Histology of chronic gastritis with and without duodenitis in patients with Helicobacter pylori infection

Inflammatory map of the gastroduodenal mucosa in patients with upper gastrointestinal symptoms. The role of H. pylori infection

INTRODUCTION AND AIM

The gastric mucosa has been studied since the pre-Helicobacter pylori (H. pylori) era, but the complete descriptions of the stomach and duodenum have been anecdotal, and those of the distal duodenum, exceptional. Our aim was to evaluate the different epidemiologic characteristics and the gastroduodenal inflammatory status in patients with upper gastrointestinal symptoms.

MATERIALS AND METHODS

We studied 138 patients divided into: the non-ulcer group (functional dyspepsia [n = 77] and GERD [n = 27]) and the ulcer group (peptic ulcer [n = 13] and duodenal ulcer [n = 21]). Ten biopsy samples (2 from the corpus, 3 from the antrum, 3 from the proximal duodenum, and 2 from the distal duodenum) were taken in each patient for histologic and/or microbiologic study.

RESULTS

The prevalence of dyspepsia, functional dyspepsia, and H. pylori was 80.4%, 69.4%, and 82.6%, respectively. The frequency of superficial chronic gastritis in the corpus was significantly higher in the ulcer group vs. the non-ulcer group, whereas there was more chronic atrophic gastritis in the antrum in the ulcer group (P < 0.05). Duodenitis was significantly more frequent in the ulcer group vs. the non-ulcer group, in both the proximal and distal duodenum. Pangastroduodenitis was a significant finding in the ulcer group. In both groups, chronic gastritis (corpus and antrum) and duodenitis (proximal and distal) were significantly related to the presence of H. pylori. Proximal duodenitis is not an uncommon finding in functional dyspepsia (37.7%) and is twice as frequent as distal duodenitis (16.9%).

CONCLUSIONS

The ulcer group presented with a gastroduodenal inflammatory map different from that of the non-ulcer group and was characterized by a higher frequency of superficial chronic gastritis in the corpus, chronic atrophic gastritis in the antrum, and a very high frequency of proximal duodenitis.

The Role of Duodenal Inflammation in Functional Dyspepsia

Functional dyspepsia (FD) is common and significantly impairs quality of life. Symptoms of FD are considered to originate from the gastroduodenal region, classified by the Rome criteria as disorders of brain-gut interaction without structural alteration. However, it is now apparent that FD is a number of syndromes, the epigastric pain syndrome (bothersome epigastric pain or epigastric burning) and the postprandial distress syndrome (with bothersome postprandial fullness or early satiation) and there are wide-ranging symptoms and severity. The origin of these troublesome symptoms is now considered to be a result of disrupted gastroduodenal neuropathophysiology. The complexity of the syndrome indicates that there must be different triggers, supported by the limited efficacy of the many treatments available. Current research based on evidence by association suggests that duodenal contents, including the duodenal microbiome, pathogens, and allergy may be triggers of FD. Recent studies have also shown that systemic responses of increased circulating lymphocytes and elevated proinflammatory cytokines and subtle inflammation in the duodenum may accompany the onset and persistence of symptoms. This inflammatory phenotype is characterized by innate inflammation, an eosinophil infiltrate in the duodenum in FD in those with postprandial distress syndrome. Routine histopathology practice does not quantify these cells so the status of FD is not yet appreciated as an inflammatory condition. Thus functional is becoming inflammatory and this breakthrough in understanding that functional does not necessarily mean no, but subtle pathology, may improve therapeutic options, which are currently aimed at symptom relief rather than targeted at underlying pathology.

Evaluation of gastric histology in children and adolescents with Helicobacter pylori gastritis using the Update Sydney System

CONTEXT

Although Helicobacter pylori infection is prevalent in our country, there are few studies evaluating the associated histological abnormalities in children.

OBJECTIVE

To evaluate the histological features of the gastric mucosa in children and adolescents with Helicobacter pylori gastritis.

METHODS

One hundred and thirty two gastric biopsies from 22 symptomatic patients infected with H. pylori (14F/8M, median age 10 y 5 mo, age range 2 y 11 mo to 16 y 9 mo) were evaluated. Evaluated gastric regions included: antrum (lesser and greater curvature), corpus (lesser and greater curvature), incisura angularis and fundus. Histological examination was performed according to the Updated Sydney System, and regional scores for polymorphonuclear and mononuclear cell infiltrate as well as bacterial density were generated.

RESULTS

Fifteen (68.2%) patients presented H. pylori-chronic active gastritis, six (27.3%) presented antrum-predominant H. pylori-chronic active gastritis, and one (4.5%) presented corpus-predominant H. pylori-chronic active gastritis. Polymorphonuclear cell infiltrate and mononuclear cell infiltrate were observed in 93.9% and 98.5% of the biopsy specimens, respectively. Higher histological scores for polymorphonuclear infiltrate, mononuclear infiltrate, and bacterial density were observed in the gastric antrum. Intestinal metaplasia and gastric atrophy were not identified in any patient. Lymphoid aggregates and lymphoid follicles were observed in the gastric antrum of three (13.6%) and seven (31.8%) patients, respectively, but they were not related to antral nodularity.

CONCLUSIONS

Chronic active gastritis was observed in all patients with H. pylori infection. However, antral or corporeal predominance was not observed in most patients.

Does Helicobacter pylori-induced inflammation of gastric mucosa determine the severity of symptoms in functional dyspepsia?

BACKGROUND

Inflammation induces some structural and biochemical alterations and oxidative damage in gastric tissue. In this study, we aimed to investigate the relationship among the severity of symptoms, oxidative stress, and grading scales of Helicobacter pylori-induced gastric inflammation in functional dyspepsia.

METHODS

Thirty-five patients with functional dyspepsia were enrolled in the study. The severity of dyspepsia within the last 6 months was evaluated by Glasgow Dyspepsia Severity Score. In biopsy specimens of gastric mucosa, severity of gastritis was estimated by the revised Sydney Classification System, and oxidative stress parameters were studied.

RESULTS

Although there was no statistically significant relationship between symptom scores and degree of chronic inflammation, a tendency for symptoms to be more severe has been observed in low levels of gastritis. Levels of sulfhydryl groups were lower in subjects with high levels of chronic inflammation, and Helicobacter pylori intensity (P < 0.001 and P = 0.02, respectively). Levels of malondialdehyde were higher in subjects with high levels of chronic inflammation (P = 0.04). There was a statistically significant but a weak positive correlation between symptom scores and sulfhydryl levels (P < 0.001, r = 0.323).

CONCLUSIONS

In conclusion, there may be an inverse relation between severity of symptoms and level of Helicobacter pylori induced gastric inflammation or oxidative stress in patients with functional dyspepsia.

Association between Helicobacter pylori concentration and the combining frequency of histopathological findings in gastric biopsies specimens

BACKGROUND: Helicobacter pylori is the most prevalent infectious agent worldwide. About 90% of patients with chronic gastritis are infected with this bacterium. Some studies have shown a association between the H. pylori concentration and the scores of gastritis activity and severity. AIM: To evaluate the association between H. pylori concentration and the combining frequency of findings on histopathological examination. METHODS: Two hundred consecutive gastric endoscopic biopsies diagnosed as chronic gastritis were retrospectively investigated. The Warthin-Starry silver stain was used to study H. pylori and the following parameters were assessed (according to the Sydney system): 1. infiltration by polymorphonuclear cells in chorio and epithelium (activity) graded as mild, moderate and marked; 2. presence of lymphoid follicles; 3. presence of intestinal metaplasia; 4. presence of regenerative cell atypias, graded as mild, moderate and marked; and 5. H. pylori concentration on the mucous covering the foveolar epithelium. RESULTS: The most frequent association was chronic gastritis and activity, regardless of H. pylori concentration. The association of five histopathological findings in the same biopsy has not occurred in the cases of higher concentration of H. pylori. CONCLUSION: Our study has not revealed any association between H. pylori concentration and an increasing in the number of histopathological findings found in the gastric mucosa. Since referring to its presence is much more important than to its concentration.

Helicobacter pylori infection and the pathogenesis of duodenal ulceration

Helicobacter pylori is a gram-negative spiral bacterium confined to the habitat of gastric-type epithelium. H. pylori causes duodenal ulceration by a cumulative effect of antral predominant gastritis with increased acid secretion, consequent gastric metaplasia in the duodenum (a site of further colonization by H. pylori), duodenitis, reduced duodenal bicarbonate secretion, and mucosal damage. Bacterial factors influence outcome. Major determinants are the production of a vacuolating toxin and the presence of CagA, an immunodominant product of a nonconserved gene cagA, a marker for the cag pathogenicity island that encodes virulence genes involved in induction of epithelial chemokine responses. In ulcer patients the mucosal immune response is polarized to a T-helper-1 (Th1) cell-mediated response, which may contribute to mucosal damage. Eradication of H. pylori restores acid output to normal. Loss of both acid and bacteria halts gastroduodenitis and allows ulcer healing. Gastric metaplasia does not regress in the short term.