Helicobacter Pylori

Aka: Helicobacter Pylori, H. pylori, Helicobacter Pylori Treatment, H. Pylori Management, Non-NSAID Associated Peptic Ulcer, Helidac, Pylera, Campylobacter pylori, Helicobacter-associated gastritis

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II. Epidemiology

  1. Helicobacter Pylori colonizes the gastric mucosa in 50% of world population and 30-40% of U.S. population
  2. Helicobacter Pylori is the most common cause of Peptic Ulcer Disease (surpassing NSAID induced ulcers)

III. Pathophysiology

  1. Helicobacter Pylori characteristics
    1. Spiral-shaped (helical), facultative anaerobic, Gram Negative Rod in the Vibrionaceae family
    2. Genus Helicobacter, but previously classified as Campylobacter pylori
    3. Motile with multiple flagella
    4. Colonizes gastric mucosa or epithelial lining
  2. Sources
    1. Acquired in early childhood via fecal-oral transmission

IV. Associated Conditions

  1. Dyspepsia
  2. Peptic Ulcer Disease
    1. Duodenal Ulcers: 95% related to H. pylori
    2. Gastric Ulcers: 70-80% related to H. pylori
  3. Stomach Cancer (epithelial or lymphoid)
    1. IARC considers H. pylori a Group I Carcinogen
    2. Mucosa-associated Lymphoid Tissue (MALT)
    3. Gastric Adenocarcinoma

V. Symptoms (Asymptomatic in 90% of cases)

  1. See Dyspepsia
  2. See Peptic Ulcer Disease

VI. Differential Diagnosis

  1. See Dyspepsia Causes
  2. See Medication Causes of Dyspepsia

VII. Labs

  1. General
    1. Stop Antibiotics for 4 weeks before Helicobacter Pylori testing
    2. Stop Proton Pump Inhibitors (PPIs) for 2 weeks before Helicobacter Pylori testing
    3. Only Serology and Rapid Urease Test are not affected by Antibiotics and PPIs
  2. Helicobacter pylori Noninvasive Testing
    1. Urea Breath Test (Carbon 13)
      1. Test Sensitivity: 96 to 100%
      2. Test Specificity: 93 to 100%
      3. Likelihood: LR+ 12, LR- 0.05
      4. Ferwana (2015) World J Gastroenterol 21(4): 1305-14 [PubMed]
    2. Helicobacter pylori Stool Antigen (HpSA Monoclonal Antibody test)
      1. Test Sensitivity: 94%
      2. Test Specificity: 97%
      3. Likelihood: LR+ 24, LR- 0.7
      4. Gisbert (2006) Gastroenterol 101(8): 1921-30 [PubMed]
    3. Helicobacter Pylori IgG Serology
      1. Test Sensitivity: 85%
      2. Test Specificity: 79%
      3. Likelihood: LR+ 2.8, LR- 0.2
      4. Does not differentiate current active infection from prior infection
  3. Helicobacter pylori Invasive Testing (upper endoscopy)
    1. Histology (endoscopic biopsy)
      1. Test Sensitivity: 70%
      2. Test Specificity: 90%
      3. Likelihood: LR+ 6.7, LR- 0.23
    2. Rapid Urease Test
      1. Test Sensitivity: 67%
      2. Test Specificity: 93%
      3. Likelihood: LR+ 9.6, LR- 0.31
    3. Helicobacter Pylori Culture (endoscopic biopsy sample)
      1. Test Sensitivity: 45%
      2. Test Specificity: 98%
      3. Likelihood: LR+ 19.6, LR- 0.31
  4. References
    1. Gisbert (2006) Am j Gastroenterol 101(4): 848-63 [PubMed]
    2. Bordin (2021) Diagnostics 11(8): 1458 [PubMed]
    3. Kayali (2018) Acta Biomed 89(8-S): 58-64 [PubMed]

VIII. Management: General

  1. Do not indiscriminately test and treat H. pylori
    1. Test only symptomatic patients consistent with H. pylori infection
    2. Test for H. pylori only if intending to treat with eradication therapy
  2. Resistance is increasing markedly
    1. Metronidazole resistance is very common
      1. Resistance overcome by the following measures
        1. Increase acid suppression
        2. Increase Metronidazole dose
        3. Increase therapy duration
    2. Clarithromycin resistance is growing (8-12%)
      1. Resistance can not be overcome
      2. Do not use protocols with Clarithromycin where H.Pylori resistance rates >15-20%
      3. Test for Antibiotic Resistance prior to use
    3. Levofloxacin resistance is also growing
      1. Test for Antibiotic Resistance prior to use
  3. Benefits of treating H. pylori
    1. Significantly drops ulcer recurrence, rebleeding risk
    2. Improves symptoms in Nonulcer Dyspepsia (variable)
    3. Unclear evidence for gastric Cancer Prevention
    4. No evidence for benefit in GERD
  4. Test for H. pylori before treatment
    1. See Helicobacter pylori Noninvasive Testing
  5. Test 4-6 weeks after treatment
    1. Indications
      1. ACG Guidelines recommend testing ALL Patients for eradication after treatment
      2. Persistant Dyspepsia or other related symptoms
      3. Peptic Ulcer Disease
      4. Mucosal-Associated Lymphoid Tumor (MALT Lymphoma)
      5. Gastric Adenocarcinoma
    2. Preparation
      1. Discontinue Proton Pump Inhibitors 2-4 weeks prior to testing
      2. Patients may use H2 Blockers or Aluminum and Magnesium Salt Antacids during this time
    3. Testing options to confirm H. pylori eradication
      1. H. pylori Stool Antigen (HpSA)
      2. Urea Breath Test
      3. Endoscopic Biopsy for H. pylori
  6. Protocol pearls
    1. Treatment duration: Treat for 14 days to maximize eradication rates
    2. Use at least 3 agents in most cases (generally avoid 2 agent regimens, esp. for salvage therapy)
    3. If failed therapy - see resistant cases below
  7. Consider concurrent Probiotic
    1. Add Saccharomyces boulardii and/or Lactobacillus to regimen
    2. Increases eradication rates and decreases Antibiotic Associated Diarrhea
    3. Szajewska (2010) Aliment Pharmacol Ther 32(9): 1069-79 +PMID:21039671 [PubMed]
    4. Zou (2009) Helicobacter 14(5): 97-107 +PMID:19751434 [PubMed]

IX. Protocols: Adult Preferred Initial Protocols (Treatment Naive)

  1. Bismuth Quadruple Therapy (BQT, up to 98% efficacy)
    1. Background
      1. Gold standard for Helicobacter Pylori due to highest efficacy, lowest resistance rates and lowest cost
      2. Consider if Penicillin allergic or prior treatment for H. pylori with Macrolide (e.g. Clarithromycin)
      3. Compliance is difficult due to four time daily dosing
      4. Bismuth causes Constipation and black discoloration of mouth and stools
    2. Components: Use all four for 14 days (extended use of the Proton Pump Inhibitor)
      1. Proton Pump Inhibitor twice daily for up to 6 weeks
        1. Omeprazole (Prilosec) 20 mg orally twice daily
        2. Lansoprazole (Prevacid) 30 mg orally twice daily
        3. May substitute Ranitidine (Zantac) 300 mg orally daily, but is less ideal
      2. Metronidazole (Flagyl) 500 mg orally four times daily for 14 days (some protocols use 2 or 3 times daily)
        1. May substitute Tinidazole (Tindamax) 500 mg orally twice daily for 14 days
      3. Tetracycline 500 mg orally four times daily for 14 days
        1. No evidence that Doxycycline has equivalent efficacy against Helicobacter Pylori
      4. Bismuth subcitrate (Pepto-Bismol) 262 mg orally four times daily for 14 days
        1. May substitute Bismuth Subsalicylate 300 to 535 mg orally four times daily
    3. Combination Packs
      1. Use Omeprazole (or other PPI) with either Helidac or Pylera
        1. Helidac and Pylera each include Metronidazole, Tetracycline and Bismuth
  2. PCAB Dual Therapy (Voquezna Dual Pack)
    1. Take all agents for 14 days
      1. Vonoprazan 20 mg orally twice daily AND
      2. Amoxicillin 1000 mg orally twice daily
  3. References
    1. Chey (2017) Am J Gastroenterol 112(2):212-239 +PMID:28071659 [PubMed]

X. Protocols: Adults Resistant Cases (Preferred for Treatment Salvage)

  1. General for failed therapy
    1. Step Up to 4-5 agent therapy without Metronidazole
  2. Quadruple therapy
    1. See Quadruple therapy above
  3. Triple Therapy with Amoxicillin and Rifabutin (Talicia)
    1. Combination capsules of Omeprazole, Amoxil and Rifabutin (Mycobutin)
    2. Four capsules per dose
      1. Each capsule contains Omeprazole 10 mg, Amoxil 250 mg, Rifabutin 12.5 mg
      2. Each total dose contains Omeprazole 40 mg, Amoxil 1000 mg, Rifabutin 50 mg
    3. Four capsules taken three times daily for 14 days
    4. Adverse effects related to Rifabutin (body fluid stained orange, CYP3A4 inducer)
      1. Hormonal Contraception requires backup Contraception for 28 days
    5. References
      1. (2020) Presc Lett 27(5):29
      2. Qasim (2005) Aliment Pharmacol Ther 21:91-6 [PubMed]

XI. Protocols: Adult Resistant Cases (Requires Antibiotic Sensitivity testing)

  1. Precautions
    1. These protocols depend on Antibiotic sensitivity testing (Clarithromycin or Levofloxacin)
  2. PCAB Triple Therapy (Voquezna Triple Pack)
    1. Confirm H. pylori sensitivity to Clarithromycin prior to use (growing resistance)
    2. Take all agents for 14 days
      1. Vonoprazan 20 mg orally twice daily AND
      2. Amoxicillin 1000 mg orally twice daily AND
      3. Clarithromycin 500 mg orally twice daily
    3. References
      1. Kiyotoki (2020) Intern Med 59(2):153-61 +PMID: 31243237 [PubMed]
  3. Concomitant Quadruple Therapy (Triple Therapy with Metronidazole)
    1. Background
      1. Confirm H. pylori sensitivity to Clarithromycin prior to use (growing resistance)
      2. Replaces the older triple therapy or LAC protocol (Lasoprazole-Amoxicillin-Clarithromycin)
        1. Addition of Metronidazole significantly improves efficacy
      3. Patients may prefer this protocol to quadruple therapy
        1. Better tolerated (no bismuth associated Black Tongue, stools, or Constipation)
        2. Better compliance (twice daily instead of four times daily)
    2. Components: Use all four for 14 days (extended use of the Proton Pump Inhibitor)
      1. Proton Pump Inhibitor for up to 6 weeks
        1. Omeprazole (Prilosec) 20 mg orally twice daily
        2. Lansoprazole (Prevacid) 30 mg orally twice daily
      2. Amoxicillin 1000 mg orally twice daily for 14 days
      3. Clarithromycin (Biaxin) 500 mg orally twice daily for 14 days
        1. Do not substitute other Macrolides
        2. Azithromycin and Erythromycin do not have adequate Helicobacter Pylori coverage
      4. Metronidazole (Flagyl) 500 mg orally twice daily for 14 days
        1. May substitute Tinidazole (Tindamax) 500 mg orally twice daily for 14 days
  4. Levofloxacin Based Therapy
    1. Do not use if Levofloxacin-based therapy has been used in the past
    2. Confirm H. pylori sensitivity to Levofloxacin prior to use (growing resistance)
    3. Take all three agents for 14 days
      1. Proton Pump Inhibitor twice daily AND
      2. Amoxicillin 1000 mg orally twice daily AND
      3. Levofloxacin 500 mg orally daily

XII. Protocols: Children

  1. Indications for testing
    1. Suspected Peptic Ulcer Disease (uncommon in children)
    2. Testing and treating is not recommended for functional Abdominal Pain
    3. Wait to test for 2 weeks after last Proton Pump Inhibitor and 4 weeks after last Antibiotic
  2. Protocol
    1. Omeprazole 1 mg/kg/day divided twice daily (max: 20 mg orally twice daily) and
    2. Take the following 3 Antibiotics for 14 days (same as concomitant therapy above)
      1. Amoxicillin 50 mg/kg/day divided twice daily (max: 1000 mg twice daily)
      2. Clarithromycin 15mg/kg/day div bid (max: 500 mg twice daily)
      3. Metronidazole 20 mg/kg/day div bid (Max: 500 mg twice daily)
  3. References
    1. Gold (2000) J Pediatr Gastroenterol Nutr 31:490-7 [PubMed]

XIII. Protocols: Pregnancy

  1. Indications for Treatment during pregnancy
    1. Severe symptoms (e.g. refractory Hyperemesis Gravidarum)
    2. If only mild symptoms, consider delaying management until after delivery and Lactation
  2. Protocol in pregnancy
    1. Treat for 7 day course
    2. First Trimester
      1. Lansoprazole (Prevacid) 30 mg orally twice daily AND
      2. Amoxicillin 1000 mg orally twice daily AND
      3. Metronidazole (Flagyl) 500 mg orally twice daily
    3. Second and Third Trimester
      1. Follow first trimester protocol
      2. Clarithromycin (Biaxin) 500 mg orally twice daily may be substituted for Metronidazole

XIV. Management: Consider maintenance antisecretory therapy

  1. Maintenance management: 50% of treatment dose
  2. Indications
    1. Complicated Peptic Ulcer Disease
    2. Elderly or frail

XV. References

  1. (2012) Presc Lett 19(2): 7
  2. Ables (2007) Am Fam Physician 75:351-8 [PubMed]
  3. Chey (2024) Am J Gastroenterol 119(9):1730-53 +PMID: 39626064 [PubMed]
  4. Cohen (2000) Gastroenterol Clin North Am 29(4):775-89 [PubMed]
  5. Fashner (2015) Am Fam Physician 91(4): 236-42 [PubMed]
  6. McConaghy (2023) Am Fam Physician 107(2): 165-72 [PubMed]
  7. Meurer (2002) Am Fam Physician 65(7):1327-36 [PubMed]

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Related Studies

Ontology: Anti-Ulcer Agent (C0003216)

Definition (NCI) Natural or synthetic Anti-ulcer Agents relieve and reduce the symptoms of ulcers in the stomach and upper small intestine, systemically and locally, by reducing gastric secretion (proton pump inhibitors), neutralizing hyperacidity (alkalinizing agents), or improving healing and protecting the mucosa (sucralfate). Recurrent gastric and duodenal ulcers caused by Helicobacter pylori infections are treated with antibiotic therapy.
Definition (CSP) class of agents, exclusive of the antibacterial agents, used to treat ulcers in the stomach and the upper part of the small intestine.
Definition (MSH) Various agents with different action mechanisms used to treat or ameliorate PEPTIC ULCER or irritation of the gastrointestinal tract. This has included ANTIBIOTICS to treat HELICOBACTER INFECTIONS; HISTAMINE H2 ANTAGONISTS to reduce GASTRIC ACID secretion; and ANTACIDS for symptomatic relief.
Concepts Pharmacologic Substance (T121)
MSH D000897
English Agents, Anti-Ulcer, Anti Ulcer Agents, Anti-Ulcer Agents, antiulcer drug, Anti Ulcer Drugs, Anti-Ulcer Drugs, Drugs, Anti-Ulcer, ANTIULCER AGENTS, anti-ulcer agents, [GA300] ANTIULCER AGENTS, anti ulcer agents, anti ulcer drug, antiulcer drugs, anti-ulcer drugs, antiulcer agents, antiulcer agent, Antacid, Anti-Ulcer Agent, Antiulcer drugs, Anti-ulcer Agent
French Agents antiulcéreux, Médicaments antiulcéreux, Anti-ulcéreux, Antiulcéreux
Swedish Magsårsmedel
Czech protivředové látky
Finnish Ulkuslääkkeet
Italian Farmaci antiulcera, Antiulcera
Russian PROTIVOIAZVENNYE SREDSTVA, ПРОТИВОЯЗВЕННЫЕ СРЕДСТВА
Croatian ANTIULKUSNA SREDSTVA
Polish Leki przeciwwrzodowe
Japanese 消化性潰瘍治療剤, 潰瘍剤, 抗潰瘍剤, 抗潰瘍薬, 消化性潰瘍治療薬, 潰瘍治療薬, 抗消化性潰瘍薬, 抗潰瘍効果, 潰瘍治療剤
Spanish Antiulcerosos, Agentes Antiulcerosos, Fármacos Antiulcerosos
Portuguese Fármacos Antiulcerosos, Agentes Antiulcerosos, Antiulcerosos
German Antiulkusmittel, Ulkusmittel
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Helicobacter pylori (C0079488)

Definition (NCI_NCI-GLOSS) A type of bacterium that causes inflammation and ulcers in the stomach or small intestine. People with Helicobacter pylori infections may be more likely to develop cancer in the stomach, including MALT (mucosa-associated lymphoid tissue) lymphoma.
Definition (NCI_CDISC) Any bacterial organism that can be assigned to the species Helicobacter pylori.
Definition (NCI) Bacteria that cause stomach inflammation (gastritis) and ulcers in the stomach. This bacteria is the most common cause of ulcers worldwide. It is often referred to as H. pylori. H. pylori infection is usually acquired from contaminated food and water and through person to person spread. The infection is common in crowded living conditions with poor sanitation. In countries with poor sanitation, 90% of the adult population can be infected. In the U.S., 30% of the adult population is infected. One out of six patients with H. pylori infection develops ulcers of the duodenum or the stomach. This bacteria is also believed to be associated with stomach cancer and a rare type of lymph gland tumor called gastric MALT lymphoma. Infected persons usually carry the infection indefinitely, unless treated with medications to eradicate the bacteria. (MedicineNet.com)
Definition (MSH) A spiral bacterium active as a human gastric pathogen. It is a gram-negative, urease-positive, curved or slightly spiral organism initially isolated in 1982 from patients with lesions of gastritis or peptic ulcers in Western Australia. Helicobacter pylori was originally classified in the genus CAMPYLOBACTER, but RNA sequencing, cellular fatty acid profiles, growth patterns, and other taxonomic characteristics indicate that the micro-organism should be included in the genus HELICOBACTER. It has been officially transferred to Helicobacter gen. nov. (see Int J Syst Bacteriol 1989 Oct;39(4):297-405).
Concepts Bacterium (T007)
MSH D016480
SnomedCT 80774000, 123131000, 18066003
CPT 1011474
LNC LP16707-9, MTHU019876
English Campylobacter pylori, Helicobacter pylori, Campylobacter pylori pylori, Helicobacter nemestrinae, Helicobacter pylori (Marshall et al. 1985) Goodwin et al. 1989, Campylobacter pylori Marshall et al. 1985 corrig. Marshall and Goodwin 1987, Campylobacter pylori subsp. pylori Marshall et al. 1985, Campylobacter pyloridis Marshall et al.1985, Campylobacter pylori corrig. Marshall et al. 1985 emend. Fox et al. 1989, Campylobacter pylori corrig. Marshall et al. 1985 emend. Fox et al. 1988, Helicobacter nemestrinae Bronsdon et al. 1991, h pylori, helicobacter pylori bacteria, campylobacter pylori, h. pylori, helicobacter pylori, helicobacter pylori organism, HELICOBACTER PYLORI, Helicobacter nemestrinae (organism), CAMPYLOBACTER PYLORI, H. PYLORI, Campylobacter pylori subsp. pylori, Campylobacter pylori subsp pylori, Campylobacter pyloridis, H. pylori, Hp - Helicobacter pylori, Helicobacter pylori (organism), Helicobacter pylori -RETIRED-
Swedish Helicobacter pylori
Czech Helicobacter pylori, Campylobacter pylori
Spanish Campylobacter pylori, Campylobacter pyloridis, H. pylori, Helicobacter pylori -RETIRED-, Helicobacter nemestrinae (organismo), Helicobacter nemestrinae, Helicobacter pylori (concepto no activo), Campylobacter pylori, subespecie pylori, Helicobacter pylori (organismo), Helicobacter pylori
Finnish Helicobacter pylori
Japanese ヘリコバクター･ピロリ, ヘリコバクターピロリ, ヘリコバクタ･ピロリ
Italian Campylobacter pylori, Helicobacter pylori
Croatian HELICOBACTER PYLORI
Polish Campylobacter pylori, Helicobacter pylori
Norwegian Campylobacter pylori, Helicobacter pylori
French Campylobacter pylori, Helicobacter pylori
German Campylobacter pylori, Helicobacter pylori
Russian HELICOBACTER PYLORI, CAMPYLOBACTER PYLORI
Dutch Campylobacter pylori, Helicobacter pylori
Portuguese Campylobacter pylori, Helicobacter pylori
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Helicobacter-associated gastritis (C0343378)

Concepts Disease or Syndrome (T047)
SnomedCT 155716003, 196741008, 186143000, 89538001
Italian Gastrite da Helicobacter, Gastrite da Helicobacter pylori
Dutch Helicobacter pylori-gastritis, Helicobacter-gastritis
French Gastrite à helicobacter pylori, Gastrite à Helicobacter
German Helicobacter pylori-Gastritis, Helicobacter-Gastritis
Portuguese Gastrite a Helicobacter pylori, Gastrite por helicobactéria
Japanese ヘリコバクター性胃炎, ヘリコバクター・ピロリ性胃炎, ﾍﾘｺﾊﾞｸﾀｰﾋﾟﾛﾘｾｲｲｴﾝ, ﾍﾘｺﾊﾞｸﾀｰｾｲｲｴﾝ
English Helicobacter gastritis, gastritis associated with Helicobacter pylori (diagnosis), gastritis associated with Helicobacter pylori, gastritis due to H. pylori, Helico pylori-assoc gastritis, gastritis helicobacter pylori, helicobacter gastritis, helicobacter pylori gastritis, Helicobacter pylori gastritis, Helicobacter gastritis (disorder), Helicobacter-associated gastritis, Helicobacter pylori-associated gastritis, Helicobacter-associated gastritis (disorder), Helicobacter Gastritis, Helicobacter Pylori-Associated Gastritis
Spanish Gastritis por Helicobacter pylori, Gastritis por Helicobacter, gastritis asociada con Helicobacter (trastorno), gastritis asociada con Helicobacter
Czech Helikobakterová gastroenteritida, Gastritida vyvolaná Helicobacter pylori
Hungarian Helicobacter gastritis, Helicobacter pylori gastritis
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Helidac Therapy Pack (C0977365)

Concepts Drug Delivery Device (T203)
English HELIDAC THERAPY KIT 525 MG/250 MG/50 MG, Helidac Therapy Kit, {112 (bismuth subsalicylate 262 MG Chewable Tablet) / 56 (Metronidazole 250 MG Oral Tablet) / 56 (Tetracycline 500 MG Oral Capsule) } Pack [Helidac Therapy], Helidac, 262.4 mg-250 mg-500 mg oral kit, TETRACYCLINE HYDROCHLORIDE 500 MG ORAL CAPSULE [HELIDAC], BISMUTH SUBSALICYLATE 262 MG ORAL TABLET, CHEWABLE [HELIDAC], HELIDAC KIT 262 MG/250 MG;MG, HELIDAC THERAPY PACK [VA Product], HELIDAC THERAPY KIT 262.4 MG/250 MG/ MG, HELIDAC THERAPY KIT 262 MG/250 MG;MG, {112 (bismuth subsalicylate 262 MG Chewable Tablet) / 56 (metroNIDAZOLE 250 MG Oral Tablet) / 56 (Tetracycline 500 MG Oral Capsule) } Pack [Helidac Therapy], Bismuth Subsalicylate/Metronidazole/Tetracycline Hydrochloride 262.4 MG-250 MG-500 MG Oral Kit [HELIDAC THERAPY], HELIDAC Therapy KIT, Helidac Therapy Pack, HELIDAC THERAPY PACK
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: bismuth subcitrate 140 MG / Metronidazole 125 MG / tetracycline hydrochloride 125 MG Oral Capsule (C1948529)

Concepts Clinical Drug (T200)
English BISMUTH 140MG/METRONIDAZOLE 125MG/TETRACYCLINE 125MG CAP,ORAL, PYLERA ORAL CAP, BISMUTH 140MG/METRONIDAZOLE 125MG/TETRACYCLINE 125MG CAP,ORAL [VA Product], Bismuth Subcitrate Potassium, Metronidazole, Tetracycline 140-125-125mg Oral capsule, Bismuth Subcitrate Potassium/Metronidazole/Tetracycline Hydrochloride 140 MG-125 MG-125 MG Oral Capsule, bismuth subcitrate potassium/metroNIDAZO/TCN 140 mg-125 mg-125 mg oral capsule, bismuth subcitrate potassium/metronidazo/TCN 140 mg-125 mg-125 mg oral capsule, bismuth subcitrate 140 MG / Metronidazole 125 MG / tetracycline hydrochloride 125 MG Oral Capsule, bismuth subcitrate 140 MG / metroNIDAZOLE 125 MG / tetracycline hydrochloride 125 MG Oral Capsule, COLLOIDAL BISMUTH SUBCITRATE/METRONIDAZOLE/TETRACYCLINE HCL@140 mg-125 mg-125 mg@ORAL@CAPSULE (HARD, SOFT, ETC.), BISMUTH/METRONID/TETRACYCLINE 140 mg-125 mg-125 mg ORAL CAPSULE, COLLOIDAL BISMUTH SUBCITRATE/METRONIDAZOLE/TETRACYCLINE HCL@140 mg-125 mg-125 mg@ORAL@CAPSULE, COLLOIDAL BISMUTH SUBCITRATE/METRONIDAZOLE/TETRACYCLINE HCL 140 mg-125 mg-125 mg ORAL CAPSULE (HARD, SOFT, ETC.), COLLOIDAL BISMUTH SUBCITRATE/METRONIDAZOLE/TETRACYCLINE HCL 140 mg-125 mg-125 mg ORAL CAPSULE, BISMUTH/METRONID/TETRACYCLINE 140 mg-125 mg-125 mg ORAL CAPSULE (HARD, SOFT, ETC.), bismuth subcitrate 140 MG / metroNIDAZOLE 125 MG / tetracycline HCl 125 MG Oral Capsule
Derived from the NIH UMLS (Unified Medical Language System)

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