FREQUENCY OF HELICOBACTER PYLORI IN HISTOLOGICALLY PROVEN GASTRITIS CASES - A STUDY OF 100 CASES.
Objective: To determine the frequency of Helicobacter pylori (H. pylori) based on endoscopic biopsy with the help of special stains in gastritis cases.
Study Design: Prospective descriptive study.
Place and Duration of Study: Histopathology department, Army Medical College Rawalpindi, from Oct 2016 to Mar 2017.
Material and Methods: One hundred (100) cases were included in the study. Gastric biopsies of the patients histologically diagnosed as gastritis were included in the study, which were evaluated for the presence of H. pylori with the help of special stain (Modified Giemsa stain).
Results: Gastric biopsies of 100 patients, who were diagnosed as gastritis on histopathological examination were analyzed with the help of Giemsa stain for the presence or absence of H. pylori. Out of these 100 cases, 60 were males and 35 were females. Most patients were between the age group of 30-40 years. Histological examination and special stain analysis revealed presence of H. pylori in 30 cases (30%), while rest of the 70 cases (70%) showed no H. pylori. Out of 30 cases positive for H. pylori, 28 cases (93%) had chronic active gastritis, while 2 cases (7%) had no element of activity.
Conclusion: Among the cases of chronic gastritis, H. pylori negative gastritis was more common than H. pylori associated gastritis. A significantly decreased frequency of H. pylori in histologically gastritis cases in our population may be due to more frequent use of complete or incomplete therapies against H. pylori by general practitioners at some stage of disease.
Keywords: Gastritis, Giemsa stain, Helicobacter pylori.
Helicobacter pylori (H. Pylori) has been considered as a common cause of gastritis worldwide. Beside gastritis and gastric ulcers, it is also implicated as an etiological agent in causing gastric carcinoma and mucosa associated lymphoid tissue (MALT) lymphoma. This diversity of clinical outcome, which may be the result of interaction between the microorganism, host and environmental factors, makes it important to detect presence of H. pylori in gastritis cases1. Diagnosis of H. pylori can be done by both non invasive and invasive techniques.
Non invasive techniques include H. pylori serology, antigen in stool and urea breath test. Invasive techniques include gastric biopsy which is stained with routine haematoxylin and Eosin (HandE) and application of special stains like Giemsa stain, toluidine blue and Warthin starry stain. H. pylori culture and polymerase chain reaction (PCR) can also be done to detect the organism2. The Sydney system, used for reporting chronic gastritis which was given in 1990 and updated in 1994 includes an important component of presence or otherwise of H. pylori and their grading, (mild, moderate, severe)3. H. pylori infection is considered as one of the commonest health problem, causing significant morbidity and economic loss with deterioration in quality of life4. Gastric biopsy analysis with routine HandE staining and incorporation of special stains can be very effective in detection of H. pylori.
Timely management of this disease can not only alleviate the morbidity, but can also prevent the later on occurring malignancies like gastric carcinoma and MALT lymphoma5. This study was carried out to find out the presence and frequency of H. pylori in histologically proven cases of gastritis. Outcome of this study could be of help in analyzing the current status of H. pylori infection in gastritis cases for management and prevention of this disease.
MATERIAL AND METHODS
This prospective descriptive study was carried out at histopathology department of Army Medical College, Rawalpindi. The study extended over a period of 06 months with effect from October 2016 to March 2017. Gastric biopsies received in histopathology department of Army Medical College, which were having the histological evidence of chronic gastritis, were analyzed for the presence of H. pylori by doing Giemsa stain. Sample Size was calculated by WHO Calculator by taking 23.37% population proportion, absolute precision 9% with 45% confidence interval. Total 100 patients were selected by non-probability convenience sampling technique.
Table: H. Pylori and other histological graded variable in histologically proven gastritis cases.
###None (0)###Mild (1)###Moderate (2)###Severe (3)###Total
Chronic inflammation###00###30###40###30###100 (100%)
H. Pylori###70###02###25###03###30 (30%)
Glandular atrophy###96###02###02###00###04 (4.0%)
Intestinal metaplasia###95###03###02###00###05 (5.0%)
Gastric biopsies of the patients, which were adequate and had the histological evidence of chronic gastritis, were included in the study. Gastric biopsies having inadequate material or histologically having unremarkable fragments of gastric mucosa were excluded from the study.
The specimens were labeled and fixed in 10% formalin. Paraffin blocks were made and sectioned at 3-5 micrometer thickness were prepared. The sections were stained with Haematoxylin and Eosin (HandE). For highlighting the presence of H. pylori, Giemsa stain was done on one section6. The slides were examined by consultant histopathologist and presence or absence of H. pylori was noted and graded. In cases of gastritis, other histopathological variables were noted and graded according to updated Sydney system of gastritis7. Data were entered and analyzed by using SPSS version 17. Perscriptive statistics like frequency and percentages were calculated for all the variables.
A total of 100 gastric biopsies which were having the histological evidence of gastritis, were analyzed for the presence or otherwise of H. pylori. They included 65 (65%) males and 35 (35%) females. The age range was between 18-70 years. Maximum number of cases 45 (45%) were between 30-40 years, followed by 25 cases (25%) which were between 20-30 years.
Out of these 100 cases of histologically proven gastritis, 30 cases (30%) showed presence of H. pylori, which were moderate in 25 cases (83.3%), severe in 03 cases (10%) and mild in 2 cases (6.7%). Most of the H. pylori associated gastritis cases showed an element of activity which was seen in 28 cases (93.3%) out of total 30 H. pylori positive cases. The grade of activity was moderate to severe in most of the cases. A summary of results including H. pylori and other graded variables is given in table.
H. pylori is considered to be the most important cause of gastritis, gastric and duodenal ulcers and is classified as class I carcinogen8. In 1983, Warren and Marshall described strong association of H. pylori with chronic gastritis9. The distribution of H. pylori associated gastritis is well established in Western society10 and its incidence varies widely in literature from 30-90%11. However, in our set, there are few reports, indicating frequency of H. pylori in histologically proven gastritis cases in Pakistani population.
In our study, the frequency of H. pylori in histologically proven gastritis cases was 30%, which is relatively less in few studies conducted in the our population earlier. In one study conducted by Mohsin et al in 1999, the frequency of H. pylori in histologically proven gastritis was 43%12, while in another local study carried out by Shiza et al, the frequency of H. pylori in histologically proven gastritis cases was 61%13. In another local study carried out by Khalid et al, the frequency of H. pylori was 83%, which is quite high as compared to H. pylori frequency in our study14. The higher frequency of H. pylori in previous local studies previously may be due to the fact, that now a days many of the patients with dyspepsia are treated with complete or incomplete triple regimen therapy by general practitioners and by the time they come for endoscopy, they may be having histological evidence of gastritis, but no H. pylori.
In few studies conducted in other Asian countries, the frequency of H. pylori was comparable to our results. In one study carried out at Khatmandu (Nepal), the frequency of H. pylori in histologically proven gastritis was 33.9%, comparable to this study. In one study carried out in India, the frequency of H. pylori was 34%, resembling results of this study15. In another study carried out at India, the frequency of H. pylori in gastritis cases was 48%16, which is relatively higher as compared to this study. In another study carried out in rural area of India, the frequency of H. pylori was 78% which is quite high as compared to our study17. Recently, in a large scale study carried out in Japan, the frequency of H. pylori in gastritis cases was 27.5%18, which was slightly less than the frequency noted in this study. In another study carried out in Japan, a significant decrease in frequency of H. pylori was noted19.
In a large scale study done in Korea, the frequency of H. pylori noted in histologically proven gastritis cases was 54.4%. This frequency decreased from 69.9% (in 1998) to 59.6% (in 2005) to 54.4% (in 2013)20. In a study done at China, the frequency of H. pylori in gastritis cases was 43.8%21. In Western studies, the frequency of H. pylori in gastritis cases is widely variable. In United States of America (USA), the frequency of H. pylori in gastritis noted in one study was 19.6%22. Among the European countries, the frequency of H. pylori is quite variable. In one study done at Italy, the frequency of H. pylori in gastritis cases was 33.9%, which is closer to this study23. In an other study done at Germany, the frequency of H. pylori in gastritis cases was 48.0%24.
In most of our cases of H. pylori associated gastritis, an element of activity was noted which was moderate to severe in most of our cases. This finding was also noted in most of the studies carried out locally as well as in different parts of the world.
A significantly decreased frequency of H. pylori noted in histologically proven gastritis in our population as compared to the past suggests that most of the patients with symptoms of dyspepsia are treated by general practitioners with complete or incomplete therapies against H. pylori, before they report to gastroenterology department for endoscopic examination. These patients may be having histological evidence of gastritis, but no H. pylori.
Among the histologically proven gastritis cases, H. pylori negative gastritis was more common than H. pylori associated gastritis.
The frequency of H. pylori in gastritis cases is decreasing in our population as compared to the past. This decrease is likely due to frequent use of complete or incomplete anti H. pylori therapies, given to the patients with symptoms of dyspepsia by the general practitioners.
More studies at a larger scale are required in the country to know the exact frequency of H. pylori in urban and rural population and in different socioeconomic groups, to do the remedial measures.
CONFLICT OF INTEREST
This study has no conflict of interest to declare by any author.
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|Publication:||Pakistan Armed Forces Medical Journal|
|Article Type:||Clinical report|
|Date:||Jun 30, 2017|
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