Persistent Dyspepsia Following H. Pylori Eradication: An Endoscopic and Histopathological Assessment in an Egyptian Cohort

Background: While Helicobacter pylori (H. pylori) eradication is a key component in managing dyspepsia, a significant subset of patients continues to experience persistent symptoms despite confirmed microbial clearance. The underlying mechanisms and endoscopic-histological correlates of this phenomenon remain poorly defined, particularly in endemic regions. Aim: To evaluate clinical, endoscopic, and histopathological features in Egyptian patients with persistent dyspepsia following confirmed H. pylori eradication. Methods: In this cross-sectional study, 70 adult patients with a documented history of H. pylori infection, successful bismuth-based quadruple therapy, negative monoclonal stool antigen (HpSAT), and persistent dyspepsia were enrolled. All patients underwent laboratory assessment, abdominal ultrasound, upper endoscopy, and gastric biopsies assessed according to the updated Sydney system. Results: Common symptoms included epigastric pain (75.7%), nausea (74.3%), and early satiety (68.6%). Ultrasound identified fatty liver in 28.6% and colonic gaseous distension in 11.4%. Endoscopy revealed pangastritis in 57.1%, atrophic changes in 24.3%, duodenitis in 61.4%, and bile reflux in 4.3%. Despite negative stool antigen tests, chronic gastritis persisted in 94.3% of patients histologically, and active inflammation was still present in 38.6%. Conclusion: Persistent dyspepsia after H. pylori eradication is frequently associated with ongoing mucosal inflammation and structural abnormalities, undetected by stool antigen testing alone. These findings underscore the need for follow-up endoscopy and biopsy in symptomatic patients, especially in high-prevalence settings, to evaluate mucosal healing, detect residual pathology, and guide targeted management.