Histological study of chronic gastritis from the United Arab Emirates using the Sydney system of classification

Prevalence of Helicobacter pylori and Its Associated Factors among Healthy Asymptomatic Residents in the United Arab Emirates

The United Arab Emirates (UAE) has been under continuous populational influences from Asia, Europe, and Africa, making it an ideal site for epidemiological studies on Helicobacter pylori. However, there has been a paucity of well-designed prevalence studies on H. pylori from UAE. The aim of this study was to determine the prevalence of H. pylori and its associated risk factors in the UAE. A prospective cross-sectional study was conducted on healthy asymptomatic residents of UAE. Socio-demographic, lifestyle, and gastrointestinal characteristics of participants were obtained through a questionnaire in parallel within the stool sample collection. A total of 350 participants were included in this study and were tested for H. pylori using the stool antigen test (Premier Platinum HpSAT). Out of the total tested study participants, 41% were found to be H. pylori-infected. Logistic regression analysis has shown a significant association between H. pylori infection and gender, age, ethnicity, profession, domestic overcrowding, source of drinking water, and gastrointestinal characteristics of participants. Based on the results from this study, we suggest that preventive measures against H. pylori infection should be considered worthy by public health authorities.

Disease manifestations of Helicobacter pylori infection in Arctic Canada: using epidemiology to address community concerns

OBJECTIVES

Helicobacter pylori infection, linked to gastric cancer, is responsible for a large worldwide disease burden. H pylori prevalence and gastric cancer rates are elevated among indigenous Arctic communities, but implementation of prevention strategies is hampered by insufficient information. Some communities in northern Canada have advocated for H pylori prevention research. As a first step, community-driven research was undertaken to describe the H pylori-associated disease burden in concerned communities.

DESIGN

Participants in this cross-sectional study completed a clinical interview and gastroscopy with gastric biopsies taken for histopathological examination in February 2008.

SETTING

Study procedures were carried out at the health centre in Aklavik, Northwest Territories, Canada (population ∼600).

PARTICIPANTS

All residents of Aklavik were invited to complete a clinical interview and gastroscopy; 194 (58% female participants; 91% Aboriginal; age range 10-80 years) completed gastroscopy and had gastric biopsies taken.

PRIMARY AND SECONDARY OUTCOME MEASURES

This analysis estimates the prevalence of gastric abnormalities detected by endoscopy and histopathology, and associations of demographic and clinical variables with H pylori prevalence.

RESULTS

Among 194 participants with evaluable gastric biopsies, 66% were H pylori-positive on histology. Among H pylori-positive participants, prevalence was 94% for acute gastritis, 100% for chronic gastritis, 21% for gastric atrophy and 11% for intestinal metaplasia of the gastric mucosa, while chronic inflammation severity was mild in 9%, moderate in 47% and severe in 43%. In a multivariable model, H pylori prevalence was inversely associated with previous gastroscopy, previous H pylori therapy and aspirin use, and was positively associated with alcohol consumption.

CONCLUSIONS

In this population, H pylori-associated gastric histopathology shows a pattern compatible with elevated risk of gastric cancer. These findings demonstrate that local concern about health risks from H pylori is warranted and provide an example of how epidemiological research can address health priorities identified by communities.

Helicobacter pylori and gastric cancer in the Middle East: A new enigma?

The Middle East is the home of ethnic groups from three main backgrounds: Semitic (Arabs and Jews), Indo-European (Persians and Kurdish) and Turkic (Turkish and Turkmens). Its geographic location, which has been under continuous influences from Asia, Europe and Africa, has made it an ideal site for epidemiological studies on Helicobacter pylori (H. pylori) infection and genotyping. The gastric cancer rate differs in this region from very high in Iran (26.1/10⁵) to low in Israel (12.5/10⁵) and very low in Egypt (3.4/10⁵). Epidemiological studies showed that the prevalence of H. pylori is almost similar in those countries with a high level of infection in childhood. Importantly, the frequency of vacA s1 and m1 regions and cagA+ genotypes were higher in non Semitic populations who inhabit the North than Semitic populations, the inhabitants of Southern parts of the Middle East. H. pylori infection prevalence, distribution pattern of virulence factors, diet and smoking could not have explained the difference in cancer rate. This reflects the multifactorial aetiology of gastric cancer and suggests that H. pylori infection does not always directly correlate with the risk for gastrointestinal disease, such as gastric cancer. Further detailed investigations and international comparative studies of each risk factor need to be performed to investigate whether this represents a true enigma.

A study of Helicobacter pylori-associated gastritis patterns in Iraq and their association with strain virulence

BACKGROUND/AIM

Helicobacter pylori (H. pylori) infection causes peptic ulceration and gastric adenocarcinoma. In Iraq, gastric cancer is rare. We investigated whether infected adults had the antral-predominant pattern of H. pylori-associated gastritis, which does not predispose to cancer.

MATERIALS AND METHODS

We evaluated histopathological changes by the Sydney scoring system in gastric biopsies taken from 30 H. pylori-infected adults and studied the correlation of these changes with the virulence factors. The Mann-Whitney test was used for the comparison of histopathological data. The presence or absence of each pathological index was evaluated with respect to the possession of virulence factors by the infecting H. pylori strain using the chi(2) test.

RESULTS

Gastric lymphocyte infiltration was more prominent in the antrum (P = 0.01). Neutrophil infiltration was mild and gastric mucosal atrophy was rare. No relationship was found between virulence factors and histopathological changes.

CONCLUSIONS

The mild pathology and antral-predominant gastritis help explain the low cancer rate in Iraq.

Nodular gastritis and pathologic findings in children and young adults with Helicobacter pylori infection

PURPOSE

The aim of this study was to investigate the pathologic characteristics of nodular gastritis in children and young adults infected with Helicobacter pylori (H. pylori).

MATERIALS AND METHODS

A total of 328 patients were enrolled in this study, and the diagnosis of H. pylori infection was done with gastroduodenal endoscopy concomitant with a CLO(TM) test and pathologic analysis of the biopsy specimens. Diagnoses of normal, superficial gastritis, nodular gastritis, and peptic ulcer disease were made from the gastroduodenal endoscopic findings. The density of H. pylori organisms in the gastric mucosa was rated as normal, mild, moderate, or marked. The pathologic findings of nodular gastritis were based on the histopathologic findings of inflammation, immune activity, glandular atrophy and intestinal metaplasia. Each of these findings was scored as either normal (0), mild (1), moderate (2), or marked (3) according to the updated Sydney system and using visual analog scales. The gastritis score was the sum of the four histopathologic scores.

RESULTS

In this study, nodular gastritis (50.6%) was most common, and mild density (51.5%) H. pylori infection was also common upon microscopic examination. Intestinal metaplasia occurred in 9 patients (2.7%).

CONCLUSION

Logistic regression revealed a significant increase in the incidence of nodular gastritis with gastritis score (p=0.008), but not an association with sex, age, or H. pylori density. Gastritis score was the only significant factor influencing the occurrence of nodular gastritis. Intestinal metaplasia, which was originally thought to be a pre-malignant lesion, occurred in 2.7% of the patients with H. pylori infection.

Does gastric atrophy exist in children?

Several clinical reports confirmed that gastric atrophy is a pathology not only limited to adult patients. In pediatrics, it is most often described in association with a H pylori infection but this bacteria does not seem to be the only etiological factor of this preneoplastic state in children. The frequency of gastric atrophy and intestinal metaplasia in children are unknown because they are not systematically sought during upper gastrointestinal endoscopy. The lack of specific histological classification of children’s gastropathies makes their diagnosis difficult for pathologists. Based on our knowledge to date, we think that it is necessary to describe, in detail, the natural course of this lesion during childhood. A close and prolonged clinical and endoscopic follow-up is important for children with gastric atrophy.

H pylori infection among 1000 southern Iranian dyspeptic patients

AIM: To describe the frequency of H pylori infection among 1000 southern Iranian dyspeptic patients.

METHODS: A prospective study was performed in a referral hospital in south of Iran from 1999 to 2005. One thousand dyspeptic patients (518 males, mean ± SD age of 49.12 ± 12.82 years) consecutively underwent upper gastrointestinal endoscopy. Multiple gastric antral biopsy samples were taken from all patients for rapid urease test and histopathologic examination (96.9% satisfactory samples). Patients were considered H pylori-infected if one or both tests were positive.

RESULTS: Six hundred and seventy-one patients (67.1%, 95% confidence interval [CI]: 64.2%-70.0%) were H pylori-infected. H pylori positivity was significantly more frequent in patients with peptic ulcer disease (PUD) than in those with non-ulcer dyspepsia (P < 0.001). Male-to-female ratio for duodenal and gastric ulcers was 2.7:1 and 1.5:1, respectively. Moreover, the duodenal-to-gastric ulcer ratio was 1.95:1. The frequency of H pylori infection among those with endoscopic diagnosis of gastritis, duodenal ulcer, gastric ulcer, and normal mucosa was 70.1% (398/568), 86.2% (150/174), 71.9% (64/89), and 33.5% (54/161), respectively. H pylori infection, male sex, and older age were independently associated with PUD in multivariate analysis. H pylori positivity was associated with chronic gastritis, and chronic active gastritis with odds ratios of 34.21 (95% CI: 12.19%-96.03%) and 81.21 (95% CI: 28.85%-228.55%), respectively.

CONCLUSION: H pylori and PUD are highly frequent in dyspeptic patients from south of Iran. H pylori is a cardinal risk factor for chronic active or inactive gastritis.

Comparison of precancerous conditions: atrophy and intestinal metaplasia in Helicobacter pylori gastritis among Chinese and Dutch patients

AIM-Atrophy and intestinal metaplasia (IM) as precancerous conditions consistently begin in the antrum and are most severe along the lesser curvature. The aim of this study was to investigate discrepancies in the prevalence, the severity of atrophy, and IM in antral mucosa of Helicobacter pylori infected gastritis and difference in age of onset among Chinese and Dutch patients. METHODS-Two hundred and sixty five Chinese patients and 261 Dutch patients with H pylori infection were enrolled. The degrees of atrophy and IM were graded according to the updated Sydney system. RESULTS-The overall prevalences of atrophy and IM were lower in Dutch patients (42% and 26%, respectively) than in Chinese patients (52% and 32%, respectively). Only the difference in atrophy reached significance (p = 0.028). However, in both Chinese and Dutch patients, the degrees of atrophy and IM were low and severe degrees were rare. The mean ages of Chinese and Dutch patients with atrophy and IM were higher than those without atrophy and IM (with atrophy (Chinese patients): mean, 42.12; SD, 9.80; with IM (Chinese patients): mean, 42.56; SD, 9.96; with atrophy (Dutch patients): mean, 55.16; SD, 12.20; with IM (Dutch patients): mean, 57.79; SD, 11.13; without atrophy (Chinese patients): mean, 39.71; SD, 10.16; without IM (Chinese patients): mean, 40.19; SD, 9.99; without atrophy (Dutch patients): mean, 45.70; SD, 12.44; without IM (Dutch patients): mean, 46.89; SD, 12.68). Atrophy and IM occurred earlier and were more severe in Chinese patients, with both reaching a peak value in patients over 60 years. CONCLUSIONS-There are geographical differences in the prevalence and severity of H pylori infected gastritis, in particular with respect to atrophy and IM, which suggests that infection with H pylori occurs earlier in life and has a higher prevalence in CHINA:

A topographic study of Helicobacter pylori density, distribution and associated gastritis

BACKGROUND AND AIMS

The topographic distribution and density of Helicobacter pylori and associated gastritis in the stomach were studied in order to determine which biopsy sites are likely to provide the maximum yield so as to reduce the fallacious results due to sampling error.

METHODS

Fifty patients with upper gastrointestinal symptoms were studied. Eleven gastric biopsies from predetermined sites were obtained and subjected to ultra-rapid urease test, imprint cytology and histology. Haematoxylin and eosin stain was used for defining gastritis and other associated histopathological details. Loeffler's methylene blue stain was used to confirm the presence of H. pylori in imprint smears and histological sections.

RESULTS

All 50 patients had H. pylori infection and evidence of chronic gastritis at one or more of the 11 biopsy sites. Maximum and minimum percentage positivity were observed at A3 (antral lesser curvature) and B4 (corpus greater curvature), respectively. Various sites in decreasing order of percentage positivity were A3 > A2 > A1 > A4 > B3 > B1 > A5 > B6 > B5 > B2 > B4. Among the biopsies obtained from the corpus, B3 (corpus lesser curvature) was the site with maximum positivity. A3 and B4 had a statistically significant difference in percentage positivity (P < 0.0001) for H. pylori and gastritis. The maximum and minimum density scores of H. pylori and gastritis were found in A3 and the B4, respectively. A3 had a significantly higher (P < 0.0001) mean density score than any other site in the stomach. The difference in the grading of H. pylori between A3 and B3 (sites of maximum positivity in antrum and corpus) was statistically significant (P < 0.0001). A statistically significant (P < 0.001) positive correlation between increasing grades of H. pylori and gastritis was observed at the site of maximum density. Eighty per cent of the patients had antral predominant gastritis and in 82%, H. pylori was predominantly observed in antral biopsies.

CONCLUSION

It is concluded that two biopsies taken from A3 are sufficient for confirmation of presence of H. pylori and associated gastritis for initiation of treatment. However, additional biopsies from B3 will help in deciding the topographic pattern of gastritis.

The long-term reinfection rate and the course of duodenal ulcer disease after eradication of Helicobacter pylori in a developing country

OBJECTIVE

The aim of this study was to evaluate the effect of Helicobacter pylori (H. pylori) eradication on the natural history of duodenal ulcer disease and the reinfection rate after treatment in a developing country.

METHODS

A total of 111 H. pylori-infected patients with duodenal ulcer were treated with either omeprazole or famotidine plus two antibiotics for 2 wk. Those failed to respond to treatment were retreated with bismuth-based triple therapy.

RESULTS

The radication rate was 76% (95% CI: 67-83%). Eventually, H. pylori was eradicated in 96 of the 111 patients (86%), who were followed-up clinically and endoscopically for a mean of 37.2 months. The cumulative reinfection rate after eradication (Kaplan-Meier) was 8%+/-3% in yr 1, 11%+/-4% in yr 2, and 13%+/-4% in yr 3. Nine of the 12 reinfections occurred during yr 1. Recurrence of duodenal ulcer was detected in five patients (5.2%), all of them during yr 1 of follow-up. Histologically, gastritis scores (according to the Sydney system) improved significantly after eradication.

CONCLUSIONS

In a high prevalence setting, H. pylori eradication and early reinfection rates after treatment are similar to rates observed in a low prevalence environment, whereas the late reinfection rate seems to be higher. However, up to 3 yr after treatment, most treated patients are free of H. pylori infection and/or ulcer activity. Even longer follow-up studies are necessary to determine whether specific retreatment policies are necessary to maintain long term eradication in developing countries.

Reversal of iron deficiency anemia after Helicobacter pylori eradication in patients with asymptomatic gastritis

BACKGROUND

Iron deficiency anemia is the most common form of anemia worldwide. Recent studies have suggested an association between Helicobacter pylori infection and iron deficiency.

OBJECTIVE

To investigate the effects of eradicating H. pylori with combination antibiotic therapy on iron deficiency anemia in patients with H. pylori-associated gastritis.

DESIGN

Case series.

SETTING

University hospital.

PATIENTS

30 patients with a long history of iron deficiency anemia in whom H. pylori-associated gastritis was the only pathologic gastrointestinal finding detected.

INTERVENTION

Eradication therapy with two antibiotics and discontinuation of iron replacement therapy.

MEASUREMENTS

Complete blood count, ferritin levels, and gastroscopy with biopsy to evaluate H. pylori status.

RESULTS

At 6 months, 75% of patients had recovered from anemia (P<0.001), ferritin values increased from 5.7+/-0.7 microg/L to 24.5+/-5.2 microg/L (95% CI, 8.85 to 29.97). After 12 months, 91.7% of patients had recovered from anemia.

CONCLUSIONS

Cure of H. pylori infection is associated with reversal of iron dependence and recovery from iron deficiency anemia.

Helicobacter pylori: the Middle East scenario

A review of Helicobacter pylori in the Middle East is presented. Prevalence studies have been performed in asymptomatic population groups from Algeria, Israel, Saudi Arabia and Turkey. These showed that the prevalence of H. pylori is similar to that of the developing countries of the world with a high level of infection in childhood (40 to 70 percent), which increases with age to 85 to 90 percent. Israel, however, has a low prevalence in children (10 percent), but there is a rapid rise in the second decade of life to 39 percent, reaching 79 percent in those over 60 years old. The prevalence rates were higher in those living in communal settlements (72 percent) than in urban dwellers (65 percent). The infection rates were higher in persons of Mediterranean and Asian origin (89 percent) compared to those of Western European/North American origin (57 percent). The prevalence rate of H. pylori infection in patients undergoing endoscopy for upper gastrointestinal symptoms has now been reported from many Middle Eastern countries, including Egypt, Iran, Israel, Oman, Saudi Arabia, the United Arab Emirates and Yemen. These studies showed that patients with gastritis and peptic ulcer disease had similar rates of infection as reported from Europe, United States and Africa (71 to 92 percent). However, patients with non-ulcer dyspepsia had higher rates of infection (61 to 89 percent). The H. pylori scenario from the prevalence rates, treatment protocols and responses to treatment does not differ very much from other developing areas of the world.

Helicobacter pylori and intestinal metaplasia with its subtypes in the gastric antrum in a Saudi population

BACKGROUND

There is a close association between intestinal metaplasia (IM) and the development of gastric cancer as well as a relationship between Helicobacter pylori, IM, and gastric cancer. Our aim was to study the frequency and subtypes of IM in a Saudi population with dyspepsia, a population with a low prevalence of gastric cancer.

METHODS

Endoscopic antral biopsy specimens were histologically studied for the presence of IM and H. pylori in consecutive patients who underwent upper gastrointestinal endoscopy for evaluation of dyspepsia. Hematoxylin and eosin and Giemsa stain were used to study IM, inflammation, and H. pylori, whereas Alcian blue, pH 2.5/periodic acid-Schiff and high iron diamine/Alcian blue, pH 2.5, were used to study IM subtypes.

RESULTS

Seven hundred and seventy-eight consecutive patients were recruited in this study, 415 men and 363 women, with a mean age of 43 +/- 17.6 years. Of the 778 patients, IM was identified in 118 (15.2%). The mean ages of patients with IM (48.8 +/- 18.7) and without IM (41.9 +/- 17.4) were statistically significant (P < 0.0001), whereas the patients' sex did not influence the presence of IM. Most had type-I IM (59.3%), whereas 26.3% and 14.4% had types II and III, respectively. The overall rate of infection with H. pylori was 75.4%. There was no difference in the frequency of IM in patients with or without H. pylori (15.5% versus 14.1%; P = 0.65). Of the 118 patients with IM, the 91 patients (77.1%) who also had H. pylori were older (55 +/- 23 years) than those without H. pylori (47 +/- 17 years, P = 0.05).

CONCLUSION

This study has documented mainly that the prevalence of IM and IM subtype III is low in our population. Furthermore, we found no significant relationship between a high rate of H. pylori infection with either IM in general or with IM subtype III in particular, possibly accounting for a low incidence of gastric cancer in the Saudi population.

Quantitative assessment of gastric atrophy using the syntactic structure analysis

AIM

To assess the topographical relation between gastric glands, using the minimum spanning tree (MST), to derive both a model of neighbourhood and quantitative representation of the tissue's architecture, to assess the characteristic features of gastric atrophy, and to assess the grades of gastric atrophy.

METHODS

Haematoxylin and eosin stained sections from corporal and antral biopsy specimens (n = 139) from normal patients and from patients with nonatrophic gastritis and atrophic gastritis of grades 1, 2, and 3 (Sydney system) were assessed by image analysis system (Prodit 5.2) and 11 syntactic structure features were derived. These included both line and connectivity features.

RESULTS

Syntactic structure analysis was correlated with the semiquantitative grading system of gastric atrophy. The study showed significant reductions in the number of points and the length of MST in both body and antrum. The standard deviation of the length of MST was significantly increased in all grades of atrophy. The connectivity to two glands was the highest and most affected by the increased grade of atrophy. The reciprocal values of the Wiener, Randic, and Balaban indices showed significant changes in the volume of gland, abnormality in the shape of glands, and changes in irregularity and branching of the glands in both types of gastric mucosa. There was a complete separation in the MST, connectivity, and index values between low grade and high grade gastric atrophy.

CONCLUSIONS

(1) Gastric atrophy was characterised by loss of the gland, variation in the volume, reduction in the neighbourhood, irregularity in spacing, and abnormality in the shape of the glands. (2) Syntactic structure analysis significantly differentiated minor changes in gastric gland (low grade atrophy) from high grade atrophy of clinical significance. (3) Syntactic structure analysis is a simple, fast, and highly reproducible technique and appears a promising method for quantitative assessment of atrophy.

Helicobacter pylori: the Middle East scenario

A review of Helicobacter pylori in the Middle East is presented. Prevalence studies have been performed in asymptomatic population groups from Algeria, Israel, Saudi Arabia and Turkey. These showed that the prevalence of H. pylori is similar to that of the developing countries of the world with a high level of infection in childhood (40 to 70 percent), which increases with age to 85 to 90 percent. Israel, however, has a low prevalence in children (10 percent), but there is a rapid rise in the second decade of life to 39 percent, reaching 79 percent in those over 60 years old. The prevalence rates were higher in those living in communal settlements (72 percent) than in urban dwellers (65 percent). The infection rates were higher in persons of Mediterranean and Asian origin (89 percent) compared to those of Western European/North American origin (57 percent). The prevalence rate of H. pylori infection in patients undergoing endoscopy for upper gastrointestinal symptoms has now been reported from many Middle Eastern countries, including Egypt, Iran, Israel, Oman, Saudi Arabia, the United Arab Emirates and Yemen. These studies showed that patients with gastritis and peptic ulcer disease had similar rates of infection as reported from Europe, United States and Africa (71 to 92 percent). However, patients with non-ulcer dyspepsia had higher rates of infection (61 to 89 percent). The H. pylori scenario from the prevalence rates, treatment protocols and responses to treatment does not differ very much from other developing areas of the world.

The prevalence of lymphoid follicles in Helicobacter pylori associated gastritis in patients with ulcers and non-ulcer dyspepsia

AIMS

To determine the prevalence of lymphoid follicles in Helicobacter pylori positive and negative gastritis in antral and body type gastric mucosa in patients with non-ulcer dyspepsia (NUD), duodenal ulcer, or gastric ulcer; to correlate follicle presence with patient age; to evaluate the correlation between the prevalence of lymphoid follicles and active and inactive gastritis and its severity; and to assess the positive predictive value of lymphoid follicle prevalence with respect to H pylori infection.

METHODS

Gastric biopsy specimens, graded according to the Sydney system, from 337 patients were studied.

RESULTS

Lymphoid follicles occurred more often in antral mucosa (78%) than in body type mucosa (41%) and were observed in 85% of patients with H pylori positive gastritis. There was no significant difference between NUD and gastric and duodenal ulcer disease with regard to the presence of lymphoid follicles. The positive predictive value of the presence of lymphoid follicles in H pylori infection was 96%. Lymphoid follicles were more commonly observed in patients aged between 10 and 29 years. Lymphoid follicles were more frequently found in pangastritis of all subtypes than in antral gastritis and also in active gastritis than in inactive gastritis. The presence of lymphoid follicles correlated strongly with the degree and severity of gastritis.

CONCLUSION

Lymphoid follicles are a constant morphological feature of H pylori associated gastritis.