Screening and Management of Helicobacter Pylori and Gastric Intestinal Metaplasia in Bariatric Surgery: Clinical Implications and a Decision Framework

Helicobacter pylori (HP) infection and gastric intestinal metaplasia (GIM) are commonly identified during the evaluation of patients undergoing metabolic and bariatric surgery (MBS) and carry important clinical implications. However, MBS-specific guidance addressing preoperative evaluation, eradication strategies, procedural selection, and long-term risk mitigation remains limited. We conducted a narrative review supported by a structured literature search and U.S. society guideline documents to synthesize evidence from the gastroenterology and MBS literature and to propose a pragmatic clinical decision framework for contemporary practice. Particular emphasis was placed on preoperative endoscopic findings; approaches to HP testing, eradication, and confirmation of cure; associations with perioperative outcomes; risk of marginal ulceration; feasibility of postoperative gastric surveillance; and the risk of non-cardia gastric malignancy following MBS.Routine high-quality preoperative endoscopy with systematic gastric biopsies frequently identifies HP infection and/or GIM, findings that may alter both medical and surgical management. When HP infection is detected, treatment should be completed and eradication confirmed, as persistent infection appears to be associated with higher rates of marginal ulceration following Roux-en-Y gastric bypass (RYGB). The presence of GIM introduces considerations related to long-term gastric cancer risk and the feasibility of postoperative surveillance, both of which are significantly influenced by surgical anatomy.In summary, HP infection should be systematically tested for, treated, and eradication confirmed prior to MBS. In patients with GIM, procedure selection should balance metabolic effectiveness with the ability to perform postoperative surveillance and mitigate long-term malignancy risk. In this context, sleeve gastrectomy or RYGB with concomitant resection of the gastric remnant may be appropriate in carefully selected patients.