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This week's topic: H. Pylori Results on a GI Map
Many GI Map results show the presence of H. pylori, but do we need to treat it?
I recently had a patient who was very upset after she tried to validate the results of a GI Map via her general practitioner. Her primary symptoms were bloating and fatigue, and she had high H. pylori (no virulence factors) on her GI Map.
This patient was upset because she tested negative for H. pylori via commercial testing (stool antigen and breath test), and I had given her a treatment protocol with an optional H. pylori nutraceutical (I listed the treatment as "optional" since she was part of a "one-and-done" lab visit that the practice was promoting, so she couldn't follow up unless she signed up for a membership). With the negative H. pylori results via per PCP, she was wary of the GI Map, and was seeking a refund.
As a result of this interaction and my experiences with GI Map over the years, I was inspired to write today's newsletter in hopes that it supports fellow clinicians who are navigating the "wild west" of functional medicine practice!
Overview of today's email:
- Review of H. Pylori
- Testing
- Practical clinical tips
Addressing H. pylori with or without antimicrobials is an art (and highly dependent on the patient and the practitioner's experience). The information provided in this email is what I personally feel is a "practical" approach to this test result, and is intended for educational purposes only.
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1. Review of H. Pylori
Helicobacter pylori is a spiral shaped flagellated gram-negative bacteria that is known to be one of the few microbes that can colonize the highly acidic stomach.
It is estimated that 50-80% of the world's population has H. pylori (dormant or active), usually acquired in childhood, but only 15% will have symptoms or elevated risks associated with this bacteria. Children are particularly sensitive (and respond faster to treatment) than adults.
There is widespread antibiotic resistance to H. pylori, and it is not always an easy microbe to eradicate. Some research also suggests that H. pylori may persist or be difficult to eradicate due to the formation of biofilms.
How does H. Pylori survive the acidic stomach?
It is able to survive due to its production of urease (which elevates the pH in the stomach to 3.5-4) and by swimming through the protective mucin layer in the stomach (where it attaches to epithelial cells beneath the gastric mucosa, causing inflammation that may trigger the immune system and mast cells).
What are some of the implications of H. pylori colonization?
Colonization with H. pylori is often asymptomatic, and there are some studies that suggest this bacteria can be protective in some situations. However, it is known to be correlated and/or a causative factor in:
- Chronic gastritis
- Peptic and duodenal ulcers
- Some gastric cancers (it's the number one risk factor for the development of gastric adenocarcinoma, which occurs in approximately 1 to 2% of infected individuals).
On a more nuanced level, H. pylori colonization may contribute to:
- Persistent upper GI symptoms (heartburn, bloating, sense of fullness, gallbladder issues, etc)
- Autoimmune conditions (especially thyroid autoimmunity)
- Chronic fatigue
- Unexplained iron deficiency anemia or B12 deficiency
- Symptoms suggesting maldigestion (e.g. unexplained hair loss)
- Because of H. pylori's influence on stomach pH, it can significantly affect the breakdown of protein (which needs a pH of 1.5-3 to be broken down). This ineffective breakdown of protein can affect the production of protein-dependent molecules including enzymes, thyroid hormones, and neurotransmitters.
- It may be correlated with the negative repercussions that result from metabolic syndrome and neurodegeneration (source).
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2. H. Pylori on GI Map
The GI Map by Diagnostic Solutions is one of the most commonly used functional medicine stool test companies, and evaluates absolute values via qPCR testing. In my experience, though, over 80% of the GI Maps tests I have run show the presence of H. pylori (and many follow up diagnostic tests that I run do not confirm active infection).
The most accepted ways to test for and DIAGNOSE H. pylori include breath testing, stool antigen testing, and antibody testing.
Quantitative PCR testing is not yet universally accepted as a way to diagnose H. pylori infection, particularly because PCR can’t differentiate live bacteria from dead bacteria and can’t determine risk of transmission. Use of qPCR testing in research is generally after a treatment protocol and not as a diagnostic test.
A few things to keep in mind about the GI Map:
- It tests to very low levels (e.g. "1e3" is equivalent to 1000 organisms per gram of stool); it also tests for virulence factors that can suggest active colonization
- One study done in 2020 suggests it has a sensitivity of 80% and specificity of 36% (but I believe this study needs to be repeated multiple times, since it was potentially biased due to funding by company associated with Doctor's Data)
Training from the company notes we may see the following as well if H. pylori is colonized in an individual (but I didn't have time to look into studies on these correlations):
- Overgrowth of akkermansia, clostridia species, bacillus, stapholococcus, streptococcus, enterococcus species, parasites, or Firmicutes phyllum
- Low or suboptimal elastase
It is important to remember that "functional" test companies often use research-based methods that are not currently considered "diagnostic" for a particular symptom or condition. |
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3. Practical Clinical Tips: When should we treat H. Pylori on a GI Map?
Should we treat H. pylori on a GI Map? Many well-meaning practitioners will say to treat any time H. pylori shows up (even in a normal range). But if you're a licensed clinician who considers the risks and benefits of a treatment protocol, treating everyone with this microbe may not be the best option.
Deciding to treat should be based on 3 things:
- Lab Patterns and Values
- Medical History
- Cost of treatment
1) Lab patterns and values (2 or more of these):
- Presence of certain virulence factors
- Presence of low or suboptimal pancreatic elastase
- Presence of high protein products (i.e. poor protein digestion)
- VERY high levels of H. pylori levels (important to look at the lab value compared to normal expected range in this case)
- Low or suboptimal ferritin that is not responsive to iron repletion
2) Medical history
- Presence of symptoms (see list in the first section of this email)
- Personal history of H. pylori treatment with continued symptoms (with or without follow up testing after a treatment protocol)
- Known autoimmune condition
- Those with significant dental issues or even asymptomatic but extensive dental history (the mouth can be a reservoir for H. pylori)
- If a close family member is being treated for H. pylori
- Hypoglycemia symptoms or post-prandial hypoglycemia
3) Cost of treatment (financial and physiologic costs)
- Consider the cost of a supplement (which may need to be used for 3-6 months and cost hundreds of dollars) versus a pharmaceutical
- Consider the potential negative repercussions on the body (especially the microbiome) when using nutraceutical or pharmaceutical treatments
When in doubt (or considering antimicrobials), verify H. pylori via commercial lab testing (stool antigen and/or breath testing)! |
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I hope this was clinically useful!
Do you agree with today's content? Let me know your thoughts by replying directly to this email!
Next newsletter topic: Nutraceuticals for H. Pylori.
Meg McElroy MS, PA-C, IFMCP
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