Prevalence of Helicobacter pylori infection in gastric and duodenal lesions as diagnosed by endoscopic biopsy.
Helicobacter pylori is associated with various diseases, mainly, many benign, premalignant, and malignant lesions of the digestive system including chronic gastritis, peptic ulcers, atrophic gastritis, intestinal metaplasia, gastric adenomas, gastric hyperplastic polyps, adenocarcinomas of the distal part of the stomach, and lymphomas of mucosa-associated lymphoid tissue. [1,2] Colonization of stomach by H. pylori and chronic active gastritis present a cause-and-effect relationship. Healing of gastric inflammatory lesions using eradication therapy, as a remedial measure of gastric inflammatory lesions may be deficient in immediate clinical benefits; however, it yields positive results such as thearrest and reversal of gastric histological lesions, and long term consequences such as reduction in gastric atrophy and intestinal metaplasia, which are precursors of gastric carcinoma.  Methods of detection are divided into invasive and noninvasive tests. Noninvasive tests include serology and carbon-labeled urea breath test. The invasive tests include the rapid urease test, histological examination, and culture. Among the invasive tests, histological examination is important in the assessment of H. pylori status. Endoscopic biopsy allows the detection of H. pylori, which determines the treatment for peptic ulcer disease.  For most studies, histological examination is the standard for detection, because the objective is the determination of the presence of organisms and prevalence of gastritis. [5,6]
Materials and Methods
This prospective study was undertaken in the Department of Pathology, New Civil Hospital, Government Medical College, Surat, Gujarat, India, from September 2011 to October 2013. Seventy consecutive endoscopic gastric biopsies, which were received from the surgical outpatient department, of the patients presenting with symptoms of dyspepsia were included in the study. Clinical details were noted including age, sex, and clinical diagnosis. These properly labeled tissues were then put in 10% formalin for 24 h. After fixation, the bits were washed in running tap water for 30 min, sent for preparation of formalin-fixed paraffin-embedded blocks and, then, tissue sections with 4-[micro]m thickness were obtained. Routine hematoxylin and eosin stain on one slide and Giemsa stain on the other slide for the demonstration of H. pylori were done in each case. The biopsies were evaluated for the histomorphological parameters associated with H. pylori infection namely, lymphoid aggregates, chronic inflammatory infiltrate (mild, moderate, and severe), activity (neutrophils), and intestinal metaplasia. Various predominant histopathological diagnoses in each case were noted down and correlated with the incidence of H. pylori infection in each case.
H. pylori in HE stain: Light pink curved rods.
H. pylori in Giemsa stain: Dark blue curved rods.
A total of 70 consecutive patients who underwent endoscopic gastric biopsies for various gastric lesions were studied, of which 40 cases revealed H. pylori positivity.
Of 70 cases, 49 (70%) cases were male and 21 (30%) cases female subjects, with a male to female ratio of 2.3:1. Among the 40 cases of H. pylori, 28 (70%) cases were male (n = 26) and 12 (30%) cases female subjects (n = 14), with a ratio of 2.33:1. This indicates the preponderance of H. pylori in male subjects.
The age of patients ranged from 20 to 80 years, with a mean age of 55.9 years. The age distribution of H. pylori shows a gradual increase in the H. pylori positivity with increasing age, reaching a maximum at the sixth decade.
As shown in Table 1, of the total 70 cases, 39 cases of chronic superficial gastritis, 9 cases of gastric ulcer, 9 cases of adenocarcinoma, 8 cases of nonulcer dyspepsia, and 5 cases of atrophic gastritis with intestinal metaplasia were observed. Of the 39 cases of chronic superficial gastritis studied, 24 (61.5%) cases were positive for H. pylori. Of the nine cases of gastric ulcer studied, six (66.6%) cases were positive for H. pylori. In five cases of intestinal metaplasia, three (60%) cases were positive for H. pylori. In nine cases of adenocarcinoma studied, five (55.5%) cases were positive for H. pylori. Of the eight cases that showed nonulcer dyspepsia, two (25%) cases were positive for H. pylori.
H. pylori are seen in sections, usually, in close contact with the mucosa within gastric pits entrapped within the overlying mucus or in the lumen of the gastric glands. In hematoxylin-and-eosin-stained sections, they are faintly eosinophilic, whereas in Giemsa-stained sections, they are better appreciated as blue or violet organisms.
Of the nine cases of gastric adenocarcinomas, five cases were of intestinal type and four cases diffuse type. Of the five cases of adenocarcinoma of intestinal type, four (80%) cases were positive for H. pylori, and of the four cases of adenocarcinoma of diffuse type, one (25%) case was positive for H. pylori [Table 2].
Among the 39 cases of chronic superficial gastritis, histological grading according to revised Sydney system was done. Chronic inflammatory infiltrate was composed of lymphocytes, plasma cells, and eosinophils, which were seen in the lamina propria in varying degrees. Mild degree of infiltrate was seen in 10 (25.67%) cases, moderate degree in 12 (30.7%) cases, and severe in 17 (43.5%) cases. Activity characterized by neutrophilic infiltrate, decreased mucus, and cuboidal epithelium were seen in 10 (25.6%) of the 39 cases of chronic superficial gastritis. Lymphoid aggregates and lymphoid follicles were noted in13 (33.3%) cases. Intestinal metaplasia with goblet cells was seen in eight (20.5%) cases. Atrophy with a decrease in the number of glands was noted in six (15.3%) cases.
As shown in Table 3, in chronic active gastritis, 8 of 10 cases of activity, 9 of 13 cases of lymphoid aggregates, 4 of 8 cases of intestinal metaplasia, and 4 of 6 cases of atrophy showed H. pylori positivity.
Considering the site of involvement, of the 40 positive cases, 18 (45%) cases showed colonization of H .pylori in incisura, 7 (17.5%) cases in lesser curvature of gastric antrum, 6 (15%) cases in greater curvature of gastric antrum, 5 (12.5%) cases in lesser curvature of corpus, and 4 (10%) cases in greater curvature of corpus.
H. pylori is associated with many diseases, mainly, many benign, premalignant, and malignant lesions of the digestive system including chronic gastritis, atrophic gastritis, intestinal metaplasia, gastric adenomas, gastric hyperplastic polyps, adenocarcinomas of the distal part of the stomach, lymphoma of mucosa-associated lymphoid tissue, colonic adenomas, and colonic adenocarcinoma. Among them, the association between various gastric diseases and H. pylori is significant.
In our study, the incidence of increased with age. The maximum prevalence in our study was in the sixth decade. In our study, male subjects showed a higher prevalence of H. pylori infection when compared with females. There is no apparent reason as to why male subjects would have greater exposure or greater susceptibility to infection than female subjects. One reason suggested for the inconsistency in results is that, in certain populations, H. pylori infections may be inadvertently eliminated because of more frequent antimicrobial treatment of women for urogenital tract infection. 
Among 39cases of chronic superficial gastritis, 24 (55.7%) cases were found to be positive for H.pylori. In 1984, Marshall and Warren,  in their study showed that, among 20 cases of chronic gastritis, 12 were positive for H. pylori (60%). Our study showed a lesser positivity that may be because many biopsies may not have been taken from the representative site.
Atrophic gastritis and intestinal metaplasia are presumed to be important stages in the development of gastric adenocarcinoma.  In our study, five cases of gastric atrophy with intestinal metaplasia were diagnosed. Of them, three (60%) cases showed positivity for H. pylori. The study by Craanen et al.  have shown that yield for H. pylori infection is reduced when intestinal metaplasia is present, emphasizing the importance of obtaining biopsy specimen from antrum. In our study, atrophic gastritis was accompanied by fibrosis and paucity of glands, and the features were similar to the findings in a previous study done by Guarner et al. 
Our study showed a positivity of six (66.66%) cases of the nine cases of gastric ulcer, which is in concordance with the other studies shown in Table 4. 
In our study, five of nine cases of adenocarcinoma (55.5%) were reported to be H. pylori positive. Studies have shown that 60%-80% of gastric cancers are related to the long-term presence of H. pylori.  In a recent metaanalysis of H. pylori and gastric cancer, 79.2% of patients with noncardiac gastric carcinomas showed positivity for H. pylori.  Table 4 shows the association of H. pylori with gastric cancer in various studies and in our study.
Craanen et al.  showed H pylori in 61.3% of intestinal-type early gastric cancer and in 54.5% of diffuse-type early gastric cancer. Parsonneth  studied H. pylori positivity in gastric cancer and found a positivity of 89.2% of patients in intestinal-type when compared with 31.8% in diffuse type of gastric cancer, and it was concordant with our study [Table 5]. 
Although histopathological examination is considered to be the gold standard, the reliability of detecting H. pylori infection depends on site, number, and the size of gastric biopsy specimens, the stain used, and the expertise in staining and visualizing the bacteria.
The frequency of H. pylori infection is common in dyspeptic patients with a maximum positivity of 66.6% in gastric ulcer and 61.5% in chronic superficial gastritis. The association between various gastric disease, especially, benign, premalignant, and malignant, and H. pylori is significant.
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Source of Support: Nil, Conflict of Interest: None declared.
Hiral Shah (1), Pinal Shah (2), Mayur Jarag (2), Rhuta Shah (2), Pinkal Shah (3), Kinnari Naik (3)
(1) Consultant Pathologist, Surat, Gujarat, India.
(2) Department of Pathology, Government Medical College, Surat, Gujarat, India.
(3) Department of Pathology, Government Medical College, Surat, Gujarat, India.
Correspondence to: Hiral Shah, E-mail: firstname.lastname@example.org
Received May 13, 2015. Accepted June 26, 2015
Table 1: H. pylori positivity in different gastric lesions by Giemsa stain Chronic Nonulcer superficial dyspesia gastritis Total no. of cases 8 39 Positivity of H. pylori 2 24 Percentage of positivity 25 61.5 Gastric Atrophic gastritis with ulcer intestinal metaplasia Total no. of cases 9 5 Positivity of H. pylori 6 3 Percentage of positivity 66.6 60 Adenocarcinoma Total Total no. of cases 9 70 Positivity of H. pylori 5 40 Percentage of positivity 55 57.1 Table 2: Types of adenocarcinoma and H. pylori positivity H. pylori Adenocarcinoma Adenocarcinoma Total (9), intestinal diffuse n (%) type (5), n (%) type (4), n (%) Positive 4 (80) 1 (25) 5 (55.5) Negative 1 (20) 3 (75) 4 (44.5) Table 3: Association of H. pylori with activity, lymphoid aggregates, intestinal metaplasia, and atrophy in 39 cases of chronic superficial gastritis Mucosal Total cases H. pylori Percentage changes positivity Activity 10 8 80 Lymphoid 13 9 69.2 aggregates Intestinal 8 4 50 metaplasia Atrophy 6 4 66.6 Table 4: Comparative studies showing H. pylori positivity and gastric cancer Study No. of cases H. pylori positive (%) Misra et al.  29 69 Parsonnet  109 84 Kim et al.  194 84 Our study 9 55.5 Table 5: Comparative studies showing H. pylori positivity in different types of gastric adenocarcinoma Study Intestinal type (%) Diffuse type (%) Parsonnet  89.2 31.8 Craanen et al.  61.3 54.5 Misra et al.  68 86 Our study 80 25
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|Title Annotation:||Research Article|
|Author:||Shah, Hiral; Shah, Pinal; Jarag, Mayur; Shah, Rhuta; Shah, Pinkal; Naik, Kinnari|
|Publication:||International Journal of Medical Science and Public Health|
|Date:||Jan 1, 2016|
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