Helicobacter pylori Infection Modulates Reflux Esophagitis Severity in Obesity: Paradoxical Associations from a Retrospective Cohort Study

Background Reflux esophagitis (RE) is common in obese individuals and impairs quality of life. We aimed to investigate the association between RE and Helicobacter pylori (Hp) infection in obese patients and provide evidence for Hp management strategies in this population. Methods A retrospective cohort study was conducted on obese patients (BMI ≥ 28 kg/m²) scheduled for bariatric surgery between July 2019 and June 2023. Patients were categorized into RE and non-RE groups based on endoscopic findings. Demographic, metabolic and Hp infection data were analyzed using t-tests, chi-square tests and logistic regression. Results Among 548 patients, the RE prevalence was 34.1%. The Hp-positive rate was significantly lower in the RE group (21.6% vs. 37.0%, P = 0.004), and Hp infection severity (ΔDOB 3.28 vs. 6.12, P = 0.002) was reduced in RE patients. Mild RE (LA-A) was more common in Hp-negative patients (19.1% vs. 9.6%, P = 0.023). Subgroup analyses revealed stronger Hp-associated protection in females and in obese patients with BMI over 32.5kg/m ² . After adjusting confounders, Hp infection remained inversely associated with RE risk (OR = 0.416, 95% CI: 0.245–0.709). Conclusions Hp infection is inversely correlated with RE in obese populations, particularly among females. These findings challenge the universal eradication of Hp in obese patients and highlight the need for tailored management strategies to avoid exacerbating reflux symptoms.