Frequency of Helicobacter pylori and Gastritis in Healthy Subjects without Gastrointestinal Symptoms J . FALLINGBORG, L. 0. POULSEN, A . GROVE & P. STUBBE TEGLBJRRG Dept. of Medical Gastroenterology and Institute of Pathology, Aalborg Hospital, Aalborg, Denmark
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Fallingborg J, Poulsen LO, Grove A. Teglbjmg PS. Frequency of Helicobacter pylori and gastritis in healthy subjects without gastrointestinal symptoms. Scand J Gastroenterol 1992;27:388-390. To investigate the frequency of Helicobucfer pylori and gastritis in asymptomatic adults, 30 healthy volunteers underwent upper endoscopy. Biopsy specimens were obtained from the corporeal and antral mucosa of the stomach. The specimens were examined by light microscopy for gastritis and the occurrence of H . pylori. In 12 subjects signs of gastritis wcre noted at endoscopy, but only in 7 of them was this diagnosis confirmed histologically. No other abnormalities were observed by the endoscopist. Histologic examination was normal in 17 subjects, but in 13 subjects (43%) inflammation was found in the gastric specimens. Ten had inflammation both in the corpus and in the prepyloric specimens, and in six of these subjects If. pylori was discovered. H . pylori was only found in subjects with inflammation in both the corpus and the antrum. Subjects with gastritis were slightly older than subjects with normal gastric mucosa (median age, 47 versus 37 years; not significant). In the group of subjects with gastritis, persons with H . pylori were older than those without (median age, 53.5 versus 36 years; p = 0.05). The results of our study indicate that gastritis is present before colonization with H . pylori occurs. This could imply that H . pylori is not the cause of gastritis but that the presence of gastritis is a prerequisite for colonization of the bacterium in the stomach.
Key words: Age; gastritis; Helicobuc,er pylori; normal subjects Jan Fallingborg, M . D., Dept. of Medicine 11, Aulborg Hospital, DK-9000 Aulbvrg, Denmark
Since the successful culture of Helicobacter pylori by Marshall in 1983 ( I ) many reports have demonstrated a high prevalence of the bacterium in patients with gastritis and duodenal ulcer. A high prevalence has also been demonstrated in patients with gastric ulcer. These observations have led to theories of the possible role of H . p y l o r i in these conditions. To determine whether H . pylori has a causal role in the process leading from a normal gastric mucosa to the development of gastritis and ulcer, it is important to study the initial and possible asymptomatic steps of this process. We therefore investigated the frequency of gastritis and H . pylori in healthy subjects without gastrointestinal symptoms.
MATERIALS AND METHODS Thirty healthy subjects, 15 men and 15 women, with a median age of 40.5 years (range, 19-65 years) were studied. The subjects did not receive any medicine, had no known diseases, and were without gastrointestinal symptoms. Routine biochemical test results were normal. All endoscopies were performed by one of us (J. Fallingborg) without premedication, using an Olympus GIF-Q20 or GIF-010 gastroscope. Biopsy specimens were obtained from two locations: from the corpus of the stomach opposite to the cardiac angle and from the prepyloric region. Two specimens were taken from each location. They were fixed
in 10% neutral buffered formalin and routinely processed. Serial sections were cut at 5 pm and stained with haematoxylin and eosin, the Brown-Hopps method, and periodic acid-Schiff/Alcian blue at pH 2.7. Microscopic examination was carried out by two pathologists independently and without prior knowledge of the endoscopic findings. The inflammatory reaction of the gastric mucosa was assessed, and the gastritis classified in accordance with the criteria of Whitehead et al. ( 2 ) . This classification includes the type of mucosa, the type of chronic gastritis (superficial or atrophic), the occurrence of activity, and the presence and type of metaplasia. In superficial chronic gastritis lymphoplasmacytic infiltration and reactive changes only affect the surface epithelium, the gastric pit region, and the related lamina propria. In atrophic gastritis the lamina propria of the gland layer is infiltrated with lymphocytes and plasma cells, and various degrees of fibrosis with atrophy of the glands occurs. Evidence of activity in both types of gastritis is manifested by the presence of polymorphonuclear leucocytes in the epithelial elements. The presence of H. p y i n r i was diagnosed on the basis of the morphology of the bacterium, the Brown-I iopps staining reaction (3), and the characteristic localization of these bacteria in the gastric mucosa (4). The cumulated frequencies of gastritis and H . p y l o r i were calculated as follows: cumulated frequency of gastritis at age X years = number of subjects X years of age with gastritis/ number of subjects S X years of age.
H. pylori and Gastritis in Healthy Subjects umulated frequency 50q
1.
Gastrltis
-k HP
I
. '
40Y
Scand J Gastroenterol Downloaded from informahealthcare.com by Nyu Medical Center on 12/04/14 For personal use only.
30%
389
mucosa (47 versus 37 years, p = 0.19). In 3 subjects the inflammation was confined to either the antrum (1 person) or the corpus (2 persons), whereas in 10 subjects gastritis was found in both locations. H . pylori was found in six subjects (20%; 95% confidence interval, 8-39%). All had acute active, chronic gastritis, and all had inflammation both in the antrum and in the corpus. Among subjects with gastritis those with H. pylori were older than those without this bacterium (median age, 53.5 years versus 36 years; p = 0.05). The 95% confidence interval of difference in age is 025 years. The cumulated frequencies of gastritis and H. pylori are shown in Fig. 1.
+A+
20%
+
DISCUSSION
Gastritis is frequently found even in healthy subjects without gastrointestinal symptoms. In the present study of 30 healthy 10% subjects 43% had gastritis, which is in agreement with the frequency reported by Kreuning et al. (9,Dooley et al. (6), and Johnsen et al. (7) but a little higher than reported by Rauws et al. (8). Several studies have demonstrated that the I I I 1 I 0% frequency of subjects with histologic gastritis increases with 0 10 20 30 40 50 60 70 increasing age (6, 7, 9). This tendency was also observed in Age (years) our study. Fig. 1. Cumulated frequencies of gastritis and Helicobacter pylori The association between acute active, chronic gastritis and (HP) in normal subjects. the newly described bacterium N.pylori has been confirmed in previous studies (8, 10). A cause-effect relationship between H. pylori and gastritis has been postulated on the basis of experimental ingestion of the bacterium by two volunteers, with ensuing gastritis (11,12). However, in both Ethics The study was approved by the local Ethics Committee, instances infection was only established after premedication and informed consent was obtained from all subjects after with cimetidine to suppress the gastric acid secretion, which indicates that the bacterium in itself is not capable of causing thorough verbal and written information about the study. infection. We found this bacterium in less than half the subjects with gastritis. It could be argued that microbiologic Statistics The Wilcoxon test for unpaired data and Fisher's exact methods should have been used to determine the presence test were used. Significance was considered at the 5% level. of H. pylori. However, histologic determination of H. pylori has been found to be an equally specific and sensitive method (6, lo), and the total frequency of H . pylori in our study RESULTS was identical to that reported by Rauws et al. (8) using a In 12 subjects signs of gastritis were observed at endoscopy, microbiologic method in healthy subjects. Previous studies but only in 7 of them was this diagnosis confirmed histologically. No other abnormalities were observed by the endoscopist. Histopathologic examination showed normal gastric mucosa in 16 of the subjects. In 1of the 30 subjects a solitary area of mild atrophy was found in the antral mucosa. Since no inflammation was found, the case was not classified as gastritis. Thirteen subjects (43%; 95% confidence interval, 25-63%) had chronic gastritis, and seven of these had acute activity. Seven of the persons with gastritis were male and V six female. There were 4 smokers (31%) in this group, compared with 10 (59%) in the group of subjects without gastritis ( p = 0.25). The median age of subjects with gastritis Fig. 2. The proposed pathogenesis of chronic gastritis. HP = Helwas slightly higher than that of subjects with normal gastric icobacrer pylori. II
@
Scand J Gastroenterol Downloaded from informahealthcare.com by Nyu Medical Center on 12/04/14 For personal use only.
390
J . Fallinghorg et al.
have demonstrated that the frequency of H. pylori increases with increasing age (6, 13). W e also found that subjects with H . pylori were older than subjects without the bacterium. Furthermore, we found that among subjects with gastritis, those with H . pylori were older than persons without this bacterium. This indicates that gastritis is present before colonization with H . pylori occurs. This could mean that the presence of H . pylori in the stomach is not t h e initiating event in the development of gastritis but that the presence of gastritis of unknown aetiology is a prerequisite for the colonization of H . pylori. However, this observation needs confirmation from prospective trials. T h e results of our study does not point t o a possible aetiologic factor. T h e lack of association between smoking and gastritis found i n our study has previously been demonstrated (14). The accumulating evidence of the beneficial effect of eradication of H . pylori on the healing of gastritis cannot b e ignored, but such an effect can b e explained without claiming a causeeeffect relationship of H . pylori and gastritis. Our findings support a theory in which gastritis is induced by one o r more unknown ‘initiating factors’. When gastritis is present, it disposes to infection with H . pylori, which again maintiins the inflammation (Fig. 2). If H.pyloriis eradicated by medical therapy, the gastritis may heal if the ‘initiating factors’ are no longer present. T h e exact pathogenesis of gastritis is not of mere academic interest, as the goal in the treatment of gastritis must b e the identification and elimination of the ‘initiating factors’ to prevent relapse of the disorder. REFERENCES 1. Marshall BJ. Unidentified curved bacilli on gastric epithelium in activc chronic gastritis. Lancet 1983;l: 1273-5. Received 22 July 1991 Accepted 16 November 1991
2. Whitehead R, Truelove SC, Gear MWL. The histological diagnosis of chronic gastritis in fiberoptic gastroscope biopsy specimens. J Clin Path01 1972;25:1-11. 3. WestblomTU,MadanE, KempJ,SurikMA,TsengJ. Improved visualisation of mucus penetration by Campylobacter pylori using a Brown-I-Iopps stain. J Clin Pathol 1988;41:232. pathogenetic 4. Wyatt J1, Dixon MF. Chronic gastritis-a approach. J Pathol 1988;154:11>24. 5. Kreuning J, Bosman FT,Kuiper G , vd Wal AM, Lindeman J. Gastric and duodenal mucosa in ‘healthy’ individuals: an endoscopic and histopathological study of SO individuals. J Clin Pathol 1978;31:69-77. 6 . Dooley CP, Cohnen H, Fritzgibbins PL, et al. Prevalence of Helicobacter pylori infection and histologic gastritis in asymptomatic persons. N Engl J Med 1989;321:1562-6. 7. Johnsen R, Bernersen B, Straume B, F ~ r d eOH, Bostad L, Burhol PG. Prevalences of endoscopic and histologic findings in subjects with and without dyspepsia. Br Med J 1991;302:74‘952. 8. Rauws EAJ, Langenberg W, Houthoff HJ, Zanen HC, Tytgat GNJ, Campylobacter pyloridis-associated chronic active antral gastritis: a prospective study of its prevalence and the effects of antibacterial and antiulcer treatment. Gastroenterology 1988; 94:3.3-40. 9. Siurala M, Isokoski K , Varis K, Kekki M. Prevalence of gastritis in a rural population. Bioptic study of subjects selected at random. Scand J Gastroenterol 1968;3:211-23. 10. Pena AS, Endtz HP, Offerhaus GJA, ct al. Value of serology (ELISA and immunoblotting) for the diagnosis of Campylobacter pylori infection. Digestion 1989;44:131-41. 11. Marshall BJ, Armstrong JA, McGehie DB, Glancy RJ.Attempt to fulfil Koch’s postulates for pyloric campylobacter. Med J Aust 1985;142:436-9. 12. Morris A, Nicholson G. lngestion of Campylobacter pyloridis and raised fasting gastric pH. Am J Gastroenterol 1987;82:1929. 13. Jones DM, Eldridge J , Fox AJ, Sethi P, Whorwcll PJ. Antibody to thc gastric campylobacter-like organism (‘Campylobacter pyloridis’)--clinical correlations and distribution in the normal population. J Med Microbiol 1986;22:57-62. 14. Jijnsson K-A, Gotthard R, Bodemar G , Brodin U. The clinical relevance of endoscopic and histologic inflammation of gastroduodenal mucosa in dyspepsia of unknown origin. Scand .I Gastroenterol 1989:24:385-9S.
Scand J Gastroenterol Downloaded from informahealthcare.com by Nyu Medical Center on 12/04/14 For personal use only.
Fallingborg J, Poulsen LO, Grove A. Teglbjmg PS. Frequency of Helicobacter pylori and gastritis in healthy subjects without gastrointestinal symptoms. Scand J Gastroenterol 1992;27:388-390. To investigate the frequency of Helicobucfer pylori and gastritis in asymptomatic adults, 30 healthy volunteers underwent upper endoscopy. Biopsy specimens were obtained from the corporeal and antral mucosa of the stomach. The specimens were examined by light microscopy for gastritis and the occurrence of H . pylori. In 12 subjects signs of gastritis wcre noted at endoscopy, but only in 7 of them was this diagnosis confirmed histologically. No other abnormalities were observed by the endoscopist. Histologic examination was normal in 17 subjects, but in 13 subjects (43%) inflammation was found in the gastric specimens. Ten had inflammation both in the corpus and in the prepyloric specimens, and in six of these subjects If. pylori was discovered. H . pylori was only found in subjects with inflammation in both the corpus and the antrum. Subjects with gastritis were slightly older than subjects with normal gastric mucosa (median age, 47 versus 37 years; not significant). In the group of subjects with gastritis, persons with H . pylori were older than those without (median age, 53.5 versus 36 years; p = 0.05). The results of our study indicate that gastritis is present before colonization with H . pylori occurs. This could imply that H . pylori is not the cause of gastritis but that the presence of gastritis is a prerequisite for colonization of the bacterium in the stomach.
Key words: Age; gastritis; Helicobuc,er pylori; normal subjects Jan Fallingborg, M . D., Dept. of Medicine 11, Aulborg Hospital, DK-9000 Aulbvrg, Denmark
Since the successful culture of Helicobacter pylori by Marshall in 1983 ( I ) many reports have demonstrated a high prevalence of the bacterium in patients with gastritis and duodenal ulcer. A high prevalence has also been demonstrated in patients with gastric ulcer. These observations have led to theories of the possible role of H . p y l o r i in these conditions. To determine whether H . pylori has a causal role in the process leading from a normal gastric mucosa to the development of gastritis and ulcer, it is important to study the initial and possible asymptomatic steps of this process. We therefore investigated the frequency of gastritis and H . pylori in healthy subjects without gastrointestinal symptoms.
MATERIALS AND METHODS Thirty healthy subjects, 15 men and 15 women, with a median age of 40.5 years (range, 19-65 years) were studied. The subjects did not receive any medicine, had no known diseases, and were without gastrointestinal symptoms. Routine biochemical test results were normal. All endoscopies were performed by one of us (J. Fallingborg) without premedication, using an Olympus GIF-Q20 or GIF-010 gastroscope. Biopsy specimens were obtained from two locations: from the corpus of the stomach opposite to the cardiac angle and from the prepyloric region. Two specimens were taken from each location. They were fixed
in 10% neutral buffered formalin and routinely processed. Serial sections were cut at 5 pm and stained with haematoxylin and eosin, the Brown-Hopps method, and periodic acid-Schiff/Alcian blue at pH 2.7. Microscopic examination was carried out by two pathologists independently and without prior knowledge of the endoscopic findings. The inflammatory reaction of the gastric mucosa was assessed, and the gastritis classified in accordance with the criteria of Whitehead et al. ( 2 ) . This classification includes the type of mucosa, the type of chronic gastritis (superficial or atrophic), the occurrence of activity, and the presence and type of metaplasia. In superficial chronic gastritis lymphoplasmacytic infiltration and reactive changes only affect the surface epithelium, the gastric pit region, and the related lamina propria. In atrophic gastritis the lamina propria of the gland layer is infiltrated with lymphocytes and plasma cells, and various degrees of fibrosis with atrophy of the glands occurs. Evidence of activity in both types of gastritis is manifested by the presence of polymorphonuclear leucocytes in the epithelial elements. The presence of H. p y i n r i was diagnosed on the basis of the morphology of the bacterium, the Brown-I iopps staining reaction (3), and the characteristic localization of these bacteria in the gastric mucosa (4). The cumulated frequencies of gastritis and H . p y l o r i were calculated as follows: cumulated frequency of gastritis at age X years = number of subjects X years of age with gastritis/ number of subjects S X years of age.
H. pylori and Gastritis in Healthy Subjects umulated frequency 50q
1.
Gastrltis
-k HP
I
. '
40Y
Scand J Gastroenterol Downloaded from informahealthcare.com by Nyu Medical Center on 12/04/14 For personal use only.
30%
389
mucosa (47 versus 37 years, p = 0.19). In 3 subjects the inflammation was confined to either the antrum (1 person) or the corpus (2 persons), whereas in 10 subjects gastritis was found in both locations. H . pylori was found in six subjects (20%; 95% confidence interval, 8-39%). All had acute active, chronic gastritis, and all had inflammation both in the antrum and in the corpus. Among subjects with gastritis those with H. pylori were older than those without this bacterium (median age, 53.5 years versus 36 years; p = 0.05). The 95% confidence interval of difference in age is 025 years. The cumulated frequencies of gastritis and H. pylori are shown in Fig. 1.
+A+
20%
+
DISCUSSION
Gastritis is frequently found even in healthy subjects without gastrointestinal symptoms. In the present study of 30 healthy 10% subjects 43% had gastritis, which is in agreement with the frequency reported by Kreuning et al. (9,Dooley et al. (6), and Johnsen et al. (7) but a little higher than reported by Rauws et al. (8). Several studies have demonstrated that the I I I 1 I 0% frequency of subjects with histologic gastritis increases with 0 10 20 30 40 50 60 70 increasing age (6, 7, 9). This tendency was also observed in Age (years) our study. Fig. 1. Cumulated frequencies of gastritis and Helicobacter pylori The association between acute active, chronic gastritis and (HP) in normal subjects. the newly described bacterium N.pylori has been confirmed in previous studies (8, 10). A cause-effect relationship between H. pylori and gastritis has been postulated on the basis of experimental ingestion of the bacterium by two volunteers, with ensuing gastritis (11,12). However, in both Ethics The study was approved by the local Ethics Committee, instances infection was only established after premedication and informed consent was obtained from all subjects after with cimetidine to suppress the gastric acid secretion, which indicates that the bacterium in itself is not capable of causing thorough verbal and written information about the study. infection. We found this bacterium in less than half the subjects with gastritis. It could be argued that microbiologic Statistics The Wilcoxon test for unpaired data and Fisher's exact methods should have been used to determine the presence test were used. Significance was considered at the 5% level. of H. pylori. However, histologic determination of H. pylori has been found to be an equally specific and sensitive method (6, lo), and the total frequency of H . pylori in our study RESULTS was identical to that reported by Rauws et al. (8) using a In 12 subjects signs of gastritis were observed at endoscopy, microbiologic method in healthy subjects. Previous studies but only in 7 of them was this diagnosis confirmed histologically. No other abnormalities were observed by the endoscopist. Histopathologic examination showed normal gastric mucosa in 16 of the subjects. In 1of the 30 subjects a solitary area of mild atrophy was found in the antral mucosa. Since no inflammation was found, the case was not classified as gastritis. Thirteen subjects (43%; 95% confidence interval, 25-63%) had chronic gastritis, and seven of these had acute activity. Seven of the persons with gastritis were male and V six female. There were 4 smokers (31%) in this group, compared with 10 (59%) in the group of subjects without gastritis ( p = 0.25). The median age of subjects with gastritis Fig. 2. The proposed pathogenesis of chronic gastritis. HP = Helwas slightly higher than that of subjects with normal gastric icobacrer pylori. II
@
Scand J Gastroenterol Downloaded from informahealthcare.com by Nyu Medical Center on 12/04/14 For personal use only.
390
J . Fallinghorg et al.
have demonstrated that the frequency of H. pylori increases with increasing age (6, 13). W e also found that subjects with H . pylori were older than subjects without the bacterium. Furthermore, we found that among subjects with gastritis, those with H . pylori were older than persons without this bacterium. This indicates that gastritis is present before colonization with H . pylori occurs. This could mean that the presence of H . pylori in the stomach is not t h e initiating event in the development of gastritis but that the presence of gastritis of unknown aetiology is a prerequisite for the colonization of H . pylori. However, this observation needs confirmation from prospective trials. T h e results of our study does not point t o a possible aetiologic factor. T h e lack of association between smoking and gastritis found i n our study has previously been demonstrated (14). The accumulating evidence of the beneficial effect of eradication of H . pylori on the healing of gastritis cannot b e ignored, but such an effect can b e explained without claiming a causeeeffect relationship of H . pylori and gastritis. Our findings support a theory in which gastritis is induced by one o r more unknown ‘initiating factors’. When gastritis is present, it disposes to infection with H . pylori, which again maintiins the inflammation (Fig. 2). If H.pyloriis eradicated by medical therapy, the gastritis may heal if the ‘initiating factors’ are no longer present. T h e exact pathogenesis of gastritis is not of mere academic interest, as the goal in the treatment of gastritis must b e the identification and elimination of the ‘initiating factors’ to prevent relapse of the disorder. REFERENCES 1. Marshall BJ. Unidentified curved bacilli on gastric epithelium in activc chronic gastritis. Lancet 1983;l: 1273-5. Received 22 July 1991 Accepted 16 November 1991
2. Whitehead R, Truelove SC, Gear MWL. The histological diagnosis of chronic gastritis in fiberoptic gastroscope biopsy specimens. J Clin Path01 1972;25:1-11. 3. WestblomTU,MadanE, KempJ,SurikMA,TsengJ. Improved visualisation of mucus penetration by Campylobacter pylori using a Brown-I-Iopps stain. J Clin Pathol 1988;41:232. pathogenetic 4. Wyatt J1, Dixon MF. Chronic gastritis-a approach. J Pathol 1988;154:11>24. 5. Kreuning J, Bosman FT,Kuiper G , vd Wal AM, Lindeman J. Gastric and duodenal mucosa in ‘healthy’ individuals: an endoscopic and histopathological study of SO individuals. J Clin Pathol 1978;31:69-77. 6 . Dooley CP, Cohnen H, Fritzgibbins PL, et al. Prevalence of Helicobacter pylori infection and histologic gastritis in asymptomatic persons. N Engl J Med 1989;321:1562-6. 7. Johnsen R, Bernersen B, Straume B, F ~ r d eOH, Bostad L, Burhol PG. Prevalences of endoscopic and histologic findings in subjects with and without dyspepsia. Br Med J 1991;302:74‘952. 8. Rauws EAJ, Langenberg W, Houthoff HJ, Zanen HC, Tytgat GNJ, Campylobacter pyloridis-associated chronic active antral gastritis: a prospective study of its prevalence and the effects of antibacterial and antiulcer treatment. Gastroenterology 1988; 94:3.3-40. 9. Siurala M, Isokoski K , Varis K, Kekki M. Prevalence of gastritis in a rural population. Bioptic study of subjects selected at random. Scand J Gastroenterol 1968;3:211-23. 10. Pena AS, Endtz HP, Offerhaus GJA, ct al. Value of serology (ELISA and immunoblotting) for the diagnosis of Campylobacter pylori infection. Digestion 1989;44:131-41. 11. Marshall BJ, Armstrong JA, McGehie DB, Glancy RJ.Attempt to fulfil Koch’s postulates for pyloric campylobacter. Med J Aust 1985;142:436-9. 12. Morris A, Nicholson G. lngestion of Campylobacter pyloridis and raised fasting gastric pH. Am J Gastroenterol 1987;82:1929. 13. Jones DM, Eldridge J , Fox AJ, Sethi P, Whorwcll PJ. Antibody to thc gastric campylobacter-like organism (‘Campylobacter pyloridis’)--clinical correlations and distribution in the normal population. J Med Microbiol 1986;22:57-62. 14. Jijnsson K-A, Gotthard R, Bodemar G , Brodin U. The clinical relevance of endoscopic and histologic inflammation of gastroduodenal mucosa in dyspepsia of unknown origin. Scand .I Gastroenterol 1989:24:385-9S.
