ASSOCIATION OF HELICOBACTER PYLORI DENSITY WITH ENDOSCOPIC AND HISTOPATHOLOGICAL FINDINGS

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1 Acta Medica Mediterranea, 2018, 34: 663 ASSOCIATION OF HELICOBACTER PYLORI DENSITY WITH ENDOSCOPIC AND HISTOPATHOLOGICAL FINDINGS METE AKIN 1, AZIZ KURTULUS 2, HAYDAR ADANIR 1, MUSTAFA TEKINALP GELEN 3 ¹Akdeniz University School of Medicine, Department of Gastroenterology, Antalya, Turkey - 2 Akdeniz University School of Medicine, Department of Internal Medicine, Antalya, Turkey - 3 Akdeniz University School of Medicine, Department of Pathology, Antalya, Turkey ABSTRACT Introduction: Helicobacter pylori (H. pylori) is a gram negative, unipolar, and spiral-shaped microaerophilic bacteria. Gastric colonization of H. pylori has been established as an etiological factor in chronic gastritis, peptic ulcers, atrophic gastritis, gastric adenocarcinoma, and lymphoma. Only a few studies have examined the effect of H. pylori density on clinical, endoscopic, and histopathological findings. The present study aims to investigate the association of H. pylori density with clinical and endoscopic findings as well as histopathological findings that are particularly observed in atrophy, intestinal metaplasia, and dysplasia. Materials and methods: This study included 105 patients that underwent upper gastrointestinal system endoscopy due to various indications. During endoscopy, biopsies were performed from gastric antrum and corpus and the density of H. pylori was assessed with histopathological examination. Patients were categorized as mild, moderate, and severe density groups according to Sydney classification. Furthermore, these groups were compared in terms of endoscopy indications, endoscopic findings, and histopathological features. Results: H. pylori density was mild in 59 (56%) patients, moderate in 23 (22%) patients, and severe in 23 (22%) patients. The most common indication for endoscopy was dyspeptic complaints. There was no significant difference between the groups in terms of dyspepsia or other endoscopy indications (p > 0.05). The most frequent endoscopic finding was gastritis. Regarding endoscopic findings, only erosive gastritis was found to be significantly more frequent in the moderate and severe H. pylori density groups compared to the mild density group (p=0.03). There was no difference between the groups regarding atrophy, intestinal metaplasia, or dysplasia (p > 0.05). Conclusion: Our results indicate that H. pylori density does not have significant effect on patients' symptoms or endoscopic and histopathological findings. Keywords: Helicobacter pylori, dyspepsia, peptic ulcer, atrophy, intestinal metaplasia, Helicobacter pylori density. DOI: / _2018_3_102 Received November 30, 2017; Accepted January 20, 2018 Introduction Helicobacter pylori (H. pylori) is a Gram negative, spiral-shaped, flagellated, microaerophilic bacteria living between gastric mucus and epithelium (1). Gastric colonization of H. pylori has been established as an etiological factor for development of chronic gastritis, peptic ulcers, atrophic gastritis, gastric adenocarcinoma, and lymphoma (2-5). While the prevalence of H. pylori infection has been on the fall in developed countries, the prevalence reaches 80% and has been continuously high in developing countries (6). Among the diagnostic tests, histopathological examination is the most valuable with both sensitivity and specificity above 90% (7). In 2012, The Updated Sydney System was introduced to aid in histopathological detection and determination of density as well as accompanying lesions (8). Few studies have investigated the effect of H. pylori density on clinical, endoscopic, and histopathological findings.

2 664 Mete Akin, Aziz Kurtulus et Al In this study, we aimed to investigate the association of H. pylori density with endoscopic and clinical findings and histopathological features of patients that underwent upper gastrointestinal system endoscopy due to various indications. Materials and methods The Ethics Committee of Akdeniz University Faculty of Medicine (Issue date: Issue number: 303) approved the study. Patient Selection The study included 105 patients aged 18 years or older that underwent upper gastrointestinal system endoscopy in the Endoscopy Unit in Gastroenterology Department of Akdeniz University Faculty of Medicine between October 2015 and January 2016, who presented with various signs and symptoms. Biopsies were performed from gastric antrum and the corpus in all patients during endoscopy, and H. pylori presence and density were assessed using histopathological examination. Patients were categorized based on H. pylori density as mild, moderate, and severe density groups. The groups were compared in terms of endoscopy indications, endoscopic findings, and histopathological features. Other than the presence of H. pylori, atrophy, intestinal metaplasia, dysplasia, and other signs (i.e. lymphocytic gastritis, regenerative hyperplasia) were also assessed. Statistical Analysis Descriptive statistics such as frequency distribution, mean and standard deviation were used to describe the sample. Categorical data were analyzed with chi-square or Fisher s Exact tests. Statistical analyses were performed using PASW 20 (SPSS/IBM, Chicago, IL, USA) software. The differences were determined with 95% significance level (or α=0.05 error margin). Results Among the 105 patients included in the study, H. pylori density was mild in 59 patients (56%), moderate in 23 patients (22%), and severe in 23 patients (22%). There was no significant difference between the groups regarding distribution of sex, mean age, or distribution of age groups (Table 1). Mild (n=59) H. pylori density Moderate Severe p-value Age (mean ± SD) ± ± ± Age groups, n (%) Endoscopic Evaluation Endoscopy procedure was performed with Fujinon EG-600WR and EG-590WR gastroscopes. For histopathological examination, biopsies were performed from both the antrum and corpus region using standard biopsy forceps (22.03) 1 (4.35) 2 (8.7) (35.6) 14 (60.87) 8 (34.78) (38.98) 7 (30.43) 12 (52.17) - >70 2 (3.39) 1 (4.35) 1 (4.35) Sex, n (%) - Male 26 (44) 9 (39) 10 (44) Histopathological Examination Biopsy samples obtained from gastric the antrum and the corpus regions during endoscopy were examined histopathologically in the Medical Pathology Department following staining with hematoxylin-eosin (H&E), Diff-Quick, and periodic acid shift antibody (PAS-AB). The density of H. pylori was classified according to Sydney System as follows: Mild density: Scattered microorganisms covering less than 1/3 of the surface. Moderate density: H. pylori density between mild and severe. Severe density: Microorganisms are not scattered but are present in large clusters that cover more than 2/3 of the surface (8). - Female 33 (66) 14 (61) 13 (56) Table 1: Distribution of patients according to the age and sex in the mild, moderate, and severe H. pylori density groups. H.pylori: Helicobacter pylori; SD: Standard deviation; n: Number of patients In all three groups, the most common indication for endoscopy was dyspeptic complaints. There was no significant difference between the groups regarding endoscopy indications (Table 2). Also in all three groups, the most frequent endoscopic finding was gastritis. There was no significant difference between the groups regarding presence of gastritis or other endoscopic findings (Table 3).

3 Association of helicobacter pylori density with endoscopic and histopathological findings Endoscopy indications Mild (n=59) H. pylori density Moderate Severe p-value Dyspepsia, n (%) 27 (45.80) 13 (56.50) 10 (43.50) 0.61 Epigastric pain, n (%) 14 (23.70) 4 (17.40) 7 (30.40) 0.58 Reflux, n (%) 9 (15.30) 4 (17.40) 3 (13.00) 0.91 Anemia, n (%) 6 (10.20) 2 (8.70) 2 (8.70) 0.96 GI bleeding, n (%) 1 (1.60) 0 (0.0) 0 (0.0) 1 Other indications, n (%) 2 (3.40) 0 (0.0) 1 (4.4) 1 Table 2: Upper gastrointestinal endoscopy indications of patients in the mild, moderate and severe H. pylori density groups. H.pylori: Helicobacter pylori; GI: Gastrointestinal; n: Number of patients Endoscopic and Histopathological Findings Endoscopic findings, n (%) Mild (n=59) H. pylori density Moderate Severe p-value Gastritis 42 (71.2) 17 (73.9) 14 (60.9) 0.57 Esophagitis 4 (6.8) 2 (8.7) 5 (21.7) 0.19 Erosive Gastritis 1 (1.7) 6 (26.1) 3 (13) 0.03 Normal 6 (10.2) 0 (0) 0 (0) 0.1 Gastric Ulcer 5 (8.5) 0 (0) 0 (0.0) 0.22 Duodenal Ulcer 1 (1.6) 0 (0) 1 (4.4) 0.68 Histopathological findings, n (%) Atrophy 44 (74.6) 14 (60.9) 15 (65.2) 0.42 Intestinal Metaplasia 7 (11.9) 1 (4.3) 1 (4.3) 0.13 Dysplasia 0 (0) 1 (4.3) 1 (4.3) 0.19 Other Pathology 1 (1.7) 2 (8.7) 1 (4.3) 0.22 Table 3: Endoscopic and histopathological findings of patients in the mild, moderate and severe H. pylori density groups. H.pylori: Helicobacter pylori; n: Number of patients When the groups were compared in terms of histopathological findings accompanying H. pylori positivity, no significant difference was observed between the groups regarding histopathological findings such as atrophy, intestinal metaplasia, dysplasia and regenerative hyperplasia, or lymphocytic gastritis (Table 3). Discussion H. pylori is a gram negative, spiral-shaped, and flagellated microaerophilic bacteria with characteristic chemotactic properties, living between the gastric mucus and the epithelium (1). Its host source is only humans, and it colonizes the gastric antrum, corpus, and cardia. Although it is not clearly established, the transmission is thought to be via both fecal-oral and oral-oral route (8,9). H. pylori is known to be an etiological agent in diseases such as chronic gastritis, peptic ulcers, atrophic gastritis, gastric adenocarcinoma, and lymphoma (2,5). In developed countries, H. pylori infection has been observed in 20% of individuals younger than 40 years old, and in 50% of individuals older than 60 years. In developing countries, its prevalence has reached up to 80% (19). The prevalence of H. pylori has been shown to be high in Turkey. One multi-center study using 13C-urea breath test reported a prevalence of 82.5% (11). Another study that investigated H. pylori prevalence with histopathological examination reported this rate as 71.3% (12). Gastric acid production is an important determinant of H. pylori colonization. In one study, Fareed et al. (13) biopsied the antrum, the corpus, and the cardia of 150 patients during endoscopy, and they detected H. pylori positivity rates as 82.7% in the antrum, 74% in the corpus, and 68% in the cardia region. They observed higher H. pylori density in the antrum due to alkaline ph, and found direct association between neutrophil activity and H. pylori density. In our study, endoscopic biopsies were taken from the gastric antrum and the corpus regions. The degree of H. pylori colonization was suggested to have an influence on development of dyspeptic complaints, as well as their severity. In one study, Braden et al. (14) screened 1,500 volunteers with urea-breath test and also performed spectrometric analysis. H. pylori density was graded as mild for delta values between 5-10%, moderate for delta values between 10-20%, and severe for delta values greater than 20%. The urea-breath test results were positive in 535 patients and among these, H. pylori colonization was found to be mild in 201 patients (37.7%), moderate in 223 patients (41.7%), and severe in 111 patients (20.8%), respectively. They found that H. pylori prevalence did not differ between asymptomatic individuals and

4 666 Mete Akin, Aziz Kurtulus et Al patients with dyspeptic complaints, and that there was no association between H. pylori density and frequency of dyspepsia. In another study by Gürel et al. (15), 33 patients diagnosed with functional dyspepsia were examined histopathologically to assess H. pylori density. They did not find any significant association between H. pylori density and frequency of dyspepsia or subtypes of dyspepsia. In our study, H. pylori density was evaluated histopathologically and was found to be mild in 56% of patients, moderate in 22% of patients, and severe in 22% of patients. We did not find any significant difference between the groups regarding frequency of dyspepsia as an endoscopy indication. There is a well-established association between peptic ulcer disease and H. pylori infection. Some H. pylori genes and virulence factors such as CagA and VacA have been reported to play role in ulcer development (16). Eradication of H. pylori has been found to be very effective in reducing the recurrence of peptic ulcers, and in increasing the ulcer healing rate (17). A recent review including meta-analysis of 5 randomized controlled trials reported that H. pylori prevalence was very high among cases with peptic ulcer perforation, and that eradication of H. pylori significantly reduced the rate of ulcer recurrence (18). Shah et al. (19) investigated the effect of histopathologically assessed H. pylori density on complications. The success of eradication treatment in 120 patients that underwent endoscopy due to alarm symptoms and dyspeptic complaints refractory to treatment with proton pump inhibitors was examined. They found significantly higher frequency of duodenal ulcer, gastric ulcer, and gastric erosions among patients with greater H. pylori density. The success of eradication treatment was significantly lower among these patients. Another study by Tokunaga et al. (20) included 113 patients that underwent operation due to perforation, hemorrhage or stenosis as complications of gastroduodenal ulcer. The H. pylori density was graded according to the number of individual bacteria counted in the highly magnified visual field of light microscopy, as 0 = 0; 1-9 = 1; = 2; = 3; and >100 = 4. The prevalence of H. pylori infection was 92% in the perforated ulcer, 55% in hemorrhagic ulcer, and 45% in stenotic ulcer. They found that the H. pylori density grade was 3 in perforation, 2-3 in hemorrhage, and 2-3 in stenosis. In addition, the authors concluded that the intensity of H. pylori infection density was influential on ulcer perforation. Yamaoka et al. (21) studied 50 duodenal ulcers and 50 gastritis patients with caga+ H. pylori, and 11 patients with caga- in order to investigate the effect of caga gene positivity on cytokine production in patients with H. pylori infection. They performed endoscopy and obtained biopsies from patients and assessed H. pylori density and cytokine production. They showed that cytokine production was greater in caga+ patients with duodenal ulcer compared to the caga+ positive patients with gastritis. The cytokine production was associated with H. pylori density, whereas no association between caga positivity and cytokine production was determined. In our study, the frequencies of gastric and duodenal ulcers did not show any significant difference between H. pylori density groups. There was also no significant difference between the groups regarding the frequency of gastritis, which is defined as edematous and hyperemic appearance of the stomach. On the other hand, erosive gastritis was significantly more frequent in patients with moderate and severe H. pylori density in comparison to patients with mild H. pylori density. In 1994, International Cancer Study Group stated H. pylori infection as a Group 1 carcinogen, which can lead to development of chronic gastritis, atrophic gastritis, intestinal metaplasia, dysplasia, and eventually gastric cancer (22). Atrophic gastritis is a chronic inflammatory process characterized by the loss of gastric mucosal glands. Presence of diffuse atrophy associated with achlorhydria and hypochlorhydria is an important risk factor in gastric cancer development. Intestinal metaplasia is characterized by transformation of gastric epithelium to intestinal type epithelium, and particularly the incomplete type of metaplasia is a precursor lesion for gastric cancer. It is generally thought that the prevalence of atrophic gastritis is higher in countries where there is high prevalence of H. pylori infection. However, gastric cancer and precancerous lesions are not high in some geographical regions despite high prevalence of H. pylori infection. This can be explained by other factors including presence of genes like CagA and VacA that may play role in the pathogenicity and virulence of H. pylori, ethnic differences in genetic polymorphisms of gastric acid secretion, and proinflammatory cytokines and environmental factors including dietary habits and personal hygiene (17).

5 Association of helicobacter pylori density with endoscopic and histopathological findings Topal et al. (23) reported that H. pylori infection played a role in the development of atrophy and intestinal metaplasia and that increased H. pylori density was associated with higher prevalence of gastritis and atrophy. Another study did not find a significant association between intestinal metaplasia and H. pylori infection, but found higher prevalence of intestinal metaplasia among individuals with mild H. pylori infection (12). Nai et al. (24) examined the relationship between H. pylori density and histopathological findings, but they did not find any significant association. The most frequent association was determined as chronic gastritis, regardless of H. pylori concentration. In our study, we did not find significant difference between H. pylori density groups regarding atrophy, intestinal metaplasia, or dysplasia. In conclusion, H. pylori is known to be an etiological factor for development of functional dyspepsia, peptic ulcers, gastric cancer, and premalignant lesions. Although H. pylori density has previously been associated with peptic ulcer and its complications in the literature, our findings do not support this relationship. Additionally, based on the literature knowledge and our study results, we can say that H. pylori density does not have a significant effect on the histopathological findings. We think large-scale prospective studies including gastric cancer cases as well, which will also assess important factors related to bacterial virulence will be beneficial in this regard. References 1) Windsor HM, O Rouke J. Bacteriology and taxonomy of Helicobacter pylori. Gastroenterol Clin North Am 2000; 29: ) Go MF, Crowe SE. Virulence and pathogenicity of Helicobacter pylori. Gastroenterol Clin North Am 2000; 29: ) Cohen H. Peptic Ulcer and Helicobacter Pylori. Gastroenterol Clin North Am 2000; 29: ) Fontham ETH, Ruiz B, Perez A. Determinants of Helicobacter pylori infection and chronic gastritis. Am J Gastroenterol 1995; 90: ) Morgner A, Bayerdorffer E, Neubauer A, Stolte M. Malignant tumors of the stomach. Gastric mucosa-associated lymphoid tissue lymphoma and Helicobacter pylori. Gastroenterol Clin North Am 2000; 29: ) Suerbaum S., Michetti P. Medical Progress: Helicobacter pylori Infection. N Engl J Med 2002; 347: ) Chey WD, Murthy U, Toskes P, Carpenter S. The 13C- Urea Blood test accurately detecs H. Pylori infection: A United States, multicenter trial. Am J Gastroenterol 1999; 94: ) Everhart JE. Recent developments in the epidemiology of H. pylori. Gastroenterology Clinics of North America 2000; 29: ) Kadanalı A, Özkurt Z. Helicobacter pylori infeksiyonu: Epidemiyoloji, patogenez ve ilişkili hastalıkları. Klimik Dergisi 2004; 17: ) Megraud F. Epidemiology of H. Pylori infection. Gastroenterol Clin North Am 1993; 22: ) Ozaydin N, Turkyilmaz SA, Cali S. Prevalence and risk factors of Helicobacter pylori in Turkey: a nationallyrepresentative, cross-sectional, screening with the ¹³C- Urea breath test. BMC Public Health 2013; 13: ) Ozdil K, Sahin A, Kahraman R. Current prevalence of intestinal metaplasia and Helicobacter pylori infection in dyspeptic adult patients from Turkey. Hepatogastroenterology 2010; 57: ) Fareed R, Abbas Z, Shah MA. Effect of Helicobacter pylori density on inflammatory activity in stomach. J Pak Med Assoc 2000; 50: ) Braden B, Caspary WF, Lembcke B. Density of Gastric Helicobacter pylori Colonization Is Not Associated with Occurrence of Dyspeptic Symptoms. Digestive Diseases and Sciences 1997; 42: ) Gürel S, Yerci Ö, Karaaslan Y, Öztürk H, Adım ŞB, Nak SG. Helicobacter Pylori (+) non-ülser dispepsili hastalarda H. Pylori yoğunluğu ile non-ülser dispepsi subtipleri arasındaki ilişki. Endoskopi Dergisi 1998; 9: ) Nguyen TL, Uchida T, Tsukamoto Y, Trinh DT, Ta L, et al. Helicobacter pylori infection and gastroduodenal diseases in Vietnam: a cross-sectional, hospital-based study. BMC Gastroenterol 2010; 10: ) Watari J, Chen N, Amenta PS, Fukui H, Oshima T, et al. Helicobacter pylori associated chronic gastritis, clinical syndromes, precancerous lesions, and pathogenesis of gastric cancer development. World J Gastroenterol 2014; 20: ) Wong CS, Chia CF, Lee HC, Wei PL, Ma HP, et al. Eradication of Helicobacter pylori for prevention of ulcer recurrence after simple closure of perforated peptic ulcer: a meta-analysis of randomized controlled trials. J Surg Res 2013; 182: ) Shah DK, Jain SS, Mohite A, Amarapurkar AD, Contractor QQ, Rathi PM. Effect of H. pylori density by histopathology on its complications and eradication therapy. Trop Gastroenterol 2015; 36: ) Tokunaga Y, Hata K, Ryo J, Kitaoka A, Tokuka A, Ohsumi K. Density of Helicobacter pylori infection in patients with peptic ulcer perforation. J Am Coll Surg 1998; 186: ) Yamaoka Y, Kodama T, Kita M, Imanishi J, Kashima K, Graham DY. Relation between clinical presentation, Helicobacter pylori density, interleukin 1beta and 8 production, and caga status. Gut 1999; 45: ) Fischbach W, Chan A, Wong B. Helicobacter pylori and gastric malignancy. Helicobacter 2005; 10: ) Topal D, Göral V, Yilmaz F, Kara IH. The relation of Helicobacter Pylori with intestinal metaplasia, gastric atrophy and BCL-2. Turk J Gastroenterol 2004; 15:

6 668 Mete Akin, Aziz Kurtulus et Al 24) Nai GA, Parizi AC, Barbosa RL. Association between Helicobacter pylori concentration and the combining frequency of histopathological findings in gastric biopsies specimens. Arq Gastroenterol 2007; 44: Corresponding author METE AKIN Akdeniz University Hospital, Department of Internal Medicine, Konyaalti, Antalya (Turkey)