Endoscopic features of Helicobacter pylori (H. pylori) gastritis may reflect bacterial load and mucosal damage, potentially influencing therapeutic response. This study aimed to evaluate the relationship between endoscopic findings and eradication outcomes among patients receiving empirical quadruple therapy in Kairouan, Tunisia.

A retrospective study was conducted including 89 adults with histologically confirmed H. pylori infection who received a 14-day empirical quadruple therapy between January and August 2024. Endoscopic abnormalities (erythema, nodularity, mosaic pattern, erosions, ulcer disease) and histology-based gastritis grading were collected. Eradication was assessed through stool antigen testing, follow-up endoscopy, or clinical improvement. An univariate analysis explored associations between endoscopic features and treatment success.

Endoscopy revealed gastric erythema in 92.1% of patients, nodularity in 21.3%, mosaic pattern in 15.7%, erosions in 16.9%, and gastric or duodenal ulcer in 8.9%. The overall first-line eradication rate was 69.7%, and the global eradication rate reached 75.2%. Patients with ulcer disease showed lower eradication rates (62,5%) compared with those without ulcers (70,3%). Nodularity and erosions were more frequently associated with moderate to severe H. pylori density on histology (p = 0,027 and 0,033 respectively), which was itself linked to a higher rate of therapeutic failure (24,07 % vs 34,03%). In contrast, isolated erythematous gastritis did not significantly affect eradication outcomes (p=0,67).

Specific endoscopic features—particularly nodularity, erosions, and ulcer disease—were associated with lower eradication rates, likely reflecting higher bacterial burden and more advanced mucosal injury. Endoscopic patterns may therefore serve as useful indicators for predicting treatment response and should be considered when tailoring eradication strategies, especially in resource-limited settings.