Therapeutic ReviewsRole of Bismuth in the Eradication of Helicobacter pyloriAlkim, Huseyin MD*; Koksal, Ali Riza MD; Boga, Salih MD; Sen, Ilker MD; Alkim, Canan MDAuthor Information Department of Gastroenterology, Sisli Hamidiye Etfal Training and Research Hospital, Sisli, Istanbul, Turkey. Address for correspondence: Associated Professor of Gastroenterology, Department of Gastroenterology, Sisli Hamidiye Etfal Education and Research Hospital, Etfal Street, 34265 Sisli, Istanbul, Turkey. E-mail: firstname.lastname@example.org The authors have no conflicts of interest to declare. American Journal of Therapeutics: November/December 2017 - Volume 24 - Issue 6 - p e751-e757 doi: 10.1097/MJT.0000000000000389 Buy Metrics Abstract Bismuth salts exert their activity within the upper gastrointestinal tract through action of luminal bismuth. Bismuth exerts direct bactericidal effect on Helicobacter pylori by different ways: forms complexes in the bacterial wall and periplasmic space, inhibits different enzymes, ATP synthesis, and adherence of the bacteria to the gastric mucosa. Bismuth also helps ulcer healing by acting as a barrier to the aggressive factors and increasing mucosal protective factors such as prostaglandin, epidermal growth factor, and bicarbonate secretion. To date, no resistance to bismuth has been reported. Also synergism between bismuth salts and antibiotics was present. It was shown that metronidazole and clarithromycin resistant H. pylori strains become susceptible if they are administered together with bismuth. Bismuth-containing quadruple therapy was recommended both by the Second Asia-Pacific Consensus Guidelines and by the Maastricht IV/Florence Consensus Report as an alternative first choice regimen to standard triple therapy, in areas with low clarithromycin resistance, and it is recommended as the first-line therapeutic option in areas with a high prevalence of clarithromycin resistance. Greater than 90% eradication success can be obtained by bismuth-containing quadruple therapy. Choosing bismuth as an indispensable part of first-line therapy is logical as both metronidazole and clarithromycin resistances can be overcome by adding bismuth to the regimen. Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.