Prevalence of Helicobacter pylori among patients with dyspepsia and correlation between endoscopic and histological diagnosis

Correspondence: Dr. Shiva Raj K C, MBBS, MD Department of Pathology KIST Medical College, Imadole, Laltipur, Nepal Email: shiva_kc_123@yahoo.com Background: Dyspepsia is a prevalent complaint in general practice and gastrointestinal clinics. Helicobacter pylori have major causal relationship with gastro duodenal disease. The following study seeks to identify the prevalence of H. pylori based on histology and to correlate endoscopic findings with histopathology.


INTRODUCTION
Dyspepsia is a prevalent complaint in general practice and gastrointestinal clinics. 1 Helicobacter pylori (H.pylori) were of major concern today because of its causal relationship with gastro duodenal disease.After the discovery of H. pylori by Marshall and Warren in 1983 by using Warthin Starry Silver stain, the etiological understanding of gastritis and its role as bacterial carcinogen have changed the management of gastritis.][9][10][11] This bacterium colonizes human gastric mucosa and can elicit lifelong inflammatory and immune responses, with release of various bacterial and host dependent cytotoxic substances.[14] The following study seeks to identify the prevalence of H. pylori based on histology and to correlate endoscopic findings with histopathology.

MATERIAL AND METHODS
This was an observational cross-sectional study at GRP Polyclinic Pvt.Ltd and Om Hospital and Research centre Pvt Ltd over a period of 6 months from from April 2015-September 2015.Data analysis was done from all consecutive individuals who had undergone gastric biopsy during upper GI endoscopy for various dyspeptic symptoms like pain abdomen, nausea, vomiting, belching, throat pain, upper gastrointestinal bleeding, weight loss etc.However, patients under the age of 14 years, with oesophageal varices were not included in the study.Prior to investigation, informed consent was taken from the patient.Permission from ethical review committee was obtained.
The upper gastrointestinal endoscopy was performed by two physicians separately and endoscopic findings were categorized into gastro-esohageal reflux disease, antral gastritis, gastric ulcer, duodenitis, duodenal ulcer, and neoplasm.The biopsy specimens were usually taken from the gastroesophageal junction, antrum or duodenum depending upon the endoscopic findings and sent for histological examination.The biopsy specimens were fixed in 10% buffered formalin, processed, embedded in paraffin, and cut and stained with Hematoxylin and Eosin (HandE) and Giemsa stain.Histological reporting was done by pathologist using Modified Sidney system which included inflammation, activity, atrophy, intestinal metaplasia, and Helicobacter Pylori colonization. 15Histologically, gastritis was classified into chronic active gastritis (CAG), chronic follicular gastritis (CFG), and chronic persistent gastritis (CPG) with or without intestinal metaplasia, atrophy and Helicobacter Pylori colonization.
All the relevant data were collected and analysed using using Statistical Package of Social Sciences (SPSS) version 16 for windows.Chi-square test with exact test was used where applicable.P values of < 0.05 were considered to denote statistical significance.1.
Intestinal metaplasia was identified in 3% (31/1020) of the patients who underwent UGI endoscopy.Only 11 (35.4%)patients with intestinal metaplasia had colonization by Helicobacter Pylori.The mean age of the patient with intestinal metaplasia was 54.2 ± 16.9 years.There was significant male predominance with male to female ratio of 1.6:1.
Atrophy was noted in 24(2.35%) of all the patients included in this study.There was female predominance male to female ratio of 0.7:1.The mean age of the patient with atrophic gastritis was 40.8±12.6.

DISCUSSION
Current standard of care for most patients with symptoms of upper GIT consists of initial endoscopic examination followed by histopathology.The individual accuracy and sensitivity of these techniques in the diagnosis of any lesions is subjective to the operator's ability to target site of pathology.Helicobacter Pylori remains the most common cause of chronic gastritis.Furthermore, since Helicobacter pylorus has carcinogenic effect, it has radically changed our understanding and clinical management of gastroduodenal disease, and much has been researched about its clinical aspects and its epidemiology. 16 this study age of the patients with dyspepsia ranged from 16-94 years with the mean of 41.7 years.Among the patients seeking for medical help due to dyspepsia 549 (53.8%) were female and 471(46.1%)were male with slight female predominance (M:F-1:1.16).A study done by Sharma et al documented 51% female seeking for medical help due to dyspepsia as compared to 49% males. 17st common upper gastrointestinal endoscopic findings were antral gastritis 57.1%) followed by duodenal ulcer (11.7%), duodenitis (10.5%) and gastric ulcer (10.0%)Similar finding was observed in a study done by Poudel A et al.He observed 58.1% cases had antral gastritis followed by 11.63% with peptic ulcer. 18Reflux esophagitis was observed in 10% of the patients which was less than study conducted by Ercelep OB et al. 19 Ulcerative lesions of stomach and duodenum was more common in males than in females as was observed in a study done by Shrestha R et al. 20 Most common pathology in histopathology was chronic active gastritis (42.1%), followed by chronic persistent gastritis (38.2%), chronic follicular gastritis (19.1%) and gastric carcinoma (0.5%).This result was in concordance with other study. 20In ulcerative lesions most common antral biopsy finding was chronic active gastritis and chronic follicular gastritis whereas in non-ulcerative lesions chronic persistent gastritis was the commonest diagnosis.Patients with chronic active gastritis and chronic follicular gastritis had higher frequency of Helicobacter Pylori positivity with incidence of 84.8% and 84.1% respectively.2][23] Study done by X Y Chen et al observed positive correlation with the prevalence and density of lymphoid follicles and aggregates with H pylori infection. 24In a study done by Genta RM et al 25 observed 100% presence of Helicobacter Pylori in patients with chronic follicular gastritis.These discrepancies may be due to: 1) Various biopsy sites, 2) intake of proton pump inhibitor which leads to subepithelial colonization of bacteria and is difficult to identify in routine histopathology procedure.Overall prevalence of H. Pylori infection was 68.1%.Overall, researchers found a consistent pattern in most developing nations, where 70 to 90% of adults harbored the bacteria; most individuals acquired the infection as children, before age ten. 5,68][9][10][11] Intestinal metaplasia was observed in 3% (n=31) of the dyspeptic patients whereas gastric atrophy was noted in 3.25% (n=24) patients.Gastric carcinoma was seen in 5 (0.5%) of cases with 80% having Helicobacter Pylori infection.The data is too small to compare with other studies.

CONCLUSION
Rate of H. pylori infected patients with dyspepsia was high.Ulcerative lesions were more common in males than in females with higher rate of infection with H. Pylori.detected by histopathology among adult patients with gastrointestinal symptoms was high (68%).Histological diagnosis of chronic active gastritis and chronic follicular gastritis was the most common pathologies in ulcerative lesions.Because of higher prevalence rate of H. Pylori; routine endoscopic biopsy should be performed so as to detect this gram negative microorganism and to treat accordingly.

Table : 1 Prevalence of Helicobacter Pylori in accordance with endoscopic diagnosis
TA total of 1020 UGI endoscopies were performed and biopsies were taken during the study period.The age of the patients ranged from 16-94 years with the mean of 41.7 ±18.Among all the patients, 549 (53.8%) were females and 471 (46.1%) were males.