To eradicate or not? Helicobacter pylori in patients with inflammatory bowel disease: an updated systematic review and meta-analysis

Background and aims The management of Helicobacter pylori ( H. pylori ) in patients with inflammatory bowel disease (IBD) presents a common clinical dilemma. While standard guidelines recommend H. pylori eradication to prevent gastric pathology, emerging evidence suggests a potential complex relationship with IBD. This study aims to critically evaluate this relationship through an updated systematic review and meta-analysis to inform clinical decision-making. Methods A comprehensive literature search on four major databases, PubMed, Embase, Medline, and Web of Science, was conducted, and all records before July 10th, 2025, were retrieved for screening. Pooled odds ratios (OR) with 95% confidence intervals (CIs) were calculated using STATA 18 software and a random-effects model (Restricted Maximum Likelihood, REML). Subgroup analyses, meta-regression, heterogeneity, sensitivity, and publication bias analyses were performed. Results Analysis of 44 studies involving 14,100 IBD patients and 291,352 controls revealed a significantly lower prevalence of H. pylori infection in IBD patients compared to controls (13.48% vs. 10.87%; OR: 0.43, 95% CI: 0.35–0.53, p < 0.01). This negative association was particularly strong for Crohn’s disease (OR: 0.36, 95%CI: 0.28–0.45) and in Eastern populations (OR: 0.34, 95%CI: 0.26–0.40). Heterogeneity was high (I 2 = 84.93%), but sensitivity analysis confirmed the robustness of the findings. No significant publication bias was detected. Conclusion This meta-analysis demonstrates a significant negative association between H. pylori infection and IBD, particularly in patients with Crohn’s disease and those of Eastern population. Furthermore, H. pylori may exert a potential immunomodulatory role in IBD. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/view/CRD42024567688 , CRD42024567688.