Innocent bystander or to be eradicated at all costs?

Introduction

When it comes to gut health, I always maintain an interest in what’s happening not just in academic and practitioner circles, but also in the wider public domain. One topic that comes up time and time again, especially in Facebook groups of lay people with health challenges - is that of Helicobacter pylori. I don’t think there’s any bigger source of confusion than this bacteria! Unfortunately, the confusion is also fuelled by well-meaning practitioners, GPs and stool testing providers. I also have many clients whose health has worsened significantly after triple-therapy treatment - or similar - for H.pylori and so I know this topic is hugely important. How H. pylori is viewed is undergoing a belated - yet, much needed - radical shift. However, we know it can take up to twenty years for new information to filter down to the coalface of medical treatment, so I want to do my part to help in this re-education.

Buckle up, because this is a series that you are definitely going to want to sink your teeth into. I split it into multiple articles because it ended up getting so long! I will be educating you about H. pylori itself - which is truly fascinating; explain our current understanding of its role in human health and why in most cases, it is not the culprit in your health concerns and is even health protective. We will then look at re-asssessing how we approach H. pylori if it's positive on a test - do we try to kill it off at all costs, or do we manage its presence?

Medical Disclaimer: The information included in this article is for entertainment purposes only. It is not intended or implied to be a substitute for professional medical advice. Reading the information in this article - and the website - in general does not constitute a physician-patient relationship. Discuss any health concerns with your medical provider before starting or changing treatment for any health condition.

H. pylori: What's the story? Innocent bystander or to be eradicated at all costs? — An important question we all need to be asking about H. pylori

H. pylori confusion

Every day, people come to the various Facebook gut health groups posting their GI Map stool test results. Many of them are understandably either panicking when they see H. pylori on their results or thinking they’ve found THE ANSWER to their gut problems. These responses are entirely understandable given what many people are dealing with, health-wise. In some cases, they are working on their own without a knowledgeable practitioner or they have been given misleading information - sometimes from a practitioner. Thankfully, most of what is recommended on the group is nutritional or naturopathic and - usually - less harmful than triple therapy can be. One recent example which I found very concerning was that of a 7 year old child on triple therapy treatment! I politely mentioned to the mother who had posted about her child that this was not a good idea, but they chose to ignore the information. It’s tempting when you or a loved one are experiencing health struggles to identify the “one thing” that is the answer to your health problems. Having something tangible come up on a test creates a sense of an “official” cause or diagnosis. As humans, we want simple answers - not complexity and nuance. Unfortunately, life doesn’t work that way and neither does human health.

Misinformation repeated often enough takes on the aura of truth, but it also keeps people in a harmful fear and stress loop that prevents them making progress with their health. Keep in mind that some working in the wellness space will also benefit from perpetuating this misinformation because more fear = more clients. Affirming someone’s belief that H. pylori is always harmful also makes people look like an expert. It’s just the truth unfortunately. Most practitioners don’t do this, but some certainly do in the wild west of the modern healthcare landscape. The US for example has many, many “wellness coaches” or “nutritionists” with very minimal qualifications who are seriously working outside of their scope of practice. It could be they are genuinely misinformed themselves, but it has the same effect regardless.

Where do we currently stand with H. pylori?

The medical research literature historically shows a significant bias towards viewing H. pylori as a pathogen and this is also seen in more general healthcare information geared towards the public. The availability of a variety of testing options for H. pylori also perpetuates the idea that H. pylori is always pathogenic and must be eradicated. It’s only more recently in the last 10 or so years that researchers and clinicians are moving away from this view, although it is very slow to permeate the various healthcare professions and the public. We know that new information or re-appraisal of any topic in healthcare can take up to twenty years to filter down from the research setting to clinical healthcare practice and that’s probably where we are right now with H. pylori. This puts patients in a confused and very vulnerable position.

What the science is indicating more and more clearly is that for most people with gut health issues and debilitating symptoms, H. pylori is a red herring or an innocent bystander. It’s a huge distraction and source of stress for many people due to the misinformation that gets repeated ad nauseum in the echo chamber of Facebook groups and on outdated website articles. In fact, we now know that H. pylori plays an important role in health for most individuals, which is what this article will investigate in more detail.

To be clear, H. pylori most certainly is relevant if it shows up in the context of some types of gastritis, ulcers or gastric cancers. But it’s most likely not relevant for the overwhelming majority of people - in fact, it’s now believed to be a commensal species that is supposed to be present in humans and one that actually confers benefits. This re-appraisal is similar to that of Blastocystis hominis, another microbe that causes people unnecessary fear and the use of potentially harmful antibiotic treatment - which, by the way, is actually an experimental treatment! As with many things in life, two things can be true at the same time. A bacteria may be harmful in some contexts but that doesn’t mean it’s harmful for most, even when digestive symptoms or illness is present.

There are so many factors that need to be present for H. pylori to cause harm, so it stands to reason - and this point comes up in the literature - that the overwhelming majority of people with H. pylori do not develop any health issues related to it. And in fact, scientists are showing H. pylori plays a protective role for our health in most cases.

What we need to be asking is why H. pylori causes harm in some people - for example, ulcers. What is different in their case? Is their gastric mucosa already impaired? Do they have uncontrolled oxidative stress? Is their immune system weak? What is the interaction with H. pylori and the host - ie. you? We know that several factors such as smoking, excessive intake of alcohol, presence of carcinogens, and diet play a crucial role in the pathogenesis of H. pylori.

If you have H. pylori on a test and you also have various digestive symptoms such as reflux - there are so many other things that are more likely causing/contributing to your symptoms such as SIBO/dysbiosis, poor digestive secretions, anatomical differences such as a hiatal hernia, high levels of stress etc. Don’t automatically point the finger at H. pylori and rush to eradicate it. It’s a very resilient microbe for a reason and you could harm your mental and physical health by making an uninformed decision.

Over-treatment of H. pylori not only has the potential to harm the individual but also contributes to the ever-growing problem of antibiotic resistance. Thankfully naturopathic treatment of H. pylori is usually safe, but many people do end up on an endless treadmill of trying to eradicate it and not being able to do so - perhaps there is a reason for that. They then may reach for strong antibiotics trying to kill it at all costs.

Read on to find out why H. pylori in most cases is an important part of a healthy microbiome and is much less likely to be a cause of your gut health problems. Remember - we have a symbiotic relationship with the bacteria and other microbes in our gut and we co-evolved with them. If H. pylori was automatically harmful or everyone, why is it so prevalent? It’s a complex topic and I hope this article clears up confusion and eases unnecessary fears. I have drawn on information from experts such as Martin Blaser M.D., Steven Sandberg-Lewis N.D. and medical researchers when writing this article.

You can find all the resources I consulted for this article at the end of this post.

Here’s what you need to know

Please note that I am using quotation marks below for the words “infection” or “infectious” because I feel that the use of this word in the scientific literature when in the context of a benign presence of H. pylori contributes to the misleading idea that H. pylori is always harmful.
Also, much of this post or article is in bullet points because I want it to be easier to read and understand the information I’m conveying.

About the microbe

H. pylori has been around for millennia - estimated between 60,000 and 100,000 years
Every mammal carries some type of Helicobacter bacterial species
There are sub-species or different strains of H. pylori
Some of the virulence* genes are considered harmful but some may also be protective - however, more research is needed on this topic
The cytotoxin-associated gene (cagA), the corresponding protein (CagA), and the vacuolating cytotoxin (VacA) seem to be associated with an increased risk of a variety of diseases of the stomach
H. pylori is considered to have a low level of virulence compared to other microbes

*Virulence is a pathogen's or microorganism's ability to cause damage to a host

Incidence of H. pylori “infection”

Epidemiologically, 85–95% of people in developing countries have H. pylori “infection” and approximately 30–50% in developed countries - this is now estimated to be much lower in the US and probably other countries like Australia too
It is currently known that the occurrence of H. pylori is high in the healthy population - about 50% of the population worldwide and more than 70% of that in developing countries
Worldwide, approximately 4.4 billion people are “infected” with H. pylori, with the majority of the H. pylori strains containing virulence genes
In the more developed nations, there is a concern that H. pylori is at risk of becoming extinct

H. pylori and its relationship to human health

H. pylori has been detected in many regions of the body
H. pylori “infection” is usually acquired in childhood and generally persists for life. Thus H. pylori is present in the majority of the world’s population for the majority of their lifetime and in most cases causes no symptoms or health problems
It’s much more common to find H. pylori in children rather than adults on testing - it plays a really important role in educating the immune system which is what the wider microbiome also does
The persistence of H. pylori in the human body is accompanied by a pronounced immune response, which is subsequently replaced by immune tolerance.
This persistence and immune tolerance strongly suggests that the relationship between H. pylori and the host is symbiotic
H. pylori is more likely to be an opportunistic or latent pathogen than a truly pathogenic bacterium
It is believed to be protective against different conditions - which will be discussed later in this article
Several studies have shown that the colonization of H. pylori could be negatively and positively associated with the induction and progression of several diseases
The “infectious” process in H. pylori is chronic and only one in ten colonized individuals; most commonly the elderly, develop clinical manifestations years later (likely because some of their defenses have weakened over time)
The vast majority of the “infected” population does not develop symptoms related to H. pylori infection - less than 2% go on to develop gastric cancer - which may in fact not be about H. pylori itself but about other environmental and/or genetic factors in affected individuals
It has been reported that less than 1% of individuals infected with H. pylori develop various diseases and about 70% of people who are found to have the bacterium are healthy bacterial carriers. The available data show that only 5%-10% of those infected develop symptoms of gastritis or peptic ulcer disease
The detection rate of H. pylori infection in patients diagnosed with peptic ulcer disease does not differ from that of H. pylori in the general population.
In 20%-50% of cases of peptic ulcer disease, the overarching etiological factor of an ulcerative lesion cannot be identified - that is to say, an idiopathic ulcer (H. pylori negative, non-steroidal anti-inflammatory drug-negative peptic ulcer).
Interestingly, epidemiological studies in recent years demonstrate a progressive increase in the idiopathic forms of peptic ulcer disease with a decrease in the global prevalence of H. pylori infection (“idiopathic” means unknown cause)
There is evidence suggesting a more favorable course with H. pylori-associated ulcers compared with other diagnosed types. Among 382 examinees diagnosed with peptic ulcer disease, the patients with a confirmed diagnosis of H. pylori-positive ulcer had a statistically significant increase in healing rates.
Co-infection with multiple H. pylori strains, which may have different genotypes and phenotypes, has been observed within the same patient. Different clinical outcomes during H. pylori infection may be due to differences in H. pylori strains - this could in future act as a marker to predict H. pylori disease outcomes
The human body has many defense mechanisms preventing H. pylori from exerting negative effects - which means that it takes a lot more than just the presence of H. pylori to cause harm. To cause harm to the host, H. pylori must be able to survive the acidic stomach, attach to the host cells, have available nickel for urease activity, release damaging tissue toxins and overwhelm intrinsic host defenses - which means just seeing the presence of H. pylori on testing is not a good enough reason to try to eradicate it