylori
• spiral-shaped,
gram negative bacteria
• highly motile
multiple unipolar flagella

• microaerophilic

• potent producer of urease

• inhabits mucus adjacent

to the gastric mucosa
Helicobacter pylori
• Adaptive features that enhance survival in
acidic environment :
- shape and motility - reduced O2 req’t
- adhesion molecules - urease production

bacterial urease ammonium

UREA and bicarbonate

- neutralizes gastric acid

Helicobacter pylori
Disease inducing factors:
• Urease - potent Ag, induces ↑ IgG & Ig A
production
• Vacuolating cytotoxin - induces inflammatory
cytokines, ↑ propensity to cause disease
• Catalase - prevents formation of reactive
oxygen metabolites from hydrogen peroxide
• Lipopolysaccharide (LPS ) - less potent inducer

of the host complement cascade

Helicobacter pylori
• Cytotoxic- associated Antigen (Cag-A)
- most important virulence factor
- causes rearrangement of the host cytoskeleton
alters cell signaling and cell cycle control
- Induce the expression of a DNA-editing enzyme
→ accumulation of mutations in the tumor
suppressor p53
- may play a role in the pathogenesis of peptic
ulcer disease
Helicobacter pylori
Helicobacter pylori
colonizes the stomach
↓
induces inflammatory cytokines
↓
gastric inflammation

antral-predominant with increased gastric acid

production - PUD

pan-predominant gastritis or corpus-

predominant with decreased gastric acid
production - gastric atrophy (int metaplasia and
gastric adenocarcinoma)
 Joint ESPGHAN/NASPGHAN
Guidelines for management of H.
pylori in children and adolescents

Jones et al. JPGN 2017; 64: 991-1003

Recommendation
Primary goal of clinical investigation of gastrointestinal
symptoms should be to determine the underlying cause of
the symptoms and not solely the presence of H. pylori
infection.
• For abdominal pain of organic cause, diagnostic upper
endoscopy is recommended
Recommendation
During endoscopy additional biopsies for rapid urease test
(RUT) and culture should only be taken if treatment is likely
to be offered if infection is confirmed
Recommendation
Testing for H pylori be performed in children with gastric
or duodenal PUD. If H pylori infection is identified then
treatment should be administered and eradication
confirmed.
• Successful H pylori eradication is associated with cure of PUD
and very low risk of relapse
• Monitoring the success of therapy is mandatory in these
patients 4 to 6 weeks after stopping antibiotics and at least 2
weeks after stopping PPI therapy
Recommendation
Before testing for H pylori, wait at least 2 weeks after
stopping PPIs and 4 weeks after stopping antibiotics
 Diagnosis of H pylori infection should be based on either:
positive culture or H pylori gastritis on histopathology with at
least 1 other positive biopsy-based test
At least 6 gastric biopsies should be obtained for the
diagnosis of H pylori infection during upper endoscopy
First line therapy
 Outcome of anti–H pylori therapy be assessed at least 4
weeks after completion of therapy.
13C-UBT or fecal antigen testing should be employed to
ensure cure of infection has been achieved
 H pylori treatment fails, rescue therapy should be
individualized considering antibiotic susceptibility, the age of
the child, and available antimicrobial options
Eradication failure treatment