Oral colonization of Helicobacter pylori: risk factors and response to eracizication therapy. (Original Article).Background: Dental plaque dental plaque n. A film of mucus and bacteria on a tooth surface. Also called bacterial plaque. is considered by some to be a secondary reservoir for Helicobacter pylori Helicobacter pylori A gramnegative rod-shaped bacterium that lives in the tissues of the stomach and causes inflammation of the stomach lining. Mentioned in: Indigestion, Ulcers Helicobacter pylori and thus responsible for gastric reinfection reinfection /re·in·fec·tion/ (-in-fek´shun) a second infection by the same agent or a second infection of an organ with a different agent. re·in·fec·tion n. . The aim of this study was to investigate whether testing dental plaque using a rapid urease test rapid urease test CLO test, see there (CLOtest) can be used to determine gastric H. pylori status. Methods: We investigated dental plaque colonization by H pylon pylon (Greek: “gateway”) In modern construction, a tower that gives support, such as the steel towers between which electrical wires are strung or the piers of a bridge. and its correlation with gastric infection in 75 dyspeptic dys·pep·tic adj. 1. Relating to or having dyspepsia. 2. Of or displaying a morose disposition. n. A person who is affected by dyspepsia. patients. CLOtest was used to determine H pylon positivity. Results: Tests for H pylon were positive in dental plaque samples from 68 patients and in stomach samples from 65 patients. The sensitivity of using CLOtest in dental plaque to determine gastric H pylori H pylori Helicobacter pylori, see there status was 89.7%, with a diagnostic accuracy of 86.7%. Gastric eradication was achieved in 83% of patients, but efforts to eradicate dental plaque colonization were unsuccessful in all patients. Conclusion: Using CLOtest to detect H pylon in dental plaque is a reliable first-line diagnostic approach for gastric H pylori infection. Dental plaque might be a sanctuary for H pylon, leading to gastric recurrence. ********** Helicobacter pylon was first identified in 1983,1 and strong evidence since then has suggested its association with chronic active gastritis, peptic ulcer peptic ulcer: see ulcer. peptic ulcer Sore that develops in the mucous membrane of the stomach (more frequent in women) or duodenum (accounting for 80% of ulcers and more frequent in men) when its ability to resist acid in gastric juice is reduced. , and gastric malignancies. (2-4) The human stomach is known as the primary reservoir of H pylon, but routes of transmission of the microorganism microorganism /mi·cro·or·gan·ism/ (-or´gah-nizm) a microscopic organism; those of medical interest include bacteria, fungi, and protozoa. among humans still remain unclear. After, the isolation of H pylori in cultures of dental plaque, researchers began suspecting the oral cavity oral cavity n. The part of the mouth behind the teeth and gums that is bounded above by the hard and soft palates and below by the tongue and the mucous membrane connecting it with the inner part of the mandible. as a possible secondary reservoir for H pylori. (5-7) Although eradication of H pylori is usually successful in the majority of patients, reinfection continues to be an important issue in Turkey. It was proposed that persistent existence of the microorganism in the oral cavity after eradication therapy could be responsible for gastric reinfection (7-9) In contrast, some other reports suggest that dental plaque is not a major reservoir responsible for gastric reinfection and that the existence of the bacteria in the mouth is intermittent, accompanying gastroesophageal reflux gastroesophageal reflux n. A backflow of the contents of the stomach into the esophagus, caused by relaxation of the lower esophageal sphincter. Also called esophageal reflux, gastric reflux. . (5,10-12) In this study, we evaluated the prevalence of H pylon in dental plaque of patients with chronic dyspepsia dyspepsia: see indigestion. . We also evaluated the correlation between dental plaque infection and gastric infection, as well as the effects of childhood socioeconomic conditions on prevalence of H pylori in dental plaque and responses of both infection sites to eradication therapy. Patients and Methods Patients with chronic dyspeptic complaints were enrolled in the study. At least 3 of the following 7 symptoms, lasting continuously no less than 4 months, were considered as evidence for chronic dyspepsia: epigastric epigastric adjective Referring to the body region between the costal margins and the subcostal plane pain, burning sensation in the chest, nausea, infrequent vomiting, meteorism, gas, and burping. Patients who had been taking antacids Antacids Definition Antacids are medicines that neutralize stomach acid. Purpose Antacids are used to relieve acid indigestion, upset stomach, sour stomach, and heartburn. , bismuth bismuth (bĭz`məth) [Ger. Weisse Masse=white mass], metallic chemical element; symbol Bi; at. no. 83; at. wt. 208.9804; m.p. 271.3°C;; b.p. about 1,560°C;; sp. gr. 9.75 at 20°C;; valence +3 or +5. preparations, proton pump inhibitors Proton Pump Inhibitors Definition The proton pump inhibitors are a group of drugs that reduce the secretion of gastric (stomach) acid. They act by binding with the enzyme H+, K(+)-ATPase, hydrogen/potassium adenosine triphosphatase , H2 receptor antagonists, or antibiotics during the 3 months before enrolling in the study and patients who had had previous gastric or gallbladder operations were excluded from the study. Lack of all teeth, recent dental plaque removal, and chronic liver failure liver failure Clinical medicine Liver insufficiency that results in death, requires a liver transplant, or is characterized by recovery after encephalopathy, or while awaiting a transplant; also defined as a condition with ≥ 3 of following: albumin < 3. or chronic renal failure chronic renal failure Chronic kidney failure Nephrology A slow decline in renal function, which may be 2º to chronic HTN, DM, CHF, SLE, or sickle cell anemia and, if extreme, leads to ESRD, mandating kidney dialysis; an abrupt decline in renal function may be were other criteria for exclusion from the study. Informed consent was obtained from each patient. To evaluate the socioeconomic status of their families during their childhood, patients were given a questionnaire to obtain data on the monthly income of their parents, the geographic areas where they lived, number of people in the family, eating habits of the family, sources of drinking water, toothbrushing habits, and current marital status. All the patients were referred for dental evaluation, and after periodontal examination, their periodontal indexes (l2a) and dental plaque (12b, 12c) were calculated according to standardized criteria: Dental plaque samples were obtained from the gingival gingival (jin´j  v pockets of teeth
6, 7, and 8 and upper and lower anterior teeth, using sterile Gracey
probes. The samples were immediately placed into CLOtest and the results
were evaluated in 1 hour.
After samples of dental plaque were obtained, patients had upper esophagogastroduodenoscopy (EGD Esophagogastroduodenoscopy (EGD) An imaging test that involves visually examining the lining of the esophagus, stomach, and upper duodenum with a flexible fiberoptic endoscope. Mentioned in: Bleeding Varices EGD esophagogastroduodenoscopy. ). After topical anesthesia (10% lidocaine lidocaine /li·do·caine/ (li´do-kan) an anesthetic with sedative, analgesic, and cardiac depressant properties, applied topically in the form of the base or hydrochloride salt as a local anesthetic; also used in the latter form as a ) and sedation (2.5-5.0 mg midazolam), EGD was performed using either a Pentax EG 2930 (Pentax Europe GmbH, Hamburg, Germany) or a Fujinon EG 200 FP videoendoscope (Fujinon Europe GmbH, Willich, Germany). During the procedure, 2 biopsy samples from the antrum antrum /an·trum/ (an´trum) pl. an´tra, antrums [L.] a cavity or chamber.an´tral cardiac antrum and 2 biopsy samples from the corpus were obtained. CLOtest (Delta West, Ltd., Bentley, Australia) was used as the rapid urease test. One specimen was placed into CLOtest and the other was used for histopathologic examination. CLOtest results were evaluated in 24 hours. Patients with positive tests for H. pylori underwent eradication therapy consisting of ranitidine ranitidine /ra·ni·ti·dine/ (rah-ni´ti-den) a histamine H2 receptor antagonist, used as the hydrochloride salt to inhibit gastric acid secretion in the treatment of gastric and duodenal ulcer, gastroesophageal reflux disease, and bismuth citrate citrate /cit·rate/ (sit´rat) a salt of citric acid. citrate phosphate dextrose (CPD) anticoagulant citrate phosphate dextrose solution. (400 mg bid), clarithromycin (500 mg bid), and amoxicillin amoxicillin /amox·i·cil·lin/ (ah-mok?si-sil´in) a semisynthetic derivative of ampicillin effective against a broad spectrum of gram-positive and gram-negative bacteria. a·mox·i·cil·lin n. (1 g bid) for 1 week. The same procedures were repeated I month after completion of the treatment. Endoscopes and biopsy forceps were kept in 10% succindialdehyde and dimethoxytetrahydrofuran (Gigasept FF; LCN LCN La Cosa Nostra LCN London Cycle Network (UK) LCN Logical Channel Number LCN Low Copy Number (DNA or RNA quantity) LCN Local Computer Network LCN Logical Cluster Number LCN Load Classification Number , Ltd., West Sussex, England) for at least 20 minutes. The same pathologist examined hematoxylin hematoxylin /he·ma·tox·y·lin/ (he?mah-tok´si-lin) an acid coloring matter from the heartwood of Haematoxylon campechianum; used as a histologic stain and also as an indicator. and eosin eosin /eo·sin/ (e´o-sin) any of a class of rose-colored stains or dyes, all being bromine derivatives of fluorescein; eosin Y, the sodium salt of tetrabromofluorescein, is much used in histologic and laboratory procedures. stain and Giemsa stain preparations of histopathologic samples. Statistical analysis was performed using SPSS A statistical package from SPSS, Inc., Chicago (www.spss.com) that runs on PCs, most mainframes and minis and is used extensively in marketing research. It provides over 50 statistical processes, including regression analysis, correlation and analysis of variance. 7.0 (Special for Social Statistical Sciences) for Windows (SPSS, Inc., Chicago, IL). test and Fisher's exact test Fisher's exact test a statistical test for association in a two-by-two table based on the exact hypergeometric distribution of the frequencies within the table. along with Spearman's r correlation and MacNemar test were used as needed. Results Seventy-five patients (42 men and 33 women) were included in the study. The overall mean age was 40.29 [+ or -] 12.96 years (range, 20-64 years), with a mean age for men of 39.09 [+ or -] 12.42 years and women, 41.81 [+ or -] 13.66 years. Table 1 shows the patients' H. pylori status before treatment. The organism was found in dental plaque and was positive in 68 patients (91%) and in gastric samples of 65 patients (8 7%). Tests of both dental plaque and gastric samples were positive in 61 patients (8 1%). In testing dental plaque to determine gastric H. pylori status, CLOtest showed a sensitivity of 89.7%, specificity of 42.9%, positive predictive value Positive predictive value (PPV) The probability that a person with a positive test result has, or will get, the disease. Mentioned in: Genetic Testing positive predictive value of 93.8%, negative predictive value The negative predictive value is the proportion of patients with negative test results who are correctly diagnosed. Worked example
Condition (as determined by "Gold standard") True False of 30.0%, and diagnostic accuracy 86.7%. There was no inconsistency between the CLOtest results and the histopathologic findings. No relationship was found between H. pylori positivity (in both dental plaque and stomach) and sex and age of patients (P > 0.05). In patients with lower socioeconomic conditions during childhood (low income, village life, drinking water source other than tap water, higher number of people in the family, poor toothbrushing habits), H. pylori positivity in both dental plaque and the stomach was significantly higher (P > 0.05). Lower periodontal index was related to lower H. pylori positivity rates in dental plaque and in the stomach (P > 0.05; Table 2). The correlation between H pylori positivity in dental plaque and periodontal index was highly positive (n 0.603, P > 0.00 1). In addition, higher plaque index was also related to higher positivity rates for H. pylori in both dental plaque and stomach, and H. pylori positivity in dental plaque was highly correlated with plaque index (n = 0.405, P> 0.001; Table 3). After tre atment, the eradication rate was 83% in the stomach. In dental plaque, however, eradication therapy had no effect, and tests for H. pylori were still positive in all cases. Discussion The detection of H pylori in dental plaque suggests that H. pylori colonization is not restricted to the gastric mucosa and that this ecologic niche may serve as a possible sanctuary that may be responsible for reinoculation of the stomach after eradication therapy. Reported positivity rates for H pylori in dental plaque in patients with dyspeptic complaints have ranged from 60% to 79% in Turkey. (13, 14) In our study, we found a higher rate of 90.7%. Although the transmission route of H pylori is unclear, some reports point to a correlation between oral H pylori positivity and gastric H pylori positivity. Nguyen et al (15) reported that 38.8% of patients with proved H pylori gastritis also had the organism identified in their dental plaque, but none of the patients without H pylori gastritis had H pylori in their dental plaque. Pytko-Polonczyk et al, (16) in their study of 55 patients with duodenal ulcer, reported that 100% of the patients were found to have H pylori in the oral cavity, whereas 95% had H pylori in the stomach. In another study, Kopaanski et al (17) reported a statistically significant correlation between the frequency of H pylori infection in the oral cavity (83.3%) and the simultaneous occurrence of infection of the gastric mucosa. On the other hand, there are also reports suggesting the absence of H pylori in dental plaque of dyspeptic patients with gastric H pylori infection. (11, 18) However, because it is difficult to isolate H pylori in the oral cavity, where a large variety of other bacteria are present, one must view such results with caution. Polymerase chain reaction polymerase chain reaction (pŏl`ĭmərās') (PCR), laboratory process in which a particular DNA segment from a mixture of DNA chains is rapidly replicated, producing a large, readily analyzed sample of a piece of DNA; the process is evaluations from different sequences may have different sensitivity and specificity. (9) In addition, interpretation of urease urease /ure·ase/ (u´re-as) an enzyme that catalyzes the hydrolysis of urea to ammonia and carbon dioxide; it is a nickel protein of microorganisms and plants that is used in clinical assays of plasma urea concentrations. testing is also important. Other urease-positive species such as Streptococcus streptococcus (strĕp'təkŏk`əs), any of a group of gram-positive bacteria, genus Streptococcus, some of which cause disease. vestibulanis or Actinomyces Actinomyces /Ac·ti·no·my·ces/ (-mi´sez) a genus of bacteria (family Actinomycetaceae). Actinomyces israe´lii viscosus may cause false-positive urease tests, but they usually react in hours and not in a very short time. (19) We used CLOtest in our study and evaluated the results in 1 hour. As such, because the distribution of the bacteria in the oral cavity may not be homogeneous, sampling is important, (20) and sampling of dental plaque from one site may lead to false-negative results. That is why we have used the gingival pockets of teeth 6, 7, and 8 and lower and upper anterior teeth, where plaque formation is most likely to occur. Our results support the previous findings that there is a high prevalence of H pylori positivity in dental plaque and that this correlates with gastric H. pylori infection. Of the 75 patients in our study, 61 had H pylori in dental plaque, and 65 had H pylori in the stomach. Sixty-one patients (81.3%) had both dental plaque and gastric infection. We achieved gastric eradication in 83% of patients, whereas dental plaque eradication was observed in none of the patients. This relationship between oral infection and gastric infection and the persistence of the infection in the oral cavity after eradication therapy supports the suggestion that H pylori infection in the oral cavity plays an important role in both the transmission of the bacteria and the recurrence of the gastric infection after successful eradication therapy. (21,22) Numerous epidemiologic studies have shown that the main risk factor for H pylori acquisition is low socioeconomic level in both developing and developed countries. (23) As such, the oro-oral transmission hypothesis seems applicable worldwide. In developing countries, fecal-oral transmission (possibly through the water supply) might be a significant mechanism of contamination both for primary infection in children and reinfection in adults. (23) Parallel to these findings, we found in our study that in patients of low socioeconomic status during childhood in areas where drinking water was not tap water, H pylori positivity in both dental plaque and the stomach was significantly higher than in others. In previous studies on H pylori positivity in dental plaque, we found no information about the objective criteria, such as periodontal index and plaque index, that would quantify the periodontal hygiene. In our study, we evaluated the relationship between these criteria and H pylori infection in dental plaque and in the stomach. Our results indicate that there is a strong correlation between increased periodontal and plaque indexes and increased frequency of both gastric and dental plaque H pylori infection. In addition, in patients with regular toothbrushing habits, there is a decrease in the frequency of infection in both sites. We believe that poor oral hygiene contributes to the high incidence of oral and gastric H pylori infection in developing countries. According to our results, the rapid urease test (CLOtest) is a reliable, fast, inexpensive means of diagnosing H pylori activity both in dental plaque and in gastric mucosa. Although there are some false-positive results, the high sensitivity and the high positive predictive value of the test are promising. Starting the evaluation of dyspeptic patients by using CLOtest to detect H pylori in dental plaque, before going ahead with endoscopic biopsies, may save time and may reduce costs. In addition, considering the fact that eradication therapy for H pylori does not improve dental plaque infection at all, evaluating patients for H pylori infection in the dental plaque may give us a clue Give Us a Clue is a televised version of charades hosted at different times by Michael Aspel 1979–1983 and Michael Parkinson 1984–1992, with two teams: one captained by Lionel Blair and the other by Una Stubbs. about the outcome of eradication measures. Our results indicate that 1) H pylori infection coexists in gastric mucosa and dental plaque, 2) H pylori infection is more prevalent in individuals of low socioeconomic status during childhood, 3) dental plaque might be responsible for recurrence of the gastric infection, 4) CLOtest, with its cost-effectiveness and high availability, can be used as a reliable, noninvasive, first-line diagnostic approach for assessing H pylori in dental plaque, and 5) H. pylori positivity in dental plaque is highly suggestive of gastric H pylori infection in most cases.
Table 1
Results of tests (using CLOtest) for H. pylori before treatment
Dental plaque, no. (%)
Stomach Positive Negative Total
Positive 61 (81.3%) 4 (5.3%) 65 (86.7%)
Negative 7 (9.3%) 3 (4%) 10 (13.3%)
Total 68 (90.7%) 7 (9.3%) 75 (100%)
Table 2
Relationship of periodontal index and H. pylori status
Tests for H. pylori
Dental plaque Stomach
Periodontal
index Positive Negative Positive Negative
0.3-0.9 1 4 2 3
1-1.9 12 3 9 6
2-5 48 - 47 1
5+ 7 - 7 -
Total 68 7 65 10
Table 3
Relationship of plaque index and H. pylori status
Tests for H. pylori
Dental plaque Stomach
Plaque
index Positive Negative Positive Negative
1 5 3 3 5
2 23 4 23 4
3 40 - 39 1
Total 68 7 65 10
Accepted May 3, 2002. References (1.) Warren JR, Marshall B. Unidentified curved bacilli bacilli /ba·cil·li/ (bah-sil´i) plural of bacillus. bacilli see bacillus. on gastric epithelium in active chronic gastritis. Lancet l983;1:1273-1275. (2.) Cave DR. Transmission and epidemiology of Helicobacter pylori. Am J Med 1996;100:12S-18S. (3.) Howden CW. Clinical expressions of H. pylon infection. Am J Med 1996;100:27S-34S. (4.) Lambert JR, Lin SK, Aranda-Michel J. H. pylon. Scand J Gastroenterol Suppl 1995;208:33-46. (5.) Krajden S, Fuksa M, Anderson J, Kempston J, Boccia A, Petrea C, et al. Examination of human stomach biopsies, saliva, and dental plaque for Campylobacter Campylobacter Genus of gram-negative spiral-shaped bacteria infecting mammals. Many species, especially C. fetus, cause miscarriage in sheep and cattle. C. jejuni is a common cause of food poisoning. Sources include meats (particularly chicken) and unpasteurized milk. pylori. J Clin Microbial microbial pertaining to or emanating from a microbe. microbial digestion the breakdown of organic material, especially feedstuffs, by microbial organisms. 1989;27:1397-1398. (6.) Nguyen AM, el-Zaatari FA, Graham DY. Helicobacter pylon in the oral cavity: A critical review of the literature. Oral Surg Oral Med Oral Pathol Oral Radial Endod 1995;79:705-709. (7.) Shankaran K, Desai HG. Helicobacter pylon in dental plaque. J Clin Gastroenterol 1995;21:82-84. (8.) Desai HG, Gill HH, Shankaran K, Mehta PR, Prabhu SR. Dental plaque: A permanent reservoir of Helicobacter pylon? Scand J Gastroenterol 1991;26:1205-1208. (9.) Thomas E, Jiang C, Chi DS, Li C, Ferguson DA Jr. The role of the oral cavity in Helicobacter pylon infection. Am J Gastroenterol 1997;92:2148-2154. (10.) Axon axon: see nervous system; synapse. AT. The transmission of Helicobacter pylori: Which theory fits the facts? Eur J Gastroenterol Hepatol 1996;8:1-2. (11.) Bernander S, Dalen J, Gastrin B, Hedenborg L, Lamke LO, Ohrn R. Absence of Helicobacter pylori in dental plaques of Helicobacter pylori positive dyspeptic patients. Eur J Clin Microbial Infect Dis 1993;12:282-285. (12.) Luzza F, Imenco M, Maletta M, Paluccio G, Nistico S, Perticone F, et al. Suggestion against an oral-oral route of transmission for Helicobacter pylon infection: A seroepidemiological study in a rural area. Dig Dis Sci 1998;43:1488-1492. (12a.) Russell AL. A system of scoring for prevalence surveys of periodontal disease, J Dent Res 1956;35:350-359. (12b.) Loe H. The Gingival Index, the Plaque Index, and the Retention Index systems. J Periodontal 1967;38(Suppl):610-616. (12c.) Silness J, Loe H. Periodontal disease in pregnancy: Part II--Correlation between oral hygiene and periodontal conditions. Acta Odontol Scand 1964;22:121-135. (13.) Kadayifci A. Epidemiology of Helicobacter pylon [in Turkish]. In: Modern Tip Seminerleri: 5. Ankara, Turkey: Gunes Kitabevi, 1999. (14.) Unsal B, Ozean G, Tuncer C, Ozdemir A, Karaoz E. Detection of H. pylori in supragingival dental plaque and in gastric mucosa [in Turkish]. Presented at the Twenty-seventh Scientific Congress of the Turkish Association of Periodontology periodontology, n See periodontics. , Istanbul, Turkey, May 29, 1997 (abstr). (15.) Nguyen AM, Engstrand L, Genta RM, Graham DY, el-Zaatari FA. Detection of Helicobacter pylori in dental plaque by reverse transcription-polymerase chain reaction. J Clin Microbiol 1993;31:783-787. (16.) Pytko-Polonczyk J, Konturck SJ, Karczewska E, Bielanski W, Kaczmarczyk-Stachowska A. Oral cavity as permanent reservoir of Helicobacter pylori and potential source of reinfection. J Physiol Pharmacol 1996;47:121-129. (17.) Kopaanski Z, Cienciala A, Banas J, Kaminski B, Witkowska B, Zastepa P, et al. Coexistence of infection of the oral cavity and stomach and duodenal duodenal /du·o·de·nal/ (doo?o-de´n'l) (doo-od´ah-n'l) of or pertaining to the duodenum. Duodenal Refers to the duodenum, or the first part of the small intestine. mucosa with Helicobacter pylori in patients with ulcer and chronic gastritis [in German]. Wien Klin Wochenschr 1995;107:219-224. (18.) Wahlfors J, Meurman JH, Toskala J, Korhonen A, Alakuijala P. Janatuinen E, et al. Development of a rapid PCR PCR polymerase chain reaction. PCR abbr. polymerase chain reaction Polymerase chain reaction (PCR) method for identification of Helicobacter pylon in dental plaque and gastric biopsy specimens. Eur J Clin Microbial Infect Dis 1995;14:780-786. (19.) Vaira D, Holton J, Caims S, Polydorou A, Falzon M, Dowsett J, et al. Urease tests for Campylobacter pylori: Care in interpretation. J Clin Pathol 1988;41:812-813. (20.) Hardo PG, Tugnait A, Hassan F, Lynch DA, West AP, Mapstone NP, et al. Helicobacter pylori infection and dental care. Gut 1995;37:44-46. (21.) Shames B, Krajden S, Fuksa M, Babida C, Penner JL. Evidence for the occurrence of the same strain of Campylobacter pylori in the stomach and dental plaque. J Clin Microbial 1989;27:2849-2850. (22.) Xia HX, Windle HJ, Marshall DG, Smyth CJ, Keane CT, O'Morain CA. Recrudescence recrudescence /re·cru·des·cence/ (re?kroo-des´ens) recurrence of symptoms after temporary abatement.recrudes´cent re·cru·des·cence n. of Helicobacter pylori after apparently successful eradication: Novel application of randomly amplified polymorphic DNA fingerprinting. Gut 1995;37:30-34. (23.) Deltenre M, de Koster E. How come I've got it? A review of Helicobacter pylori transmission. Eur J Gastroenrerol Hepatol 2000;12:479-482. RELATED ARTICLE: Key Points * Dental plaque might be a sanctuary for Helicobacter pylon, leading to gastric recurrence. * H. pylori positivity is highly suggestive of gastric H pylon infection in most of the cases. * Eradication therapy may not be as effective in dental plaque infection as it is in gastric infection. * CLOtest use in dental plaque is a reliable first-line diagnostic approach for gastric H pylori infection From the Departments of Gastroenterology and Pathology, Gulhane Military Medical Academy, Haydarpasa Training Hospital, Istanbul, Turkey. Reprint requests to Melih A. Ozel, MD, 2202 Massachusetts Ave NW, Washington, DC 20008. Copyright [c] 2003 by The Southern Medical Association 0038-4348103/9603-0244 |
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