H. pylori often causes no symptoms. That does not make it benign.

H. pylori is one of the most underdiagnosed conditions I encounter in clinical practice. In my experience performing gastroscopies, up to 30% of patients who come in for an upper GI assessment turn out to have H. pylori, many of them with no symptoms at all, and no idea they were carrying it.

That last part is the problem. The absence of symptoms does not mean the infection is benign. What I often find on gastroscopy in these patients is pronounced inflammation of the stomach lining and duodenum, sometimes with erosions, which is early damage that precedes ulcers. In more severe cases, they may present with severe pain and even bleeding due to ulcers.

Long-term H. pylori infection is associated with chronic inflammation, which over time can progress to intestinal metaplasia, a pre-cancerous state of the stomach lining.

That is what makes H. pylori worth taking seriously, even when you feel fine.

H. pylori, in full Helicobacter pylori, is a spiral-shaped bacterium that colonises the stomach lining and the duodenum, the first section of the small intestine. To survive in such an acidic environment, it produces enzymes that neutralise the stomach acid immediately around it, allowing it to persist for years, often decades, without treatment and without causing obvious symptoms.

A 2017 Singapore Medical Journal review by Chew and colleagues cited a local seroprevalence of 31%. This was an antibody-based measure of past or current infection, not a current count of people with active infection.

Transmission most often occurs through oral-to-oral contact (shared utensils, close personal contact) or faecal-to-oral routes, in settings with poor sanitation or crowded living conditions. Infections acquired in childhood often persist into adulthood without causing symptoms. Without treatment, H. pylori rarely resolves on its own.

This is the point most health information gets wrong. The majority of people with H. pylori have no symptoms. This is often interpreted as reassurance. It should not be.

On gastroscopy, patients with no symptoms frequently show significant inflammation of the stomach and duodenal lining, and in some cases erosions, which are shallow breaks in the mucosal surface that are precursors to ulcers. This damage is happening silently.

Chronic H. pylori-associated inflammation is a well-established driver of intestinal metaplasia, a condition where the normal stomach lining is gradually replaced by intestinal-type cells. Intestinal metaplasia is a recognised precancerous state and is the change I am most concerned about detecting. It does not cause symptoms. The only way to find it is to look.MAPS III guideline, 2025.

This is why I do not treat H. pylori as a condition that only matters when it hurts.

When H. pylori symptoms do appear, they typically arise because the infection has progressed to gastritis or peptic ulcer disease. The most common include:

• A gnawing or burning sensation in the upper abdomen, particularly on an empty stomach
• Persistent bloating or a feeling of fullness after eating only a small amount
• Nausea or vomiting
• Frequent burping
• Loss of appetite
• Unexplained weight loss
• Dark or tarry stools, which may indicate bleeding and warrant urgent medical attention

A breath or stool test may be an appropriate first step for some patients. Gastroscopy may be recommended based on your age, warning symptoms, persistent symptoms and gastric-cancer risk. It allows the stomach lining to be examined and biopsies to be taken when needed. NUHS dyspepsia guidance.

Other factors a doctor may consider when deciding whether to test include:

• Individuals with a personal or family history of gastric cancer
• Those with close, prolonged contact with a confirmed H. pylori carrier
• Patients on long-term NSAIDs or aspirin, which increase the risk of ulcer complications in the presence of H. pylori
• People whose age, medical history or individual risk makes testing appropriate after assessment

H. pylori testing addresses the upper GI tract specifically. Patients who also present with lower abdominal pain or changes in bowel habits should discuss the full symptom picture with a specialist, as these may point to separate or co-existing conditions.

There are several ways to test for H. pylori. The right method depends on your symptoms, medical history, and whether a broader upper GI assessment is clinically indicated.

Singapore treatment reviews describe a two-week course combining acid suppression and antibiotics. Ang and Ang explained in their 2021 review why the duration of triple therapy had been extended from one week to two. Your doctor will prescribe the regimen appropriate for you. Complete the course as directed.

In a retrospective Singapore study, Pei and colleagues reported successful first-line triple therapy in 891 of 972 patients treated in 2019 and 2020, or 91.7%. This describes that study group, not a promised result for an individual patient.

Once treatment is finished, a follow-up breath or stool test checks whether the infection has cleared. It is generally performed at least four weeks after antibiotics. Follow the clinic’s instructions about medicines and fasting before the test. Chew and colleagues, Singapore Medical Journal, 2017 review; European breath-test guideline.

Where first-line treatment does not succeed, second-line regimens are available. I will advise on the next step based on your clinical picture and, where relevant, local antibiotic resistance patterns.