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Doctors Often Misdiagnose This Bacterial Infection That Strikes Travelers

Find out how to diagnose and treat this nasty bacterial infection, H.pylori. Or, even better, avoid it altogether.

As I writhed in pain on the ER bed at the height of yet another COVID-19 wave in Long Island, New York, I didn’t realize it was just the beginning of the worst four months of my life. No, it wasn’t because I contracted the virus. It was an entirely different beast altogether, called H.pylori, a bacteria that is seldom on people’s minds and rarely addressed in gastroenterology offices and emergency rooms across the United States.

A few weeks earlier, I was having the time of my life: gorilla trekking in Rwanda’s Volcanoes National Park and meeting the last two Northern White rhinos in Kenya’s Ol Pejeta Conservancy. As an Indian American who grew up in a small south Indian town, I assumed I had an iron stomach. I could easily take down extremely spicy Thai food at a Michelin-starred street food vendor in Bangkok, eat fried grasshoppers at a roadside shack in Oaxaca, Mexico, or savor falafel wraps on the streets of New York City without any repercussions. Alas, my luck had run out.

My harrowing health journey began shortly after my African sojourn, with severe stomach cramps, excessive gas and bloating, and diarrhea that kept me up all night. When I tried to walk, it felt like someone was repeatedly punching me in my abdomen. My primary doctor sent me to the ER; after six hours of waiting and being poked and prodded, I still had no diagnosis. Suspecting a stomach virus, I was referred to a gastroenterologist (GI) doctor, who prescribed me travelers’ diarrhea pills and sent me home.

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“You don’t need a stool test because whatever you had is probably out of your system by now,” I recall him saying, without even so much as laying a hand on my swollen tummy.

I did get better, but only temporarily. Two months later, the pain returned with a vengeance. My stomach turned like a washing machine full of rocks, and it doubled in size overnight. No amount of Tums or ginger ale provided relief. I lost my appetite, and nausea became a constant companion. The next day, I went to a different GI doctor, who recommended GasX and told me to wait it out. The bloat did not go away; in fact, my stomach felt like an overinflated balloon that could pop at any moment.

When a return trip to the ER that night still gave no answers, the GI doctor prescribed a generic 10-day antibiotic course to rid any bacteria that may have been causing my issues. I took the pills religiously, but my symptoms got worse. I subsisted on Gatorade and water and couldn’t walk around or work. When the course ended, and I still couldn’t get out of bed, I knew something was seriously wrong. Then a family friend, who happens to be a top GI doctor on Long Island, helped determine the root cause. A stool test, followed by an endoscopy, diagnosed me with an H.pylori infection.

A Commonly Misdiagnosed Infection

You may have heard of irritable bowel syndrome (IBS), E. coli, C.diff, and probably had traveler’s diarrhea on your trips. H. pylori, short for Helicobacter pylori (pronounced Hel-ee-koh-BAK-ter Pie-LORE-ee), is a relatively new bacteria to the health scene, only being discovered in 1982. It creates an enzyme called urease that neutralizes stomach acids in order to survive. Its shape helps it penetrate and weaken the stomach lining, causing many problems when it colonizes. These include gastritis (stomach inflammation), sores or ulcers, and in rare cases, even cancer.

Despite its low profile in the U.S., 60% of the world population has this bacteria; it is as high as 80 to 90% in developing nations, says Dr. Supriya Rao, managing partner at  Integrated Gastroenterology Consultants, in Massachusetts. “Overcrowding, poor sanitation, and living in close quarters with your family all the time causes the transmission to be very high.”

Despite its global prevalence, “20% of people with H. pylori go on to develop issues,” she adds. Common symptoms include abdominal pain lasting hours to several days or weeks, worsening acid reflux, bloating, gas, nausea, and vomiting. Pain is at its worst on an empty stomach.

“The estimated proportion that develops ulcers is 10%. The proportion that develops stomach cancer is low, 1-3%, and the risk can also be associated with hereditary susceptibility, family history, and other underlying health problems,” says Dr. Lin Chen, an infectious disease expert, Director of Travel Medicine at Mount Auburn Hospital and an Associate Professor at Harvard Medical School.

Certain populations are more susceptible. According to Johns Hopkins Medicine, almost half of all African Americans carry the bacteria. Of those immigrating from developing countries, at least 50% of Eastern Europeans and 50% of Latinos have H. pylori.

“There could be lots of people walking around the U.S. right now with it, but for most of those people, it will never materialize into anything,” says Dr. Rao. “Some people will have H. pylori and never know about it, and then over time, can start having some inflammation. Some people may feel it, and they have extraordinary pain.”

Because H. pylori incidence is not as high in the U.S. relative to resource-limited countries–and the fact that travelers’ diarrhea has the highest profile–Dr. Chen believes travelers with GI problems are often evaluated and treated for those first. “Travel and tropical medicine specialists often consider H. pylori when evaluating ill travelers with gastrointestinal symptoms.”

How It Spreads

H.Pylori bacteria spreads during kissing, when consuming food that’s not cleaned or cooked safely, drinking contaminated water, and when coming into contact with contaminated vomit or stool. For TV personality Aparna Shewakramani, of the Netflix show Indian Matchmaking, it was on a trip to Jaipur where she felt peer pressured into eating food from a vendor at a cultural fair. Having been diagnosed with Crohn’s Disease, she was extra careful with only eating home-cooked meals or food at five-star hotels, but she made an exception for hot parathas served on stone. Six months later, she began experiencing acid reflux and sharp stomach pain.

Huda Haddad, an entrepreneur in Manitoba, Canada, remembers getting sick with it in Puerto Escondido, Mexico, where the doctor told her that it was most likely from the water. She describes having profound gastric pain and seeking help from GI doctors in Canada and the Mayo Clinic to receive a diagnosis and treatment finally. Others have been infected with H.pylori in Sri Lanka, the Caribbean, and parts of Africa and South America.

Diagnosis and Treatment

“One of the first things I check is a stool test to see if H. pylori could contribute to those symptoms,” says Dr. Rao. The test will check for bacterial cultures, stool ova, parasitic infections, C. diff, and H. pylori, especially if the person traveled to an area where it is endemic.

Another way is through a urea breath test, which unfortunately may not be readily available at most GI offices. The test involves breathing into a bag twice and examining the samples before and after taking a urea pill. If the stool test takes too long to come back (often, the lab will let various cultures grow to get to the root cause), and the symptoms are severe, an endoscopy is performed, and a biopsy is taken to determine H.pylori infection and any ulcers.

Treatment for H.pylori infection includes a quadruple therapy of four medications taken three to four times a day (preferably with food) over a period of two weeks to eradicate the bacteria completely. According to Dr. Rao, these include Metronidazole, Tetracycline, Bismuth (essentially Pepto Bismol), and a proton-pump inhibitor (PPI) such as Omeprazole to reduce stomach acid and heal the lining.

Antibiotics involved in this regimen can be tough on the GI tract, “which is already feeling bad from what you’re going through,” says Dr. Rao. “But it’s the only way to make sure you eradicate, and you need to test for eradication a month later to be sure it’s completely gone.”

To help your gut along this grueling process, it’s important to eat healthy foods that are fermented and rich in fiber “to help rebuild some of those good bacteria,” says Dr. Rao. She recommends getting a good night’s sleep and exercise (if possible) to help your microbiome recover.

Precautions for Your Travels

After going through this ordeal last year, it would be easy to refrain from traveling to certain places. But, five months after successful treatment, I boarded the plane to Botswana, my fifth African country, and I wasn’t worried one bit.

I am certainly more careful with what I eat, but I am also equipped with the tools to keep me safe. Below are some tips to avoid H.pylori on your travels:

– Wash your hands often and use hand sanitizer to prevent pylori and other travel-related illnesses.

– Drink filtered or boiled water and eat only cooked vegetables. When consuming fruits, safe options include those with heavy peels, like bananas and oranges.

– Consider taking Pepto Bismol daily. “There’s data to show that taking a tablet of Pepto-Bismol daily when you are abroad can help prevent any kind of diarrheal illnesses,” says Dr. Rao. Just keep in mind that this will turn your stool black.

– Refuse to eat at a place you feel might be unsanitary. When visiting someone’s home, it’s often part of the hospitality of the culture to have a bite or a sip, says Shewakramani, but adds that it’s fine not to oblige if you feel it might not be safe to eat or drink. “Gently but politely figure out a way to say that you won’t be able to eat. Make up an allergy if you need to, but make sure that you get out of it and don’t worry so much about the hosts.”

– Be mindful of your symptoms. If you start to feel sick or think you had food poisoning during a trip, but the symptoms persist, Shewakramani recommends opening up a note on your phone and jotting down your symptoms. “Check in with your body for like 10 seconds each day. And notice anything that might be abnormal like acid reflux, excessive burping, or anything that you may just push aside because it might be more linked [to what you experienced during the trip] than you think.”

– If you continue to feel sick and are not getting the care you need, seek it out. “You care the most about your own body and know your body the best. Be clear about when your symptoms started, share with the doctor if there’s travel involved and where you’ve traveled. And what kinds of food you were eating,” says Dr. Rao.

tonyfitz27 May 15, 2023

RedHill Bio has Talicia for H Pylori

newmarket2 May 11, 2023

You don't mention Xifaxan/rifaximin. 
It is commonly prescribed for traveler's diarrhea, although it might not work on its own if you have H.phlori.