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The fifth revision (2024) of the Guidelines for the Diagnosis and Treatment of Helicobacter pylori Infection, published by The Japanese Society for Helicobacter Research (JSHR), was developed fully in accordance with the Minds (Medical Information Network Distribution Service) Clinical Practice Guideline Development Manual 2020, ver. 3.0 []. Evidence was appraised using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework, which categorizes evidence quality into four levels (A‒D) and recommendations as either “Strong” or “Weak” []. The predetermined agreement level was defined as 70% in the guidelines. Consensus on clinical questions (CQs) was achieved through a modified Delphi process and a nominal group technique, requiring the participation of at least two-thirds of committee members. Each CQ underwent structured voting using five response options, and the recommendations were finalized according to predefined thresholds. Limited yet clinically meaningful evidence, such as non– Helicobacter pylori Helicobacter species, was retained rather than reclassified as future research questions (FRQs). The guidelines provided recommendations based on scientific evidence, with the validity of each medical practice related to Helicobacter pylori ( H. pylori ) infection management, and several CQs included recommendations for therapies or tests that are not covered by the national health insurance system in Japan. The primary objective of the guidelines is not merely to reflect current routine clinical practice or insurance coverage but rather to present optimal diagnostic and therapeutic strategies based on scientific evidence. When considering such non-covered medical practices, approval from the institution’s ethics committee is required in each practical setting. It is also necessary to ensure that decisions are made by specialists for the implementation of the most appropriate treatment while considering the patients’ values and preferences as needed.

Updates in the current revision include the reassessment of diagnostic accuracy during proton-pump inhibitor (PPI) use, incorporation of potassium-competitive acid blockers (P-CABs) in first-line eradication therapy, and recommendation of drug susceptibility testing prior to eradication therapy. The most updated and informative flowchart of H. pylori therapy is shown. The 2024 guidelines also highlight the importance of early detection and eradication of H. pylori infection during junior high school as a preventive strategy against gastric cancer. Furthermore, the guidelines retain best-practice CQs supported by limited evidence, including data from single-arm studies, thereby maintaining a focus on pediatric and adolescent management while anticipating future updates as new data become available. This article provides an overview of each CQ across four domains—diagnosis, treatment, and prevention of gastric cancer in adults as well as adolescent populations—and includes selected background questions (BQ) within the diagnostic and therapeutic sections.

Are gastroscopy images useful for diagnosing current H. pylori infection? Endoscopic images can classify H. pylori infection status, making them useful for diagnosing current infections. Comment: In 2014, the endoscopy-based Kyoto Classification of Gastritis was established to assess H. pylori infection and gastric cancer risk []. For current infection, it identifies diffuse redness (loss of regular arrangement of collecting venules) and mucosal swelling as “frequently observed,” whereas enlarged folds and sticky mucus are “observed” (Fig. a). Yoshii et al. quantified the diagnostic odds ratios for these findings and found that diffuse redness (26.8) was the strongest predictor, followed by mucosal swelling (13.3), sticky mucus (10.2), and enlarged folds (8.6) []. Improvement in diffuse redness is an indicator of successful eradication. Recent advances in Linked Color Imaging (linked color imaging) have enhanced sensitivity for detecting H. pylori infection by effectively highlighting features such as diffuse redness (Fig. b) []. What is important for the accurate diagnosis of H. pylori infection, particularly during administration of PPIs? Use of multiple diagnostic tests is recommended to diagnose H. pylori infection accurately. Urea breath test (UBT), rapid urease test (RUT), and pepsinogen (PG) levels cannot be used during PPI.

Comment: No diagnostic test has 100% sensitivity or 100% specificity. Diagnostic test results should be interpreted based on the endoscopic findings of the gastric mucosa []. Additional tests should be performed if the diagnostic test results are inconclusive. Since PPI administration suppresses H. pylori urease activity, UBT and RUT are not reliable during PPI therapy []. In contrast, the domestic stool antigen test (SAT) based on a monoclonal antibody can be used during PPI administration after local validation [, ]. Nucleic acid amplification test (NAAT) using intragastric fluid is also not influenced by PPI administration (Table ) []. Both UBT and SAT are recommended for evaluating eradication therapy results [].

Is UBT recommended for diagnosing H. pylori infection? UBT is recommended for diagnosing H. pylori infection before and after eradication. (Recommendation: strong (100% strong agreement), evidence level B). Comment: Appropriate cutoff values for UBT in diagnosing H. pylori infection before and after eradication are 2.5‒3.5‰ and 3.5‒4.0‰, respectively. Before eradication, the sensitivity and specificity were 96.2‒100% and 83.3‒100%, respectively, with a cutoff value of 2.5‰ [, ]. After eradication, the sensitivity and specificity were 66.7‒100% and 95.8‒98.8%, respectively, with a cutoff value of 3.5‰ []. Assessment of H. pylori eradication should be performed at least 4‒6 weeks after treatment. However, UBT may yield false-positive results owing to the presence of urease-positive bacteria other than H. pylori [, ] . The UBT may yield false-negative results during antibiotic or PPI/P-CAB use; therefore, antibiotics should be discontinued for 4 weeks and PPI/P-CAB for 2 weeks before testing [].

Is H. pylori eradication recommended based on a positive serum H. pylori antibody test result? Starting eradication based solely on a positive serum antibody test result is not recommended, since serum antibodies do not only reflect current infection status. (Recommendation: strong (91.3% strong agreement), evidence level B). Comment: Accuracy of serum antibody tests depends on the H. pylori strain from which the antigen is extracted; thus, local validation is important []. In Japan, enzyme immunoassays (EIA) are widely used in serum antibody kits. Recently, many facilities have adopted the latex method, mainly H. pylori -latex ‘Seiken’ (Denka Co., Ltd., Tokyo, Japan). The Denka latex kit diagnoses H. pylori infection with a sensitivity of 86‒98.1% and specificity of 78.0‒95%, using a cutoff value of 10.0–10.8 U/mL []. H. pylori infection should be comprehensively diagnosed using endoscopic findings (such as Kyoto Classification of Gastritis) combined with tests such as serum antibodies, UBT, SAT, RUT, histopathology, culture, and NAAT [, ]. Serum antibody titers decrease by less than half within 6 months after H. pylori eradication, making them a potential indicator of successful eradication [, ].

Is antibiotic susceptibility testing of H. pylori necessary before initiating eradication therapy? Antibiotic susceptibility testing should be performed before initiating H. pylori eradication, and the eradication regimen expected to achieve the highest eradication rate should be selected. NAAT is also useful for detecting bacterial genetic mutations associated with clarithromycin (CAM) susceptibility. (Recommendation: strong (77.3% strong agreement), evidence level A). Comment: CAM resistance is a critical factor that hinders H. pylori eradication. In Japan, the CAM-resistance rate remains high (35.5%), although resistance to amoxicillin (AMPC) and metronidazole (MNZ) is low []. Japanese studies comparing individualized regimens (P-CAB, AMPC, CAM, or MNZ) based on susceptibility testing with empirical regimens (P-CAB, AMPC, and CAM) found that individualized treatment achieved significantly higher eradication rates and reduced costs [, ]. Traditional culture-based sensitivity testing is time-consuming; however, new molecular diagnostic methods offer advantages. NAAT can detect mutations in the CAM-resistance gene (23S rRNA) from gastric fluid within approximately 1 h with a high accuracy (97.0%), enabling rapid, tailored treatment []. Continued surveillance of antibiotic resistance trends is essential for optimizing eradication regimens.

Is serum pepsinogen (PG) test useful for diagnosing H. pylori infection? PG II levels and the PG I/II ratio are useful auxiliary diagnostic tools for H. pylori infection. An increase in the PG I/II ratio after treatment is useful for assessing successful H. pylori eradication. However, these methods do not directly detect bacteria or their components. (Recommendation: weak (40.9% strong, 36.4% weak agreement), evidence level C). Comment: The serum PG test is a non-invasive blood test that reflects gastric inflammation and serves as a useful auxiliary tool for diagnosing H. pylori . For infection diagnosis, high PG II levels (sensitivity, 86.5‒90.0%; specificity, 66.0‒90.7%) or a low PG I/II ratio (sensitivity, 86.8‒89.0%; specificity, 79.6‒89.9%) are effective indicators [, ]. To confirm H. pylori eradication, successful treatment reduces inflammation and increases the PG I/II ratio. Criteria based on the percentage increase relative to pretreatment levels demonstrate high performance (sensitivity, 87.8‒100%; specificity, 83.3‒97.2%) [–].

Treatment flowchart for evidence-based eradication therapy for H. pylori infection in Japan is shown in Fig. . It is recommended that all infected individuals undergo eradication treatment and receive antimicrobial susceptibility testing before eradication therapy. Consultation with a specialist is essential for rescue therapies or eradication treatments in special situations. The metronidazole-based regimen is not covered by the current Japanese health insurance as the first-line eradication therapy and should be prescribed with caution for infections caused by metronidazole-resistant bacteria and because of safety concerns.

What is the optimal dosage of CAM for first-line eradication therapy: 400 mg/day or 800 mg/day? The recommended CAM dose for first-line eradication is 400 mg/day (200 mg twice daily). Comment: A systematic review and meta-analysis evaluated the optimal dosage of CAM in first-line 7-day triple therapy for H. pylori eradication, which consists of a PPI, vonoprazan (VPZ), AMPC, and CAM. It compared the efficacy and safety of 400 mg/day versus 800 mg/day of CAM [–]. A meta-analysis of eight randomized controlled trials (RCTs) in Japan found no significant difference in eradication rates between the two dosages (odds ratio (OR), 0.92; 95% confidence interval (CI), 0.73‒1.17). This evidence had high certainty and low heterogeneity (Fig. a). Regarding safety, a meta-analysis of four RCTs showed a significantly higher frequency of adverse events at 800 mg/day (OR, 1.35; 95% CI, 1.08‒1.68). Although no serious safety concerns were identified in either group, the increased incidence of side effects at higher doses was notable (Fig. b). In Japan, given that the 800 mg/day dose offers no superior eradication benefit and is associated with a higher frequency of adverse events, the 400 mg/day dose (200 mg twice daily) is recommended. What is the optimal treatment duration for H. pylori eradication therapy? In Japan, H. pylori eradication therapy is recommended for 7 days.

Comment: A meta-analysis comparing 7-day and 14-day eradication regimens showed that while the 14-day regimen increased the rates of adverse events in the PPI + AMPC + CAM (PAC) regimen (16.0% vs. 19.6%, p = 0.01), it significantly improved the eradication rate (74.9% vs. 83.5%, p < 0.001) []. Based on this evidence, the clinical international guidelines and consensus reports for H. pylori infection recommend a 14-day PAC regimen over a 7-day regimen [, ]. In contrast, in an RCT conducted in Japan comparing 7-day and 14-day PAC regimens, no significant difference was observed between the two groups []. When VPZ was used, equivalent results were observed with both the 7-day VPZ + AMPC + CAM (VAC) and 14-day PAC regimens, which carry a higher risk of adverse events []. Therefore, VAC is the standard treatment in Japan.

Should H. pylori eradication therapy be performed in elderly patients? H. pylori eradication therapy is beneficial for older adult patients, effectively preventing short-term peptic ulcer recurrence, and showing good tolerability. (Recommendation: weak (38.1% strong, 33.3% weak agreement), evidence level C). Comment: Large cohort studies and randomized trials in populations aged ≥ 60 or ≥ 65 years have demonstrated significant reductions in gastric cancer incidence, especially after long-term follow-up (standardized incidence ratio, 0.42; 95% CI, 0.18–0.84) [], as well as marked prevention of ulcer relapse []. In older adult aspirin users, eradication reduced the risk of ulcer bleeding within 2.5 years []. Adverse events occurred in only 8.5–9.7% of older adult patients, similar to the rates observed in younger adults []. Moreover, cost-effectiveness analyses indicate that screening and eradication in individuals aged 60–80 years yield a greater quality-adjusted life year at lower costs than no intervention []. Overall, H. pylori eradication in older adults appears to be effective, safe, and economically reasonable, although data for those aged ≥ 80 years remain limited.

Which acid-suppressing drug is better for H. pylori eradication therapy: VPZ or PPI? VAC is strongly recommended as first-line therapy, regardless of CAM susceptibility. For second-line therapy, either PPI + AMPC + MNZ (PAM) or VPZ + AMPC + MNZ (VAM) is recommended. (Recommendation: strong (90% strong agreement), evidence level A). Comment: VPZ-based first-line regimens demonstrated significantly higher eradication rates than PPI-based regimens (intent-to-treat, ITT analysis: 87.6% vs. 70.8%), as shown in the meta-analyses in Fig. a. This advantage was particularly pronounced in CAM-resistant strains (75% vs. 38%). For second-line therapy, the success rates were comparable between the VPZ- and PPI-based regimens, as shown in the meta-analyses in Fig. b. Side effect rates do not differ significantly between the regimens [, –]. VPZ-based regimens can be more cost-effective because they reduce the need for second-line treatments []. Recommended regimens First-line eradication: VAC (20 mg/750 mg/200 mg) bid for 1 week Second-line eradication: VAM (20 mg/750 mg/250 mg) bid for 1 week or PAM (standard dose*/750 mg/250 mg) bid for 1 week *: esomeprazole 20 mg, rabeprazole 10 mg, or lansoprazole 30 mg.

In first-line eradication therapy, which is more useful: routine insurance-covered standard triple therapy or tailored eradication? For first-line H. pylori eradication, tailored eradication therapy based on antimicrobial susceptibility testing yields higher eradication rates than standard triple therapy and is, therefore, recommended. As adverse events and drug–drug interactions can occur, patient-specific selection of agents is advised. (Recommendation: strong (100% strong agreement), evidence level A). Comment: A meta-analysis of RCTs comparing PAC with susceptibility-guided regimens demonstrated the superiority of tailored eradication (risk ratio (RR), 3.11; 95% CI, 1.96–4.94) (Fig. c). In Japan, VAC is standard and effective against CAM-susceptible strains but is less effective against resistant strains. A nationwide cohort study reported eradication rates of 96.3% in CAM-susceptible and 82.9% in resistant strains, and substituting CAM with MNZ achieved 98.0% eradication []. A single-center study similarly showed 94.0% eradication with standard therapy versus 98.5% with MNZ-based therapy []. These findings confirm the benefits of susceptibility-guided therapies. Personalization should also consider comorbidities and cytochrome P450-mediated interactions. Tailored eradication in the first-line stage maximizes both efficacy and safety.

What regimen should be selected when antimicrobial susceptibility testing is performed prior to first-line therapy? If the strain is susceptible to CAM, VAC is recommended. In cases of CAM resistance, one of the following regimens should be selected based on susceptibility testing for MNZ and fluoroquinolones: VAM, VPZ + AMPC + sitafloxacin (STFX), VAS for 1 week, or VPZ + AMPC (VA) for 2 weeks. (Recommendation: strong (100% strong agreement), evidence level B). Comment: Antimicrobial susceptibility testing-guided eradication regimens achieve significantly higher success rates than standard triple therapy [–]. Susceptibility testing was conducted using 23S rRNA and gyrA mutation detection or agar dilution methods. VPZ is known to be superior to PPIs as an acid suppressant. STFX is preferred over levofloxacin (LVFX). Recommended regimens. •CAM-susceptible: VAC (20 mg/750 mg/200 mg) bid for 1 week •CAM-resistant, MNZ-susceptible: VAM (20 mg/750 mg/250 mg) bid for 1 week •CAM-resistant, MNZ-unknown, and quinolone-susceptible strains: VAS (20 mg/750 mg/100 mg) bid for 1 week CAM-resistant, MNZ-unknown, and quinolone-resistant/unknown: VAM or VA (20 mg bid/500 mg qid) for 2 weeks CAM-resistant, MNZ-resistant, and quinolone-susceptible: VAS (20 mg/750 mg/100 mg) bid for 1 week

CAM-resistant, MNZ-resistant, and quinolone-unknown: VAS (20 mg/750 mg/100 mg) bid for 1 week or VA (20 mg bid/500 mg qid) for 2 weeks CAM-resistant, MNZ-resistant-, and quinolone-resistant: VA (20 mg bid/500 mg qid) for 2 weeks

Which eradication therapy should be selected if susceptibility testing is not performed at first-line therapy? •The recommended eradication regimens are either VAC or PAM. (Recommendation: strong (90.5% strong agreement), evidence level A). Comment: The prevalence of CAM-resistant strains in Japan currently exceeds 30% []. For patients living in areas with high CAM-resistance rates (> 15%), the Maastricht VI/Florence Consensus Report suggests that first-line therapy using CAM should not be selected when susceptibility testing is not performed before eradication []. In Japan, with low MNZ- and high CAM-resistance rates (approximately 5% and > 30%, respectively), the PAM regimen shows a higher eradication rate than the PAC regimen in meta-analyses (Fig. a) []. However, evidence of VAM efficacy is insufficient. Given that the degree and duration of acid inhibition are related to eradication rates [], the VAC regimen demonstrates higher efficacy than the PAC regimen (Fig. b). Recommended regimens. VAC (20 mg/750 mg/200 mg) bid for 1 week PAM (standard dose/750 mg/250 mg) bid for 1 week

What is the recommended second-line eradication regimen when AMPC and CAM are selected for first-line therapy? Either 7-day VAM or PAM regimen is recommended. (Recommendation: strong (85.0% strong agreement), evidence level A). Comment: Regional variations in antibiotic resistance profiles necessitate tailored H. pylori eradication strategies [, ]. Globally, high MNZ (> 30%) and moderate CAM (10–20%) resistance often favors bismuth- or fluoroquinolone-based second-line therapies. However, in Japan, the pattern is unique, with high CAM resistance (30–40%) but exceptionally low MNZ resistance (< 5%) [, ]. Consequently, MNZ-containing regimens are the standard second-line therapy. A meta-analysis confirmed that MNZ-containing regimens had significantly lower failure rates (OR, 0.55; 95% CI, 0.39–0.78) than MNZ-free regimens, proving superior in both low- (OR 0.29) and high-resistance (OR 0.66) regions (Fig. c) []. Many Japanese studies have reported high eradication rates (ITT > 80%, per-protocol, PP > 90%) []. VPZ further enhanced these results [, ], highlighting regional optimization. Recommended regimens. VAM (20 mg/750 mg/250 mg) bid for 1 week PAM (standard dose/750 mg/250 mg) bid for 1 week

What is the recommended rescue therapy for CAM-resistant patients failing first-line VPZ/PPI + AMPC + MNZ? Potential therapeutic options include PPI + AMPC (PA), either as 14-day dual therapy or as triple therapy combined with rifabutin (RFB) or a quinolone. (Recommendation: weak (42.1% strong, 52.6% weak agreement), evidence level B). Comment: CAM-resistant patients who fail first-line MNZ-based therapy are presumed to have dual (CAM/MNZ) resistance. As no studies exist specifically for such populations, evidence was extrapolated from RCTs and subgroup analyses of patients with confirmed dual resistance. Among primary RCTs, a 14-day furazolidone/bismuth quadruple therapy showed the highest efficacy (95.2%) []. However, these drugs have not been approved in Japan. Other regimens with moderate efficacy include 14-day PA high-dose dual therapy [, ] and 7-day RFB-based triple therapy (PPI + AMPC + RFB [PAR]) []. A subgroup analysis also reported the high efficacy of a 14-day quinolone-based triple therapy (PPI + AMPC + LVFX; PAL) []. The PPI+AMPC+quinolone triple therapy showed acceptable safety profiles, as confirmed by Japanese trials [, ]. Recommended regimens: •High-dose PA (AMPC 3 g/day) for 2 weeks •PAR (AMPC 2 g, REB 300 mg/day) for 1 week •PAL (AMPC 2 g, LVFX 500 mg/day) for 2 weeks

Recommended third-line eradication therapy in Japan? A 7-day VAS triple therapy is preferred, anticipating the highest eradication rate and acceptable safety. Alternative regimens include PAS, PPI + MNZ + STFX (PMS), and VPZ + AMPC + RFB (VAR). (Recommendation: weak (36.8% strong, 63.2% weak agreement), evidence level A). Comment: CQ2-8 addresses the optimal third-line H. pylori therapy in Japan following the failure of standard 7-day first-line (CAM-based) and second-line (MNZ-based) triple therapies. A systematic review (17 studies: 6 RCTs and 11 single-arm studies) and network meta-analysis (NMA) of five RCTs were conducted (Fig. a). The NMA found that 7-day VAS likely yielded the highest eradication rate (RR, 2.73; 95% CI, 0.89–8.34) compared to PPI-based alternatives (Fig. b). However, the evidence quality was moderate owing to imprecision (CI crossed 1.0) [–]. Single-arm studies support this regimen (approximately 90% efficacy). Although most therapies have reported no major safety issues, PAR was terminated early because of its poor tolerability. VAR also demonstrated promising efficacy (> 90%). Recommended regimen: VAS (20 mg/750 mg/100 mg) bid for 1 week.

When should dual therapy with VA be selected? In first-line eradication therapy, we recommend dual therapy with the VA regimen when H. pylori is resistant to CAM or when there is a risk of disadvantages related to the second antimicrobial agent, such as CAM, MNZ, and STFX. (Recommendation: weak (36.8% strong, 63.2% weak agreement), evidence level A). Comment: A meta-analysis showed no significant difference in eradication rates between VA and VAC (pooled RR, 0.98; 95% CI, 0.95‒1.01; p = 0.100) [, –]. However, the VAC eradication rate for CAM-susceptible strains was higher than that for VA []. In two Japanese studies, eradication rates exceeded 90% when VPZ 20 mg bid and 500 mg of AMPC were administered tid or qid [, ].

What eradication regimen should be selected for patients with penicillin allergy? For patients with penicillin allergy, H. pylori eradication should be guided by antimicrobial susceptibility testing whenever possible. Suitable regimens include VPZ + CAM + MNZ (VCM), VPZ + MNZ + STFX (VMS), or PPI + MNZ + STFX (PMS). Comment: Internationally, bismuth-containing quadruple therapy is widely recommended and achieves high eradication rates in patients with penicillin allergy. In Japan, a prospective study reported 100% eradication with a VPZ-based regimen and VCM compared with 83.3% with a PPI-based regimen and PCM [], with consistent findings in retrospective cohorts [, ]. Rescue regimens using VMS/PMS achieved eradication rates of 88.2–100% [, ]. However, efficacy is markedly reduced in strains resistant to both MNZ and STFX []. Therefore, susceptibility-guided antibiotic selection is recommended. Although the above regimens appear feasible, the current evidence remains insufficient. Recommended regimens. VPZ (20 mg bid), CAM (200/400 mg bid), and MNZ (250 mg bid) for 1 week VPZ (20 mg bid), MNZ (250 mg bid), and STFX (100 mg bid) for 1 week. PPI, standard dose bid, MNZ (250 mg bid), and STFX (100 mg bid) for 1 week.

What regimen should be selected for patients with impaired renal function? In patients with impaired renal function, VCM—administered with an appropriate dose reduction of antibiotics based on renal function—is recommended, whereas VAC is considered the next alternative. However, the indications for treatment should be carefully considered. (Recommendation: strong (84.2% strong agreement), evidence level C). Comment: According to an RCT comparing the effects of PCM and PAC in patients with impaired renal function, PCM was superior to PAC in terms of the incidence of acute renal failure and eradication rates []. The recommended regimens for patients with impaired renal function include VPZ, CAM, and MNZ []. Three studies evaluating the effects of PAC therapy in patients with and without chronic kidney disease demonstrated similar eradication rates and adverse effects in both groups [–]. VAC at reduced doses, depending on renal function, remains a potential option.

Which eradication therapy should be selected in patients receiving hemodialysis? For patients receiving hemodialysis, the AMPC dose should be reduced to 250 mg (one-third dose), and the recommended regimen is PAC. (Recommendation: weak (58.0% strong, 42.0% weak agreement), evidence level C). Comment: Given the delayed pharmacokinetics of AMPC, adverse effects should be minimized []. A recent meta-analysis demonstrated comparable eradication rates between patients and healthy individuals, both with the same and reduced dosage regimens (RR, 0.85; 95% CI, 0.48–1.50) []. The adverse event rates in the reduced-dose regimen were similar to those in healthy individuals (1.26 [0.23–6.99]) []. From a pharmacological perspective, the regimen should consider the dosage (1/2 to 1/3), dosing frequency (bid), and dosing timing (after hemodialysis) []. There is no evidence of VPZ-based eradication regimens in patients undergoing hemodialysis. Recommended regimen. PPI (standard dose bid) + AMPC (250 mg bid) + CAM (200 mg bid) for 1 week. *Hemodialysis in the morning: On hemodialysis days, medications after hemodialysis ends and with dinner. *Hemodialysis in the afternoon or evening: On hemodialysis days, medications should be administered after breakfast before hemodialysis.

What is the recommended eradication regimen for patients with hepatic impairment? Standard regimens are options for hepatic impairment; however, indications require careful assessment of the severity and eradication of hepatic dysfunction. Adverse events should be closely monitored during treatment. (Recommendation: weak (35.0% strong, 65.0% weak agreement), evidence level B). Comment: Most H. pylori eradication drugs are metabolized in the liver, and hepatic dysfunction may affect treatment outcomes. Although randomized controlled trials are lacking, observational studies have reported comparable efficacy and safety in patients with liver disease and those with normal hepatic function. Eradication rates remained high in patients with cirrhosis/chronic hepatitis and nonalcoholic fatty liver disease/nonalcoholic steatohepatitis, without significant adverse events [–]. Pharmacokinetic studies have shown reduced clarithromycin metabolism in patients with severe hepatic dysfunction, but without clinically relevant effects on clearance or safety. Therefore, standard regimens are generally applicable with careful assessment and monitoring. Recommended regimens. VPZ (20 mg bid) or EPZ (20 mg bid) + AMPC (750 mg bid) and CAM (200 mg bid) for 1 week VPZ (20 mg bid) or EPZ (20 mg bid) + AMPC (750 mg bid) and MNZ (250 mg bid) for 1 week