Fall in the prevalence of chronic gastritis over 15 years: analysis of outpatient series in Finland from 1977, 1985, and 1992

Risk of gastric carcinoma will be low in generations born at turn of the 20th and 21st centuries in Finland. Modelling NORDCAN data of the age group specific incidence rates of gastric cancer with PLS-regression and with attention to age ('age effect') and year of the birth ('cohort effect')

BACKGROUND AND METHODS

We examined in NORDCAN database how the annual age group-specific incidence rates (IR) of gastric cancer (GCA), and correspondingly the GCA risk, have declined in Finland during the twentieth century, and whether this decline corresponds to a decrease in the cohort-specific prevalence rate of Helicobacter pylori (Hp) gastritis that is considered an important precancerous risk condition for GCA.

RESULTS

In modelling with partial least squares regression (PLSR), the logarithmically transformed IRs (ln(IR) of GCA were well explained with age and birth cohort as explanatory model variables. By considering the observed (actual) and the PLSR-modelled IRs, the IR of GCA (and the risk of GCA) has decreased gradually in Finland from 1900 onward, cohort by cohort. By prediction of the future with PLSR, the IRs of GCA will be markedly lower in all cohorts during the twenty-first century than in the twentieth century. By PLSR modelling, less than 10 GCA cases per 100,000 people are predicted to appear annually in cohorts (generations) born at the turn of the 20th and 21st centuries, even when these people will be 60-80 years old in the years 2060-2070.

CONCLUSIONS

The IR of GCA and GCA risk progressively declined by cohort in Finland during the whole twentieth century. This decline corresponds in extent and time window to earlier observations in the decline of the prevalence rate of Hp gastritis in the same birth cohorts and supports the hypothesis of the role of Hp gastritis as an important risk condition of GCA.

When will Helicobacter pylori gastritis disappear in history in Finland?

OBJECTIVES

To predict how the10-year birth cohort specific prevalence rates of chronic non-atrophic (CG) and atrophic gastritis (AG), related to Helicobacter pylori (Hp) infection, will decline during the 21^st century among the native adult Finns.

MATERIALS AND METHODS

The predictions are based as continuums of our earlier observations of gradual and significant declines in birth cohort specific prevalence rates of CG and AG in endoscopic biopsies from gastric antrum and corpus of 2298 adult dyspeptic outpatients or asymptomatic volunteers born 1890-1977 that were endoscopied in 1972-1997 in Finland.

RESULTS AND DISCUSSION

We could predict that the Hp related CG and AG will gradually disappear in history among the native Finns during the 21^st century. From the 2020s onward, the CG and AG would decrease with time in prevalence rate, cohort-by-cohort, and would be more and more highlighted in the middle aged or elderly age groups only. Finally, since all birth cohorts (generations) infected with Hp have passed away by 2080, the Hp related gastrites would not appear anymore in notable counts among the native Finns. Correspondingly, gastric cancers and peptic ulcers (both duodenal and gastric), which are etiopathogenetically linked with Hp gastrites, would similarly become gradually more and more infrequent and rare disorders among native Finns during the 21^st century.

Prevalence rates of heathy stomach mucosa, chronic non-atrophic and atrophic gastritis in endoscopic biopsies in adults born in Finland in 1890-1977

BACKGROUND

Helicobacter pylori infection, chronic gastritis (CG) and atrophic gastritis (AG) are a continuum of consecutive events in the stomach mucosa. We studied the birth cohort and age group-specific prevalence rates of 'healthy' (N) and 'diseased' stomachs with CG or AG in endoscopic biopsies in adult people born in Finland in 1890-1977.

MATERIALS AND METHODS

Study series consisted of 690 and 1608 adults with a diagnostic gastroscopy in 1972-1997. All subjects were divided to 10-year age groups and birth cohorts. Based on biopsy histology, relative frequencies (prevalences) of N, CG and AG were estimated by the observed number of cases with N, CG and AG in each study category.

RESULTS

Prevalence rate of a histologically 'diseased' stomach (CG or AG) decreased and that of 'healthy' stomach (N) increased, cohort-by-cohort, from 1900 onward by rate 9-12% per every 10-year period in the two study subpopulations, respectively. Prevalences of CG remained unchanged over study groups when N, CG and AG were noted concurrently. By noting 'diseased' stomachs only, the prevalence rate of AG increased, and that of CG decreased with age, at rate 9-13% per every 10 years of calendar age.

CONCLUSIONS

Over 70-year period from 1900 onward, the prevalence rate of 'diseased' stomach (CG or AG) decreased and that of 'healthy' (N) stomach increased in birth cohorts over 50%, by rate about 10% over every 10-year period of time. In birth cohorts, CG progressed to AG with aging of the subjects at a rate of about 10% over every 10 years of calendar age.

Are Helicobacter pylori Infection and Fucoidan Consumption Associated with Fucoidan Absorption?

We examined the associations of Helicobacter pylori and mozuku consumption with fucoidan absorption. Overall, 259 Japanese volunteers consumed 3 g fucoidan, and their urine samples were collected to measure fucoidan values and H. pylori titers before and 3, 6, and 9 h after fucoidan ingestion. Compared to the basal levels (3.7 ± 3.4 ng/mL), the urinary fucoidan values significantly increased 3, 6, and 9 h (15.3 ± 18.8, 24.4 ± 35.1, and 24.2 ± 35.2 ng/mL, respectively) after fucoidan ingestion. The basal fucoidan levels were significantly lower in H. pylori-negative subjects who rarely ate mozuku than in those who regularly consumed it. Regarding the ΔMax fucoidan value (highest value − basal value) in H. pylori-positive subjects who ate mozuku at least once a month, those aged ≥40 years exhibited significantly lower values than <40 years old. Among subjects ≥40 years old who regularly consumed mozuku, the ΔMax fucoidan value was significantly lower in H. pylori-positive subjects than in H. pylori-negative ones. In H. pylori-positive subjects who ate mozuku at least once monthly, basal fucoidan values displayed positive correlations with H. pylori titers and ΔMax fucoidan values in subjects <40 years old. No correlations were found in H. pylori-positive subjects who ate mozuku once every 2–3 months or less. Thus, fucoidan absorption is associated with H. pylori infection and frequency of mozuku consumption.

The Role of the Acid Pocket in Gastroesophageal Reflux Disease

Gastroesophageal reflux disease is one of the commonest chronic conditions in the western world and its prevalence is increasing worldwide. The discovery of the acid pocket explained the paradox of acid reflux occurring more frequently in the postprandial period despite intragastric acidity being low due to the buffering effect of the meal. The acid pocket was first described in 2001 when it was detected as an area of low pH immediately distal to the cardia using dual pH electrode pull-through studies 15 minutes after a meal. It was hypothesized that there was a local pocket of acid close to the gastroesophageal junction that escapes the buffering effect of the meal, and that this is the source of postprandial acidic reflux. The presence of the acid pocket has been confirmed in other studies using different techniques including high-resolution pHmetry, Bravo capsule, magnetic resonance imaging, and scintigraphy. This review aims to describe what we know about the acid pocket including its length, volume, fluid constituents, and its relationship to the lower esophageal sphincter and squamocolumnar junction. We will discuss the possible mechanisms that lead to the formation of the acid pocket and examine what differences exist in patients who suffer from acid reflux. Treatments for reflux disease that affect the acid pocket will also be discussed.

Increase in the Prevalence of Atrophic Gastritis Among Adults Age 35 to 44 Years Old in Northern Sweden Between 1990 and 2009

BACKGROUND & AIMS

Atrophic corpus gastritis (ACG) is believed to be an early precursor of gastric adenocarcinoma. We aimed to investigate trends of ACG in Northern Sweden, from 1990 through 2009, and to identify possible risk factors.

METHODS

We randomly selected serum samples collected from 5284 participants in 1990, 1994, 1999, 2004, and 2009, as part of the population-based, cross-sectional Northern Sweden Multinational Monitoring of Trends and Determinants in Cardiovascular Disease study (ages, 35-64 y). Information was collected on sociodemographic, anthropometric, lifestyle, and medical factors using questionnaires. Serum samples were analyzed for levels of pepsinogen I to identify participants with functional ACG; data from participants with ACG were compared with those from frequency-matched individuals without ACG (controls). Blood samples were analyzed for antibodies against Helicobacter pylori and Cag pathogenicity island protein A. Associations were estimated with unconditional logistic regression models.

RESULTS

Overall, 305 subjects tested positive for functional ACG, based on their level of pepsinogen I. The prevalence of ACG in participants age 55 to 64 years old decreased from 124 per 1000 to 49 per 1000 individuals between 1990 and 2009. However, the prevalence of ACG increased from 22 per 1000 to 64 per 1000 individuals among participants age 35 to 44 years old during this time period. Cag pathogenicity island protein A seropositivity was associated with risk for ACG (odds ratio, 2.29; 95% confidence interval, 1.69-3.12). Other risk factors included diabetes, low level of education, and high body mass index. The association between body mass index and ACG was confined to individuals age 35 to 44 years old; in this group, overweight and obesity were associated with a 2.8-fold and a 4.7-fold increased risk of ACG, respectively.

CONCLUSIONS

Among residents of Northern Sweden, the prevalence of ACG increased from 1990 through 2009, specifically among adults age 35 to 44 years old. The stabilizing seroprevalence of H pylori and the increasing prevalence of overweight and obesity might contribute to this unexpected trend. Studies are needed to determine whether these changes have affected the incidence of gastric cancer.

Chronic gastritis

Prevalence of chronic gastritis has markedly declined in developed populations during the past decades. However, chronic gastritis is still one of the most common serious pandemic infections with such severe killing sequelae as peptic ulcer or gastric cancer. Globally, on average, even more than half of people may have a chronic gastritis at present. Helicobacter pylori infection in childhood is the main cause of chronic gastritis, which microbial origin is the key for the understanding of the bizarre epidemiology and course of the disease. A life-long and aggressive inflammation in gastritis results in destruction (atrophic gastritis) of stomach mucosa with time (years and decades). The progressive worsening of atrophic gastritis results subsequently in dysfunctions of stomach mucosa. Atrophic gastritis will finally end up in a permanently acid-free stomach in the most extreme cases. Severe atrophic gastritis and acid-free stomach are the highest independent risk conditions for gastric cancer known so far. In addition to the risks of malignancy and peptic ulcer, acid-free stomach and severe forms of atrophic gastritis may associate with failures in absorption of essential vitamins, like vitamin B12, micronutrients (like iron, calcium, magnesium and zinc), diet and medicines.

Time Trends in Helicobacter pylori Infection and Atrophic Gastritis Over 40 Years in Japan

BACKGROUND

Helicobacter pylori infection produces progressive mucosal damage that may eventually result in gastric cancer. We studied the changes that occurred in the presence and severity of atrophic gastritis and the prevalence of H. pylori infection that occurred coincident with improvements in economic and hygienic conditions in Japan since World War II.

MATERIALS AND METHODS

The prevalence of H. pylori infection and histologic grades of gastric damage were retrospectively evaluated using gastric biopsy specimens obtained over a 40-year period. Gastric atrophy and intestinal metaplasia were scored using the updated Sydney classification system.

RESULTS

The prevalence of H. pylori and severity of atrophy were examined in 1381 patients including 289 patients examined in the 1970s (158 men; mean age, 44.9 years), 787 in the 1990s (430 men; 44.2 years), and 305 in the 2010s (163 men; 53.2 years). Overall, the prevalence of H. pylori infection decreased significantly from 74.7% (1970s) to 53% (1990s) and 35.1% (2010s) (p < .01). The prevalence of atrophy in the antrum and corpus was significantly lower in the 2010s (33, 19%, respectively) compared to those evaluated in either the 1970s (98, 82%) (p < .001) or 1990s (80, 67%) (p < .001). The severity of atrophy and intestinal metaplasia also declined remarkably among those with H. pylori infection.

CONCLUSIONS

There has been a progressive and rapid decline in the prevalence of H. pylori infection as well a fall in the rate of progression of gastric atrophy among H. pylori-infected Japanese coincident with the westernization and improvements in economic and hygienic conditions in Japan since World War II.

Incidence and complications of peptic ulcer disease requiring hospitalisation have markedly decreased in Finland

BACKGROUND

The characteristics of peptic ulcer disease (PUD) are changing.

AIM

To evaluate time trends in the incidence of PUD and its complications in hospitalised patients at the beginning of the 21st century, drug therapies in out-patient care as a risk factor for recurrent PUD, and medication used by PUD patients compared with the background population.

METHODS

In this retrospective epidemiologic cohort study, data from the years 2000-2008 came from The Hospital District of Helsinki and Uusimaa, and the Finnish Care Register. All hospitalised adult patients with PUD in the capital region of Finland were included. The data were linked with nationwide Prescription Register of the Finnish Social Insurance Institution allowing detailed individual medicine purchase data.

RESULTS

A total of 9951 peptic ulcers were detected among 8146 individual patients during the study period. The mean annual incidence of all peptic ulcers decreased from 121/100,000 (95% CI: 117-125) in 2000-2002, to 79 (95% CI: 76-82) in 2006-2008 [Incidence rate ratio = 0.62 (95% CI: 0.58-0.64), P < 0.001 after age and sex adjustment]. Decrease in incidence was seen in all age groups and in both sexes. The overall rate of severe complications of PUD was reduced. One-year cumulative incidence of recurrent ulcers was 13%. Use of several drugs was associated with increased risk for recurrence. The purchases of various drugs were more common among PUD patients compared with background population.

CONCLUSIONS

Both the incidence and complication rates have markedly decreased during the study period. Recurrent peptic ulcer disease was associated with polypharmacy.

Eradication of gastric cancer is now both possible and practical

In 1994, Helicobacter pylori was declared a human carcinogen. Evidence has now accumulated to show that at least 95% of gastric cancers are etiologically related to H. pylori. An extensive literature regarding atrophic gastritis and its effects on acid secretion, gastric microflora, and its tight association with gastric cancer has been rediscovered, confirmed, and expanded. Methods to stratify cancer risk based on endoscopic and histologic findings or serologic testing of pepsinogen levels and H. pylori testing have been developed producing practical primary and secondary gastric cancer prevention strategies. H. pylori eradication halts progressive mucosal damage. Cure of the infection in those with non-atrophic gastritis will essentially prevent subsequent development of gastric cancer. For all, the age-related progression in cancer risk is halted and likely reduced as eradication reduces or eliminates mucosal inflammation and reverses or reduces H. pylori-associated molecular events such aberrant activation-induced cytidine deaminase expression, double strand DNA breaks, impaired DNA mismatch repair and aberrant DNA methylation. Those who have developed atrophic gastritis/gastric atrophy however retain some residual risk for gastric cancer which is proportional to the extent and severity of atrophic gastritis. Primary and secondary cancer prevention starts with H. pylori eradication and cancer risk stratification to identify those at higher risk who should also be considered for secondary cancer prevention programs. Japan has embarked on population-wide H. pylori eradication coupled with surveillance targeted to those with significant remaining risk. We anticipate that countries with high gastric cancer burdens will follow their lead. We provide specific recommendations on instituting practical primary and secondary gastric cancer prevention programs as well identifying research needed to make elimination of gastric cancer both efficient and cost effective.

Chaihu-Shugan-San, an oriental herbal preparation, for the treatment of chronic gastritis: a meta-analysis of randomized controlled trials

ETHNOPHARMACOLOGICAL RELEVANCE

Chronic gastritis is a very common disease of the digestive tract. Although herbal preparation Chaihu-Shugan-San (CSS) has been widely used as an alternative treatment for chronic gastritis in East Asia, its effectiveness is not verified. The purpose of this meta-analysis is to evaluate the effectiveness of CSS in treating various types of chronic gastritis.

MATERIALS AND METHODS

Retrospective review of pertinent literature via Embase, China National Knowledge Infrastructure database, Wanfang Data, Vip Information and the Cochrane Library search using the keywords "Chaihushugan" or "Chaihu Shugan" or "Chai Hu Shu Gan" or "Chaihu Shu Gan". Twenty-one trials were identified including 2572 patients (1384 in CSS group and 1188 in chemotherapy group). Each trial was independently reviewed by two assessors.

RESULTS

The risk ratios of bile reflux gastritis, chronic superficial gastritis, chronic atrophic gastritis, and chronic erosive gastritis in the CSS-treated and chemotherapy groups were 1.30, 1.20, 1.24, and 1.48, respectively. CSS had more therapeutic effect in various types of chronic gastritis patients for improving clinical response compared with the chemotherapy group. Of the 21 trials administrating CSS to patients, no adverse event was reported.

CONCLUSIONS

CSS was more effective compared to chemotherapy in the treatment of chronic gastritis and no serious side-effects were identified. However, the evidence is insufficient because of the low methodological quality of the included trials. More full-scale, randomized, double-blind, placebo-controlled clinical trials are recommended to further evaluate the therapeutic benefit of CSS.

Rationale in diagnosis and screening of atrophic gastritis with stomach-specific plasma biomarkers

BACKGROUND AND AIMS

Atrophic gastritis (AG) results most often from Helicobacter pylori (H. pylori) infection. AG is the most important single risk condition for gastric cancer that often leads to an acid-free or hypochlorhydric stomach. In the present paper, we suggest a rationale for noninvasive screening of AG with stomach-specific biomarkers.

METHODS

The paper summarizes a set of data on application of the biomarkers and describes how the test results could be interpreted in practice.

RESULTS

In AG of the gastric corpus and fundus, the plasma levels of pepsinogen I and/or the pepsinogen I/pepsinogen II ratio are always low. The fasting level of gastrin-17 is high in AG limited to the corpus and fundus, but low or non-elevated if the AG occurs in both antrum and corpus. A low fasting level of G-17 is a sign of antral AG or indicates high intragastric acidity. Differentiation between antral AG and high intragastric acidity can be done by assaying the plasma G-17 before and after protein stimulation, or before and after administration of the proton pump inhibitors (PPI). Amidated G-17 will rise if the antral mucosa is normal in structure. H. pylori antibodies are a reliable indicator of helicobacter infection, even in patients with AG and hypochlorhydria.

CONCLUSIONS

Stomach-specific biomarkers provide information about the stomach health and about the function of stomach mucosa and are a noninvasive tool for diagnosis and screening of AG and acid-free stomach.

Helicobacter pylori and the birth cohort effect: evidence for stabilized colonization rates in childhood

BACKGROUND

The prevalence of Helicobacter pylori has declined over recent decades in developed countries. The increasing prevalence with age is largely because of a birth cohort effect. We previously observed a decline in H. pylori prevalence in 6- to 8-year-old Dutch children from 19% in 1978 to 9% in 1993. Knowledge about birth-cohort-related H. pylori prevalence is relevant as a predictor for the future incidence of H. pylori-associated conditions.

AIM

The aim of this study was to investigate whether the birth cohort effect of H. pylori observed between 1978 and 1993 continued in subsequent years.

METHODS

Anti-H. pylori IgG antibodies and anti-CagA IgG antibodies were determined in serum samples obtained in 2005/2006 from 545 Dutch children aged 7-9 years who participated in the Prevention and Incidence of Asthma and Mite Allergy birth cohort. The H. pylori and CagA antibodies were determined by enzyme-linked immunosorbent assays that have been extensively validated in children, with a 94% sensitivity for H. pylori colonization and a 92.5% sensitivity for colonization with a cagA-positive strain.

RESULTS

Of the 545 children (M/F 300/245), most (91.5%) were of Dutch descent. The H. pylori positivity rate was 9% (95% CI 6.6-11.4%). The prevalence of CagA antibodies was 0.9% (95% CI 0.1-1.6%). No significant differences were demonstrated in H. pylori and cagA prevalence in relation to gender or ethnicity.

CONCLUSION

The prevalence of H. pylori in childhood has remained stable in the Netherlands from 1993 to 2005, suggesting a stabilization of the previously decreasing trend in subsequent birth cohorts. This finding may reflect stabilization in determinants such as family size, housing, and hygienic conditions (or offset by day care). If confirmed in other populations in developed countries, it implies that colonization with H. pylori will remain common in the coming decades. Remarkably however, the rate of colonization with cagA(+) H. pylori strains has become very low, consistent with prior observations that cagA(+) strains are disappearing in Western countries.

Body mass index, chronic atrophic gastritis and heartburn: a population-based study among 8936 older adults from Germany

BACKGROUND

Obesity and overweight have been positively related to gastro-oesophageal reflux disease (GERD). It has been suggested that this relationship is as a consequence of an increased gastric acid reflux, which is caused by an enhanced intra-abdominal pressure.

AIM

To assess potential interaction of the association between body mass index (BMI) and GERD by chronic atrophic gastritis, which goes along with decreased acid production.

METHODS

In the baseline examination of ESTHER, a study conducted in 9953 older adults in Saarland, information on frequency of heartburn, potential risk factors and medical history was obtained by self-administered standardized questionnaire. Serological measurements of pepsinogen I and II were taken for definition of chronic atrophic gastritis.

RESULTS

In total, 2565 (28.7%) of the included subjects experienced heartburn within the previous 4 weeks. A pronounced dose-response relationship was observed between BMI and heartburn occurrence (P < 0.001) among people without chronic atrophic gastritis, but not among people with chronic atrophic gastritis (P-value for interaction = 0.018). Obese/overweight people with chronic atrophic gastritis had a much lower risk of heartburn compared with obese/overweight people without chronic atrophic gastritis (OR = 0.31, 95% CI = 0.24-0.40).

CONCLUSION

Our results are consistent with the hypothesis that BMI is related positively to GERD symptoms by its impact on acid reflux.

Clinicopathological features and prognostic factors of proximal gastric carcinoma in a population with high Helicobacter pylori prevalence: a single-center, large-volume study in Korea

BACKGROUND

The incidence of gastric cancers has fallen in recent decades. However, a substantial reduction in Helicobacter pylori prevalence and a substantial increase in the incidence of proximal gastric cancer (PGC) have been observed in the West and Japan, but not in other East Asian countries. The purpose of this large-volume study was to analyze prevalence, clinicopathological features, and prognosis of PGC compared with other types of gastric cancer in Korea, where there is high incidence of H. pylori infection.

METHODS

Between 2000 and 2005, a total of 3,193 patients were enrolled. We analyzed clinicopathological features and survival outcomes.

RESULTS

Chronological analysis showed increasing incidence of PGC over the study period. PGC patients were younger and had higher incidence of Bormann types III and IV than did distal gastric cancer (DGC) patients. Also, PGC was associated with a significantly higher proportion of poorly differentiated type, T3 and T4 stage, and positive lymph nodes compared with DGC. Peritoneal and other distant metastases were more common in PGC group than in DGC group. The 5-year survival rate was significantly lower in PGC than in DGC group, regardless of curative resection. Also, the N0 and N1 category significantly influenced the 5-year survival rate. Tumor-node-metastasis (TNM) stage, hepatic metastasis, and curative resection were significant prognostic factors in PGC patients.

CONCLUSIONS

PGC has increased in incidence with the respective decline in H. pylori prevalence in Korea. Survival was worse for patients with PGC than for those with DGC, regardless of curative respectability. PGC is often diagnosed at more advanced stage than other gastric cancers, and therefore early detection is critical for successful treatment.

Study of association between atrophic gastritis and body mass index: a cross-sectional study in 10,197 Japanese subjects

OBJECTIVES

The aim of this study was to elucidate the association between body mass index (BMI) and both Helicobacter pylori and atrophic gastritis.

METHODS

The study involved 10,197 subjects participating in a Japanese mass endoscopic gastric cancer screening program. Atrophic gastritis was assessed by pepsinogen I to II ratio.

RESULTS

In logistic regression models, BMI had an inverse association with atrophic gastritis, with the odds ratios (OR) decreasing progressively to 0.67 (95% confidence interval [CI] 0.57-0.79, P<0.0001) in the highest BMI quintiles (BMI >or=25.66) group compared with the lowest BMI quintiles (BMI <20.97) group. In linear regression models, atrophic gastritis predicted BMI (regression coefficient -0.326, 95% CI -0.469, -0.184, P<0.0001), whereas H. pylori antibody was not a predictor (regression coefficient 0.072, 95% CI -0.053, 0.198, P=0.3).

CONCLUSIONS

A small, inverse association between BMI and atrophic gastritis was found in the general population. In contrast, no association was observed between H. pylori seropositivity and BMI.

Migrant communities constitute a possible target population for primary prevention of Helicobacter pylori-related complications in low incidence countries

OBJECTIVE

Pre-selection of individuals with epidemiological risk factors for Helicobacter pylori infection and atrophic gastritis could increase the efficiency of serologic screening to prevent peptic ulcer disease and gastric cancer in Western countries. The aim of this study was to determine the prevalence of and risk factors for H. pylori infection and atrophic gastritis in a migrant community in The Netherlands.

MATERIAL AND METHODS

Inhabitants from an urban district in Rotterdam, The Netherlands with a large proportion of immigrants were randomly selected. Information was collected on demographic factors, socio-economic status, lifestyle, history of dyspeptic symptoms and medication use. In addition, serologic H. pylori and CagA status and the presence of atrophic gastritis were evaluated.

RESULTS

In total, 288 subjects were included. Surinamese or Antillean, Turkish, Cape Verdian and Moroccan subjects were H. pylori-infected in 65%, 82%, 86% and 96% of cases, respectively, whereas the infection rate in Dutch subjects was 46% (all p<0.05). Within multivariate logistic regression analysis, ethnicity and number of persons in a household were identified as independent risk factors for H. pylori infection. In addition, mean pepsinogen I level and pepsinogen I/II ratio were significantly lower in subjects of non-Dutch origin as compared to Dutch subjects (both p<0.001). No Dutch subjects suffered from atrophic gastritis, as compared with 12 subjects of non-Dutch origin (p=0.13).

CONCLUSIONS

The prevalence of H. pylori is high in migrant populations in The Netherlands. Furthermore, markers of atrophic gastritis are increased in subjects of foreign origin. Therefore, these migrant communities may constitute a target group for serologic screening to prevent H. pylori-related complications in Western countries.

Epidemiological trends of pre-malignant gastric lesions: a long-term nationwide study in the Netherlands

BACKGROUND

The pre-malignant gastric lesions atrophic gastritis (AG), intestinal metaplasia (IM) and dysplasia (DYS) have long been identified as principal risk factors for gastric cancer.

OBJECTIVE

To evaluate epidemiological time trends of pre-malignant gastric lesions in the Netherlands.

METHODS

Patients with a first diagnosis of AG, IM or DYS between 1991 and 2005 were identified in the Dutch nationwide histopathology registry. The number of new diagnoses per year were evaluated relative to the total number of patients with a first gastric biopsy. Time trends were evaluated with age-period-cohort models using logistic regression analysis.

RESULTS

In total, 23 278 patients were newly diagnosed with AG, 65 937 patients with IM, and 8517 patients with DYS. The incidence of AG declined similarly in men and women with 8.2% per year [95% CI 7.9% to 8.6%], and DYS with 8.1% per year [95% CI 7.5% to 8.6%]. The proportional number of new IM cases declined with 2.9% per year [95% CI 2.7% to 3.1%] in men and 2.4% [95% CI 2.2% to 2.6%] in women. With age-period-cohort models a cohort phenomenon was demonstrated for all categories of pre-malignant gastric lesions in men and in women with IM and DYS. Period phenomena with a larger decline in number of diagnoses after 1996 were also demonstrated for AG and IM.

CONCLUSIONS

The incidence of pre-malignant gastric lesions is declining. Period and cohort phenomena were demonstrated for diagnoses of AG and IM. These findings imply that a further decrease of at least 24% in the incidence of gastric cancer in the coming decade may be anticipated in Western countries without specific intervention.

Epidemiology of premalignant gastric lesions: implications for the development of screening and surveillance strategies

Gastric cancer is one of the most common cancers worldwide; however, gastric cancer incidence varies greatly between different geographic areas. As gastric cancer is usually diagnosed at an advanced stage, the disease causes considerable morbidity and mortality. To detect gastric carcinomas at an early and curable stage, screening and surveillance seem necessary. Premalignant gastric lesions are well known risk factors for the development of intestinal type gastric adenocarcinomas. In a multistep cascade, chronic Helicobacter pylori-induced gastritis progresses through premalignant stages of atrophic gastritis, intestinal metaplasia and dysplasia, to eventually gastric cancer. Therefore, this cascade may provide a basis for early detection and treatment of gastric cancer. Epidemiology of gastric cancer and premalignant gastric lesions should guide the development of screening and surveillance strategies, as distinct approaches are required in countries with low and high gastric cancer incidences.

The detection, surveillance and treatment of premalignant gastric lesions related to Helicobacter pylori infection

Gastric cancer is an important worldwide health problem and causes considerable morbidity and mortality. It represents the second leading cause of cancer-related death worldwide. A cascade of recognizable precursor lesions precedes most distal gastric carcinomas. In this multistep model of gastric carcinogenesis, Helicobacter pylori causes chronic active inflammation of the gastric mucosa, which slowly progresses through the premalignant stages of atrophic gastritis, intestinal metaplasia and dysplasia to gastric carcinoma. Detection and treatment of premalignant lesions may thus provide a basis for gastric cancer prevention. However, at present, premalignant changes of the gastric mucosa are frequently disregarded in clinical practice or result in widely varying follow-up frequency or treatment. This review provides an overview of current knowledge on detection, surveillance and treatment of patients with premalignant gastric lesions, and identifies the uncertainties that require further research.

Twice-a-day quadruple therapy for eradication of Helicobacter pylori in the elderly

BACKGROUND

Midday and evening twice-a-day quadruple therapy appears to be the most effective therapy for Helicobacter pylori infection in Northern Sardinia, a site where antibiotics resistance is common.

AIM

The objective of our study was to estimate the efficacy, side-effects, and compliance of a quadruple therapy containing esomeprazole in a group of dyspeptic elderly patients.

PATIENTS AND METHODS

Consecutive elderly patients positive for H. pylori infection and not previously treated for eradication were enrolled. Therapy consisted of esomeprazole 20 mg, tetracycline 500 mg, metronidazole 500 mg, and bismuth subcitrate tablets 240 mg, all twice-a-day with the midday and evening meals, for 10 days. Efficacy was evaluated using 13C-urea breath testing. Compliance was assessed after completing treatment and at follow up. Side effects were graded based on daily activities.

RESULTS

Ninety-five dyspeptic patients (range 65-81 years), 52 men and 43 women, were enrolled. The intention-to-treat cure rate was 91% (81 of 89; 95% CI = 88-99%) and, 95% (81 of 85; 95% CI = 83-96%) per-protocol analysis. Compliance was excellent. Mild-moderate side effects occurred in 27 patients.

CONCLUSIONS

Esomeprazole containing quadruple therapy was highly successful for initial eradication of H. pylori in elderly patients.

Age-specific incidence of Helicobacter pylori

BACKGROUND & AIMS

Helicobacter pylori is most likely acquired in childhood, but the incidence of infection has not been determined prospectively by using an appropriate noninvasive test. The aim of this study was to determine the age-specific incidence of Helicobacter pylori infection in children and the risk factors for infection.

METHODS

Three hundred twenty-seven healthy index children between 24 and 48 months of age were enrolled over 15 months. At baseline, the Helicobacter pylori infection status of each index child and his or her older siblings and parents was assessed by using the carbon 13-urea breath test. All noninfected index children were then followed up with an annual carbon 13-urea breath test for 4 years to determine whether they became infected with Helicobacter pylori and, if so, the age at first infection. Information on potential risk factors was collected at baseline and each subsequent visit.

RESULTS

At baseline assessment, 28 of 327 (8.6%) index children were infected with Helicobacter pylori. The mean age of the 28 infected children was 32.78 months (SD, 5.14 months). Over the next 4 years, 279 index children not infected at baseline contributed 970 person-years of follow-up to the study. During this time, 20 children became infected with Helicobacter pylori. The rate of infection per 100 person-years of follow-up was highest in the 2-3-year age group (5.05 per 100 person-years of follow-up (95% confidence interval, 1.64-11.78) and declined progressively as children aged. Only 1 child became infected after 5 years of age. Having an infected mother, an infected older sibling, and delayed weaning from a feeding bottle (ie, after 24 months of age) were all risk factors for infection.

CONCLUSIONS

Children who become infected with Helicobacter pylori are infected at a very young age, and the risk of infection declines rapidly after 5 years of age. These findings have important implications for studies on the mode of transmission of infection.

Prevalence of Helicobacter pylori infection, endoscopic gastric findings and dyspeptic symptoms among a young Japanese population born in the 1970s

BACKGROUND

With the prevalence of Helicobacter pylori (H. pylori) infection rapidly decreasing in Japan, endoscopic findings and dyspeptic symptoms need to be re-evaluated.

METHODS

In a health check-up program, endoscopy was performed on 530 young Japanese subjects (371 men and 159 women) born in the 1970s. Helicobacter pylori infection was evaluated using serology and a rapid urease test. Endoscopic gastritis was classified according to the Sydney classification system, in addition to nodular gastritis. Dyspeptic symptoms were also recorded before endoscopy.

RESULTS

Of the 530 subjects, 87 (16.4%) were H. pylori positive. Of the 443 H. pylori-negative subjects, 349 (78.8%) were considered to have endoscopically normal gastric mucosa. However, of the 87 H. pylori-positive subjects, only 19 (21.8%) tested normal (P < 0.001). The prevalence of several types of gastritis was significantly higher in H. pylori-positive subjects compared with H. pylori-negative subjects: atrophic gastritis (37.9% vs 1.1%, P < 0.001), flat erosive gastritis (29.9% vs 7.2%, P < 0.001), rugal hyperplastic gastritis (12.6% vs 0.0%, P < 0.001), and nodular gastritis (13.8% vs 0.0%, P < 0.001). Other types of gastritis were not related to H. pylori status. The prevalence of subjects with dyspeptic symptoms was significantly higher in H. pylori-positive subjects compared with H. pylori-negative ones (28.7% vs 6.5%, P < 0.001).

CONCLUSION

It is suggested that in consideration of its recent low prevalence and the slow increase in its infection, the prevalence of H. pylori-related gastritis will gradually decrease in Japan. Further studies will be required to ascertain if there is a need for H. pylori eradication in this young population.

Geographic pathology of Helicobacter pylori gastritis

BACKGROUND AND AIM

Helicobacter pylori is etiologically associated with gastritis and gastric cancer. There are significant geographical differences between the clinical manifestation of H. pylori infections. The aim of this study was to compare gastric mucosal histology in relation to age among H. pylori-infected patients from different geographical areas using the same grading system. The prevalence of atrophy and intestinal metaplasia were also compared with the respective gastric cancer incidence in the different countries.

METHODS

A total of 1906 patients infected with H. pylori from seven countries were evaluated. Entry criteria included H. pylori positive cases with antral and corpus biopsies between the ages of 18 and 75 years. The minimum number of cases required from a country was 100. Hematoxylin-eosin stained biopsies from antrum and corpus were scored semiquantitatively using the parameters suggested by the Sydney Classification System. Statistical evaluation was performed using Kruskal-Wallis test and Spearman's rank correlation test.

RESULTS

The severity of gastric atrophy varied among the different groups with the highest scores being present in Japan. The lowest scores were found in four European countries and in Thailand. The scores for intestinal metaplasia were low in general except for Xi-an, Japan, and Shanghai. For all the countries, the presence of atrophy in the antrum correlated well (r = 0.891) with the incidence of gastric cancer.

CONCLUSION

Using a standardized grading system in a large study of H. pylori-related geographic pathology, we found major differences in the overall prevalence and severity of H. pylori gastritis in relation to age. These differences mirrored the respective incidences of gastric cancer in those geographical areas.

Helicobacter pylori Infection among Patients Visiting a Clinic in Kasama City, Ibaraki Prefecture

We examined Helicobacter pylori infection in patients who visited the Iso Clinic (Kasama City, Ibaraki Prefecture) with abdominal complaints, and determined the prevalence of H. pylori infection by age, sex, endoscopic diagnosis, abdominal complaint, gastric mucosa, and living environment. Peptic ulcer disease was observed in 23.2% of the patients examined with endoscopy, but there was no association between abdominal complaints and the prevalence of H. pylori infection. The prevalence of H. pylori infection was high among patients with peptic ulcer disease and atrophic gastritis. The prevalence of H. pylori infection was higher in the generation born before tae start of the period of rapid economic growth (71.5%) than in the generation born afterward (64.8%). No significant difference was observed between males and females. The prevalence of H. pylori infection was high in those who drank well water during childhood and those who were raised in a house with a nonflushing of toilet (67.2% and 67.5%, respectively). There were no associations with river basin of residence, alcohol consumption, or smoking. The prevalence of H. pylori infection among patients who visited Iso Clinic was higher than that among patients seen at Tama-Nagayama Hospital, Nippon Medical School (Tama City, Tokyo). The difference is attributable to the higher prevalence of H. pylori infection in the elderly.

Gastric mucosal morphological consequences of acid suppression: a balanced view

In the chapter, an analysis of the literature on the relationship between Helicobacter pylori, the use of proton pump inhibitors and the development of atrophic gastritis is presented, and the difficulties of classifying gastritis and the new possibilities of quantifying chronic inflammation by morphometric analysis are discussed. The issue surrounding the necessity of eradicating H. pylori in H. pylori-positive patients has still not been solved. Most studies have now accepted that proton pump inhibitors indeed accelerate the onset of atrophic gastritis in H. pylori-positive patients, but evidence against such an association was published in one recent (Scandinavian) study; conclusions from this study have, however, been challenged by several groups. Some data are available on the efficacy of H. pylori eradication with regard to the prevention of atrophy. The limited significance of the development of parietal cell protrusions and fundic gland cysts is better understood, but much less is known of the development and long-term consequence of H. pylori-induced autoimmune gastritis. Finally, recent studies in H. pylori-positive patients indicate that treatment with proton pump inhibitors may promote bacterial N-nitrosation formation. These data taken together suggest that the eradication of H. pylori may be based not only on morphological arguments, but also on bacterial alterations in the gastric milieu.

Helicobacter pylori infection--current treatment practice

Helicobacter pylori infection, which is present in 30 - 60% of the population in developed countries and in more than 60% in developing countries, is established to be a major cause of gastritis, peptic ulcer disease and gastric cancer. Eradication therapy has been incorporated into clinical practice over the past 15 years. Treatment regimens include a 2 week bismuth-based triple therapy (a bismuth compound plus metronidazole, tetracycline or amoxycillin), a 1 week proton-pump inhibitor (PPI)-based triple therapy and a 1 week ranitidine bismuth citrate (RBC)-based triple therapy (a PPI or RBC plus any two of the three antibiotics, metronidazole, amoxycillin and clarithromycin). These regimens achieve eradication rates of >> 80%. H. pylori resistance to metronidazole and clarithromycin decreases the clinical efficacy of most regimens, despite the high eradication rates for resistant strains achieved by the RBC-triple therapy in some recent trials. The dose of antibiotics (especially clarithromycin) and the duration of treatment may also influence the eradication rate. Doctors' beliefs impact on clinical practice and, thus, influence the clinical application of eradication therapy. Whereas peptic ulcer disease and primary gastric low-grade B-cell mucosa-associated lymphoid tissue lymphoma (MALToma) have become established as definite indications for eradication therapy, there remain controversies surrounding non-ulcer dyspepsia, gastro-oesophageal reflux disease, atrophic gastritis, intestinal metaplasia, use of non-steroidal anti-inflammatory drugs (NSAIDs) and H. pylori-related extradigestive diseases.

Trend toward a reduced prevalence of Helicobacter pylori infection, chronic gastritis, and gastric cancer in Japan

It is speculated that declines in H. pylori infection and gastritis over the past few decades may lead to a decline in gastric cancer in Japan, supplemented by excellent procedures for the early detection of gastric cancer. Because H. pylori infection rarely is acquired in adult life, once it is eradicated, reinfection would not be expected in adult patients. It seems likely that adequate treatment of H. pylori infection would provide long-term protection against gastric cancer.

Gastritis and gastric cancer. Western countries

Helicobacter pylori infection is the cause of chronic gastritis that progresses to atrophic gastritis over years and decades in more than half of affected individuals. H. pylori gastritis and, particularly, subsequent atrophic gastritis increase the risk for gastric cancer on multifactorial basis. Largely unknown cascades of manifold reactions result in gene errors of epithelial cells in gastric and atrophic stomach, which raise the likelihood of gastric neoplasias and cancer among people infected by H. pylori. The prevalences and incidences of gastric cancer and H. pylori are similarly decreased during the past decades in western countries, supporting the view that H. pylori infection is a key event and a trigger of the phenomena that result in cancer in some of the infected subjects.

Can helicobacter pylori serology still be applied as a surrogate marker to identify peptic ulcer disease in dyspepsia?

BACKGROUND

Helicobacter pylori infection and associated peptic ulcer disease (PUD) has become less common in some countries.

AIM

To determine if H. pylori serology alone or combined with a history of ingestion of non-steroidal anti-inflammatory drugs (NSAIDs) and an age threshold can be used as an indirect ulcer test.

METHODS

Two hundred and fifty-two consecutive Australian patients (121 males, mean age 52 years) referred for endoscopy were enrolled. Blood was tested by a validated ELISA. At endoscopy, eight biopsies were taken for CLO-testing, culture and histology. NSAID use over the prior 3 months was recorded.

RESULTS

One hundred and six (42%) patients were seropositive for H. pylori, 48 (19%) patients had PUD and 30 (12%) used NSAIDs. Serology alone had a sensitivity of 52% and a specificity of 60% for identifying PUD; the sensitivity and specificity were 60% and 55%, respectively, when combined with a history of NSAID use. Serology, regardless of NSAID use, would have saved 23% in endoscopy workload but would have missed 17% of PUD cases if an age threshold of < 45 years was chosen for omitting endoscopy.

CONCLUSIONS

Serology was a poor ulcer test despite an excellent performance for detecting H. pylori. A strategy combining serology and an age threshold with a history of NSAID use to reduce endoscopy workloads may not always be appropriate.

Disease management in ulcer disease

BACKGROUND

Our knowledge of Helicobacter pylori infection indicates that it is possible to eliminate ulcer disease and improve quality of life for ulcer patients. Treatment is evidence-based and cost-effective. However, though we now have the tools, we have not yet been able to eliminate ulcer disease from society. Dissemination of knowledge and treatment implementation have been problematic. In primary care, there is diagnostic and therapeutic chaos regarding this infection. Disagreement exists on indications for treatment. Expenditure on acid-reducing drugs has greatly increased. Clearly we are not treating all ulcer patients properly (undertreatment); instead we have incorporated H. pylori therapy ('test and treat') into our approach to dyspepsia (overtreatment). Anti-H. pylori therapy in patients with non-ulcer dyspepsia may increase costs because most patients still suffer from symptoms after antibiotic therapy, and therefore require further diagnostic procedures and prescription of new drugs. In order to redeem the great promise of H. pylori, we must focus less on new ulcer patients, because the incidence is rapidly decreasing in Western Europe. Prevalence of ulcer disease, however, is still high. Thus we need to focus more on prevalent cases. We ought to seek and treat those persons already known to have ulcer disease. Systematic 'case-finding' strategies must be performed using standard protocols. Only such 'disease management' programmes performed at the primary care level will suffice to eliminate ulcer disease while also being cost-effective.

Review article: exploring the link between Helicobacter pylori and gastric cancer

Cancer of the distal stomach, both of the intestinal and diffuse type, is strongly associated with Helicobacter pylori colonization. This bacterium causes chronic active inflammation of the gastric mucosa in the majority of colonized subjects. In a considerable number of them, this will eventually lead to a loss of gastric glands, and thus the establishment of atrophic gastritis, which is associated with the development of intestinal metaplasia and dysplasia. Development of atrophy and metaplasia of the gastric mucosa are thus strongly associated with H. pylori infection, instead of a direct and inevitable consequence of ageing. Approximately 40-50% of infected subjects develop these conditions, but they are rare in non-infected subjects. The presence of these consecutive disorders leads to a 5-90-fold increased risk for cancer of the distal stomach, in particular of the intestinal type. This sequence explains the increased risk for gastric cancer in H. pylori-infected subjects, as has been shown in various cross-sectional and longitudinal studies. In a combined analysis of three longitudinal studies, a significant trend was observed towards an increased odds ratio with longer intervals between (retrospective) serological diagnosis of H. pylori infection and observation of gastric cancer, this risk being more than eight-fold increased if the interval had been at least 15 years. This is thought to reflect development of atrophic gastritis and intestinal metaplasia with loss of H. pylori colonization in the years prior to development of cancer. Atrophic gastritis and gastric cancer thus appear closely associated with the presence of H. pylori, yet not all infected subjects will eventually develop atrophy and only a small minority develop gastric cancer. Factors that influence the risks for atrophy and cancer in the presence of infection may be related to the time that infection occurred and to characteristics of the bacterial strain and the host. Evidence for the role of these factors is now increasing. Recognition of the causal role of H. pylori in the induction of gastric cancer theoretically presents tools for cancer prevention. The efficacy of screening and bacterial eradication for prevention of distal gastric cancer is being studied in a number of large-scale intervention studies in different populations. It is hoped that these studies will also provide answers to the potential preventive role of H. pylori colonization in the development of gastro-oesophageal reflux disease and associated conditions, in particular development of cancer of the proximal stomach. Infection with H. pylori plays an important role in the aetiology of atrophic gastritis and gastric cancer. Studies suggest an eight-fold increased risk for both conditions in the presence of infection. Factors that influence the risk for both conditions in the presence of infection are the age at which infection occurred and the presence of cagA as a marker for more pathogenetic H. pylori strains. The efficacy and side-effects of intervention for the prevention of distal gastric cancer has yet to be established.

Comparison of biopsy and serological methods of diagnosis of Helicobacter pylori infection and the potential role of antibiotics

OBJECTIVE

Endoscopic biopsy and serological methods were compared for their ability to detect Helicobacter pylori infection in patients undergoing upper gastrointestinal endoscopy at a state university hospital.

METHODS

Subjects were characterized on the basis of gastrointestinal symptoms, endoscopic findings, socioeconomic and demographic features, and the use of certain medications, tobacco, and alcohol. Current infection was detected in gastric antral specimens by rapid urease testing, histopathology, and bacterial culture. Serum levels of IgG to H. pylori were measured by ELISA.

RESULTS

Of 240 subjects, 115 (47.9%) were currently infected as determined by rapid urease testing, histopathology, and/or culture results, whereas 63.3% had elevated anti-H. pylori IgG levels (p < 0.001). This difference in the prevalence of current infection and seropositivity was preserved when the study population was analyzed according to age, race, gender, and other characteristics. Prior use of antibiotics was associated with a significant reduction in the frequency of H. pylori infection.

CONCLUSIONS

Serological evidence of H. pylori infection was consistently greater than the prevalence of infection documented by biopsy methods in this study, suggesting suppression or recent clearance of infection. Further studies are needed to examine the factors that may affect the detection of H. pylori infection.

Histological diagnosis of Helicobacter pylori gastritis is predictive of a high risk of gastric carcinoma

Chronic Helicobacter pylori infection has been identified as a major risk factor for the subsequent development of gastric carcinoma On the basis of seroepidemiological studies the relative risk for infected persons was estimated to range between 3 and 6. Our study attempted to determine the relative risk of gastric carcinoma in H. pylori-infected individuals based on the histological evaluation of gastritis in gastric carcinoma patients in the light of a declining prevalence of H. pylori infection in Western countries. We histologically determined the H. pylori infection rate in 215 patients with early gastric carcinoma (tumor stage pT1), and compared it with that of 215 asymptomatic persons matched by age and sex who were tested by the 13C urea breath test. On the basis of these data an odds ratio of 16.7 (CI 9.6-29.1) was calculated for the relative risk of developing gastric carcinoma in H. pylori-infected people. The histological diagnosis of gastritis permits a separate risk assessment for patients with autoimmune gastritis, and by excluding these patients from the analysis we calculated an odds ratio for H. pylori-infected persons of 150 (CI 36.4-622.9). The endoscopic-histological diagnosis of H. pylori infection is associated with an increased risk of the subsequent development of gastric carcinoma of approximately 150-fold compared with H. pylori-negative patients who do not have chronic atrophic corpus gastritis of the autoimmune type (type A gastritis).

Reduced incidence of Helicobacter pylori infection in young Japanese persons between the 1970s and the 1990s

Although the incidence of gastric carcinoma in Japan has declined in the past several decades, there is no information about trends in helicobacter pylori infection. The purpose of the study was to clarify trends in H. pylori infection and in histologic gastritis in young Japanese subjects evaluated between 1975 and 1978 (the 1970s) versus 1991 and 1994 (the 1990s). The prevalence of H. pylori infection and the grade of gastritis in biopsy specimens were evaluated in 173 young Japanese without localized lesions in the upper gastrointestinal tract. Findings in 75 specimens obtained from subjects in the 1970s were compared with those of 98 specimens obtained from subjects in the 1990s. The prevalence of H. pylori infection in the 1970s (54.7%) was significantly higher than that in the 1990s (28.6%) (p < 0.01). The grade of inflammation and the prevalence of both mucosal atrophy and intestinal metaplasia also were significantly higher in the 1970s than in the 1990s (p < 0.01 and p < 0.05). Our data thus show a trend toward a reduced prevalence of H. pylori infection and of histologically apparent gastritis (especially atrophic gastritis). This decrease may be linked to the reported decline of gastric carcinoma in Japan.

Helicobacter pylori gastritis--epidemiology

The acquisition of Helicobacter pylori is the main cause of chronic gastritis in humans. In Europe, a small proportion (less than 1%) of gastritis cases are caused by H. Heilmannii, and somewhat more (5%) are autoimmune in origin, in which condition H. pylori may not probably play a role. Recent findings on chronic gastritis and H. pylori acquisition in developed countries can be summarized as: (1) H. pylori gastritis is acquired in childhood and adolescence (age less than 20) in more than 50% of cases; (2) the risk and rate of acquisition is highest in early childhood, after which the rate exponentially declines; (3) new infections occur in adulthood but are quite rare (annual incidence 0.4%, on average, in Finland); (4) H. pylori gastritis is a birth cohort-related phenomenon; i.e., different cohorts show a rate and prevalence of H. pylori gastritis that varies between cohorts; (5) the rate and risk of H. pylori infection is high in cohorts born in the beginning of the century, but is much lower in those born later; (6) this decline is due to a decrease in the rate and risk of H. pylori acquisition in childhood in particular. H. pylori gastritis-related complications, such as peptic ulcer diseases and gastric cancer, show epidemiological features similar to H. pylori gastritis. Both peptic ulcer and gastric cancer have declined in incidence over time. Gastric cancer is a birth-cohort phenomenon in the same way as is H. pylori gastritis, and the incidence of gastric cancer shows a positive but exponential relationship with the "birth-cohort-specific" prevalence of gastritis in the general population.

Gastritis classified in accordance with the Sydney system in patients with primary Sjögren's syndrome

BACKGROUND

According to some earlier reports, chronic atrophic gastritis is a common finding in Sjögren's syndrome. However, the findings are controversial. The aim of this study was to investigate the occurrence of gastritis classified in accordance with the Sydney System in patients with primary Sjögren's syndrome.

METHODS

Thirty-two consecutive patients (27 women, 5 men) with primary Sjögren's syndrome, and 64 age- and sex-matched control subjects with dyspepsia underwent gastroscopic examination. Mucosal biopsy specimens were taken from the gastric antrum and corpus.

RESULTS

Eight (25%) patients with Sjögren's syndrome and three (4.1%) control subjects had atrophic antral gastritis (P = 0.01). Atrophic corpus gastritis was more frequently found in control subjects, but the difference was not statistically significant. None of the subjects had severe (grade 3) atrophy. Gastric inflammation, in either the corpus or antrum, was found in 85% of patients with Sjögren's syndrome and in 61% of control subjects (P = 0.02). Helicobacter pylori was present in 31% of Sjögren's syndrome patients and in 39% of controls (NS).

CONCLUSIONS

In patients with primary Sjögren's syndrome mild atrophic changes in the antrum were common, but severe mucosal atrophy was rare. Compared with control subjects, gastric inflammation was seen more often in patients with Sjögren's syndrome.

Different expression of Helicobacter pylori gastritis in children: evidence for a specific pediatric disease?

BACKGROUND

Infection with Helicobacter pylori causes active chronic gastritis. Once the infection is acquired, gastritis will persist for almost the rest of one's life. To date, very few data are available on H. pylori gastritis in relation to age. Therefore, we attempted to investigate whether H. pylori gastritis in children exhibits features different from H. pylori gastritis in adults of two different age groups.

MATERIALS AND METHODS

Fifty consecutive children with a median age of 11 years (range, 3-18 years) were compared with two groups of 50 adult patients, one group with a median age of 43 (range, 19-56 years) and another group with a median age of 70 years (range, 59-86 years). All patients had H. pylori gastritis unrelated to active peptic ulcer disease. Two biopsy specimens were taken from the antrum and two from the corpus, and the following gastritis parameters were evaluated: degree and activity of gastritis, H, pylori colonization, replacement of foveolar epithelium by regenerative epithelium, mucous depletion, presence of atrophic gastritis with intestinal metaplasia, and presence of lymphoid follicles.

RESULTS

Degree and activity of gastritis, extent of H. pylori colonization, degree of replacement by regenerative epithelium, extent of mucous depletion, degree of atrophic gastritis with intestinal metaplasia, and the presence of lymphoid follicles in the antrum, as well as the presence of lymphoid follicles in the corpus differed significantly (chi-square test: p < .05). All these differences--except the once frequent occurrence of atrophic gastritis with intestinal metaplasia in adults--were attributable to a higher expression of these gastritis parameters in children.

CONCLUSIONS

We conclude that H. pylori gastritis, particularly in the antrum, is more severely expressed in childhood. One reason for this might be a child-specific immune response to an infection with H. pylori. Alternatively, infection may represent a pediatric disease characterized by a nonatrophic, highly expressed form of gastritis, which changes its appearance once the host becomes adapted over time.

High frequency of helicobacter negative gastritis in patients with Crohn's disease

The frequency of gastric Crohn's disease has been considered low. This study was undertaken to determine the prevalence of chronic gastritis and Helicobacter pylori infection in patients with Crohn's disease. Oesophagogastroduodenoscopy was performed on 62 consecutive patients suffering from ileocolonic Crohn's disease. Biopsy specimens from the antrum and corpus were processed for both histological and bacteriological examinations. H pylori antibodies of IgG and IgA classes were measured in serum samples by enzyme immunoassay. Six patients (9.7%) were infected with H pylori, as shown by histology, and in five of them the infection was also verified by serology. Twenty one patients (32%) had chronic H pylori negative gastritis (negative by both histology and serology) and one of them also had atrophy in the antrum and corpus. Granulomas were found in four patients. The characteristic appearance of H pylori negative gastritis was focal and mostly mild inflammation resembling the inflammatory changes seen in the gut in Crohn's disease. Patients with H pylori negative chronic gastritis had a significantly more active disease in their gut than those with normal gastric mucosa (p < 0.01). It is concluded that H pylori positive gastritis is rare, while H pylori negative gastritis is relatively common in patients with Crohn's disease. H pylori negative 'Crohn's gastritis' seems to be associated with active Crohn's disease.

Rate of Helicobacter pylori acquisition among Finnish adults: a fifteen year follow-up

BACKGROUND AND METHODS

To investigate the acquisition rate of Helicobacter pylori infection among Finnish adults, we obtained, in 1991, serum samples from 181 subjects who were shown to have histologically normal, noninfected gastric mucosa in 1974-76.

RESULTS

During the 15-year follow-up period 12 (6.6%) of the 181 subjects developed H. pylori antibodies (IgG), the overall annual acquisition rate being 0.44%. The acquisition rate correlated somewhat with age. Antibodies developed in 1(4.5%) of the 22 subjects less than 40 years old (in 1991) and in 4 (31%) of 13 subjects who were 70 years old or older. If it is assumed that H. pylori acquisition is a continuous and stable event through the whole life span, and the rate is similar in all birth cohorts, the observed annual acquisition rate of 0.44% or an increase of this rate with age does not explain the current prevalence of chronic gastritis in Finland. Extrapolations of the known and estimated prevalence rates of chronic gastritis in 1974/76 and 1991 indicated rather that the H. pylori acquisition is a birth-cohort-dependent phenomenon and that most of the acquisitions occurred in childhood in every cohort (generation). After being high in childhood (less than 20 years old), the acquisition rate exponentially slowed down with age in all cohorts.

CONCLUSIONS

Among adults the acquisition rate of H. pylori infection is low, and the main period of acquisition is childhood. The relationship between the acquisition rate and age is inverse and exponential.

Seroepidemiological study of Helicobacter pylori infection in infancy

The incidence of Helicobacter pylori infection in very young children was determined, based on the emergence of specific IgG antibodies in sequential serum samples from birth to 2 years of age. The risk of acquiring H pylori infection in infancy as a result of maternal exposure to the organism was also assessed, based on the determination of maternal cord-blood antibodies. Serum IgG class H pylori antibodies were analysed in the cord blood samples of 195 newborns and in their follow up samples until the age of 2 years. Maternal antibodies were detected in the cord-blood samples of 21 children (10.6%). These antibodies disappeared in all but one child before 7 months of age and no new seroconversions occurred in these children. Ten originally cord-blood negative children seroconverted up to the age of 2 years (5.1%). It is concluded that a major proportion of H pylori infections observed in young adults in Finland are acquired during the first two years of life. Maternal seropositivity is not a straightforward risk factor for acquiring H pylori infection in infancy.

Bacterial infection as a cause of cancer

Bacterial infections traditionally have not been considered major causes of cancer. Recently, however, bacteria have been linked to cancer by two mechanisms: induction of chronic inflammation and production of carcinogenic bacterial metabolites. The most specific example of the inflammatory mechanism of carcinogenesis is Helicobacter pylori infection. H. pylori has been epidemiologically linked to adenocarcinoma of the distal stomach by its propensity to cause lifelong inflammation. This inflammation is in turn thought to cause cancer by inducing cell proliferation and production of mutagenic free radicals and N-nitroso compounds. H. pylori is the first bacterium to be termed a definite cause of cancer in humans by the International Agency for Research on Cancer. Mutagenic bacterial metabolites are also suspected to increase risk for cancer. This model is best exemplified in colon cancer. Bile salt metabolites increase colonic cell proliferation. Exogenous compounds such as rutin may be metabolized into mutagens by resident colonic flora. Moreover, Bacteroides species can produce fecapentaenes, potent in vitro mutagens, in relatively high concentrations. In vivo data on human carcinogenesis by bacterial metabolites, however, are inconsistent. Local bacterial infections may also predispose to nonnodal lymphomas, although the mechanisms for this are unknown. Gastric lymphomas and immunoproliferative small intestinal disease have been most strongly linked to underlying bacterial infection. Because bacterial infections can be cured with antibiotics, identification of bacterial causes of malignancy could have important implications for cancer prevention.

Incidence of gastric cancer and prevalence of chronic gastritis in outpatients: comparison between two geographical areas in Finland

We present some evidence that there exists a positive relationship between the incidence of gastric cancer and the prevalence rate of chronic gastritis, regarding the time trends and geography of these diseases in Finland. Both gastric cancer and chronic gastritis have declined in occurrence during the last 15 years, and there exists a similar geographic distribution of these diseases in Finland on the north-south axis: both are more prevalent in Lapland than in Southern Finland. The distribution of the socioeconomic conditions in Finland also shows a north-south axis: the proportion of people with low social class, number of children (birth rate) per household is higher, and the yearly income on average is lower in Lapland than in Southern Finland. We conclude that the epidemiology of chronic gastritis and gastric cancer show similar epidemiological features, regarding at least the time trends and geography of these diseases in Finland.

Helicobacter pylori infection in Estonian population: is it a health problem?

The role of Helicobacter pylori infection in traditionally noncommunicable diseases as chronic gastritis, peptic ulcer and gastric carcinoma became more evident during the first decade of H. pylori studies. To analyse and evaluate the prevalence of H. pylori infection in Estonia as a population health problem, the data of three randomly selected samples of Estonian population aged over 15 years were used. The infection rate assessments in two representative samples of the population (Kambja 157 persons and Kuressaare 224 persons) were based on H. pylori colonization in the gastric mucosa, and in one sample (Karksi-Nuia 1467 persons) on seroconversion of H. pylori IgG antibodies. The persons studied were divided into groups according to birth cohorts. The population studies in Estonia showed a high prevalence of H. pylori infection among Estonians: 73% in the Kuressaare sample, 78% in the Kambja sample, and 87% in the Karksi-Nuia sample. From the Kuressaare population sample 38 families with 290 persons were included in a family H. pylori infection study and 92.5% of the persons in these families were found to be H. pylori positive. H. pylori infection was frequent in persons who were born at the beginning of this century as well as in those born after World War II up to 30 years ago. It was concluded that H. pylori infection is common in Estonia, both in random persons and their families. It is probable that the infection rate of H. pylori depends to a great extent on the socioeconomic conditions of this country and that acquisition of H. pylori in Estonia starts at an early age.

Helicobacter pylori infection in Finnish children and adolescents. A serologic cross-sectional and follow-up study

BACKGROUND

The purpose was to examine the epidemiology of Helicobacter pylori infection in Finnish children and adolescents.

METHODS

Blood samples taken from healthy subjects (n = 461) 3-18 years old were studied cross-sectionally for the presence of H. pylori antibodies. Additionally, blood samples drawn in 1980, 1983, 1986, and 1989 from 74 children born in 1977 were tested. Serum IgG-class antibodies to H. pylori were determined by an enzyme immunoassay.

RESULTS

In the cross-sectional series the mean antibody levels and the percentage of seropositive children increased with age. The overall seroprevalence was 10.2%. During the follow-up period from 3 to 12 years of age the seropositivity increased from 4.6% to 5.7%. On the basis of the seroconversions between 3 and 12 years of age the annual incidence of H. pylori infection was calculated to be only 0.3%.

CONCLUSIONS

In children seropositivity for H. pylori of the IgG class is often a sign of an infection acquired in early childhood. It seems likely that the age-dependent increase in the seropositivity reflects cumulation of a chronic infection.