Helicobacter pylori infection increases following cholecystectomy

Exploring the Relationship Between Helicobacter pylori Infection and Biliary Diseases: A Comprehensive Analysis Using the United States National Inpatient Sample (2016-2020)

BACKGROUND

Helicobacter pylori (H. pylori) infection is widely recognized for its association with gastric diseases. Prior studies on the relationship between H. pylori infection and biliary diseases have faced constraints, including inadequate control of confounding factors and small sample sizes. This study aims to explore the association between H. pylori infection and biliary diseases using a large, population-based sample with adequate control for various covariates.

METHODS

 The National Inpatient Sample (NIS) from 2016 to 2020 was used to investigate the association between H. pylori infection and biliary diseases. We identified patients with H. pylori infection using the International Classification of Diseases, Tenth Revision (ICD-10) code (B96.81). Descriptive analysis and inferential statistics, including univariate and multivariate regression, were performed to explore the relationship between H. pylori and selected biliary diseases.  Results: Overall, 32,966,720 patients were analyzed. Among them, 736,585 patients had biliary diseases (n=1,637 with H. pylori and n=734,948 without H. pylori). The baseline characteristics revealed notable differences in demographics and healthcare variables between both groups. Univariate regression analysis demonstrated significant associations between H. pylori infection and various biliary diseases such as gallbladder stones, gallbladder cancer, cholangitis, acute cholecystitis, and biliary pancreatitis, with the highest risk for chronic cholecystitis (odds ratio: 5.21; 95% confidence interval: 4.1-6.62; p<0.0001). Multivariate regression analysis, after adjusting for various covariates, confirmed these associations, providing insights into the potential causal relationship between H. pylori and biliary diseases.

CONCLUSION

 This study strengthens the evidence suggesting a potential association between H. pylori infection and biliary diseases. The findings need to be validated in prospective clinical studies.

The link between Helicobacter pylori infection and gallbladder and biliary tract diseases: A review

Helicobacter pylori is a gram-negative pathogen commonly associated with peptic ulcer disease and gastric cancer. H. pylori infection has also been reported in cholelithiasis, cholecystitis, gallbladder polyps, and biliary tract cancers. However, the association between H. pylori and gallbladder and biliary tract pathologies remains unclear due to the paucity of literature. In response to the current literature gap, we aim to review and provide an updated summary of the association between H. pylori with gallbladder and biliary tract diseases and its impact on their clinical management. Relevant peer-reviewed studies were retrieved from Medline, PubMed, Embase, and Cochrane databases. We found that H. pylori infection was associated with cholelithiasis, chronic cholecystitis, biliary tract cancer, primary sclerosing cholangitis, and primary biliary cholangitis but not with gallbladder polyps. While causal links have been reported, prospective longitudinal studies are required to conclude the association between H. pylori and gallbladder pathologies. Clinicians should be aware of the implications that H. pylori infection has on the management of these diseases.

A systematic review of the aetiology and management of post cholecystectomy syndrome

BACKGROUND

10% of patients who undergo a cholecystectomy go on to develop post-cholecystectomy syndrome (PCS). The majority of these patients may suffer from extra-biliary or unrelated organic disorders that may have been present before cholecystectomy. The numerous aetiological causes of PCS result in a wide spectrum of management options, each with varying success in abating symptoms. This systematic review aims to provide a summary of the causative aetiologies of post cholecystectomy syndrome, their incidences and efficacy of available management options.

METHODS

The Medline, Embase and Cochrane databases were searched for studies patients who developed PCS symptoms following laparoscopic cholecystectomy, published between 1990 and 2016. The aetiology, incidence and management options were extracted, with separate collation of randomised control trials and non-randomised studies that reported intervention. Outcomes included recurrent symptoms following intervention, unscheduled primary and secondary care attendances and complications.

RESULTS

Twenty-one studies were included (15 case series, 2 cohort studies, 1 case control, 3 RCTs). Five studies described medical treatment (nifedipine, cisapride, opiates); seven studies described endoscopic or surgical intervention. Early presentation of PCS (<3 years post-cholecystectomy) was more likely to be gastric in origin, and later presentations were found to be more likely due to retained stones. Sphincter of Oddi dysfunction (SOD) accounted for a third of cases in an unselected population with PCS.

CONCLUSIONS

Causes of post cholecystectomy syndrome are varied and many can be attributed to extra-biliary causes, which may be present prior to surgery. Early symptoms may warrant early upper gastrointestinal endoscopy. Delayed presentations are more likely to be associated with retained biliary stones. A large proportion of patients will have no cause identified. Treatment options for this latter group are limited.

Should We Perform Routine Upper Gastrointestinal Endoscopy Before Cholecystectomy?

In some patients, there is not any symptomatic relief after cholecystectomy due to the overlap of the symptoms of biliary and gastroduodenal pathologies known as postcholecystectomy syndrome. The aim of this study was to assess the effectiveness of upper gastrointestinal (UGI) endoscopy in reducing the possibility of postcholecystectomy syndrome. This retrospective study was conducted in 194 cases. In patients sampled for histopathologic examination, screening for Helicobacter pylori and intestinal metaplasia was carried out with Giemsa stain and PAS–Alcian stain. Patients who did not undergo UGI endoscopy before operation were designated as Group A (n = 100) and those who underwent routine UGI endoscopy before operation were called Group B (n = 94). Symptomatic relief after cholecystectomy and endoscopic findings were evaluated. Thirty-one of the 39 patients diagnosed with H. pylori, underwent eradication treatment. Seven of the 31 patients undergoing H. pylori eradication during the preoperative period had ongoing symptoms at the postoperative period. On the other hand, only 2 of 8 patients who did not undergo H. pylori eradication during the preoperative period had unremitting symptoms during the postoperative period. Only three of 100 patients who did not receive a UGI endoscopy during the preoperative period had unremitting symptoms during the postoperative period. The main outcome of the study is to evaluate the necessity of performing routine UGI endoscopy before cholecystectomy. Our results show that it is not necessary, because if you take biliary colic as the one and only symptom of indication for cholecystectomy, the ratio of postcholecystectomy syndrome is 3% to 5% and the reason is 50% organic.

Impact of Helicobacter pylori on the growth of hepatic orthotopic graft tumors in mice

Helicobacter pylori is a well-known causative organism of chronic gastric diseases and has been found in many hepatic carcinoma samples. To explore the expression of apoptosis-related proteins and carcinoma development in H. pylori-infected livers, we utilized BALB/cAnSlac mice to establish an H. pylori-infected model by oral inoculation and orthotopic grafts of hepatic tumors by H22 cells, respectively. We found that H. pylori colonies could not be cultured from all liver and tumor samples. However, its 16S rRNA was detectable in 85.3% of livers and 66.7% of tumors in the infected mice. Inflammatory cells were observed and thinly distributed in the lobule portions of the liver, and H. pylori mainly existed in the infected hepatic sinusoids and the necrotic areas of the infected tumors. No significant difference was found in liver to body weight ratio between the infected and uninfected. Moreover, the pathological tumor difference was unremarkable between the two. The proliferating cell nuclear antigen (PCNA) and Bcl-2-associated X protein (Bax) expression in the infected tumors was significantly higher and lower, respectively, than those of the uninfected tumors. However, no significant difference in Bcl-2 (B-cell lymphoma 2) expression existed. The results indicate that H. pylori found in the livers which were infected by H. pylori oral inoculation could contribute to the infiltration of inflammatory cells in livers. Although H. pylori has no significant impact on the liver to body weight ratio or tumor Bcl-2 expression, it may upregulate PCNA expression and downregulate Bax expression, respectively. All our findings show that H. pylori may promote proliferation and inhibit apoptosis of tumor cells.

Relationship between gallbladder stones and Helicobacter pylori colonization of the gallbladder mucosa

AIM: To investigate the relationship between gallbladder stones and Helicobacter pylori (H. pylori) colonization of the gallbladder mucosa.

METHODS: H. pylori was detected in bile and gallbladder mucosa of 64 patients with gallbladder stones (experimental group) and 16 patients without gallbladder stones (control group). Polymerase chain reaction (PCR) was used to detect specific DNA fragments. Enzyme-linked immunoabsorbent assay (ELISA) was used to detect H. pylori IgG antibody. Immunohistochemistry was also used to detect H. pylori specific protein in gallbladder mucosa specimens.

RESULTS: ELISA analysis showed that the rate of H. pylori infection did not differ significantly between the experimental group and control group (48.44% vs 43.75%, P < 0.05). PCR analysis showed that the rate of H. pylori colonization of the gallbladder mucosa was significantly higher in the experimental group than in the control group (39.06% vs 12.50%, P = 0.04), but the rate of H. pylori in bile did not significantly between the two groups (59.38% vs 56.25%, P < 0.05). Immunohistochemistry analysis detected 19 positive cases in the experimental group and only 1 positive case in the control group.

CONCLUSION: H. pylori infection in the biliary tract does not play a major role in the process of gallbladder stone formation, but H. pylori colonization in the gallbladder mucosa is involved in the formation of gallstones.

The association between cholecystectomy and gastroesophageal reflux symptoms: a prospective controlled study

OBJECTIVE

A large controlled prospective observational study to compare pre- and postsurgery changes in reflux symptoms between cholecystectomy and hernia repair surgery patients.

SUMMARY BACKGROUND DATA

Six studies have suggested that gastroesophageal reflux worsens after cholecystectomy. However, all these studies had design limitations.

METHODS

We recruited 302 patients scheduled to undergo elective cholecystectomy (study group) or hernia repair (controls) at 2 hospitals. Both groups filled out the validated Reflux Symptom Score (RSS) and Gastrointestinal Symptom Rating Scale (GSRS) questionnaires 1 to 15 days prior to and 4 to 12 weeks after the operation. Changes in symptom scores between the pre and postsurgery assessments were measured, and compared between the 2 groups.

RESULTS

Baseline RSS and GSRS reflux subscores were higher in the study group than controls (1.44 vs. 1.02 and 1.91 vs. 1.43, respectively; P < 0.05). There were no significant differences in any of the symptom score changes between the 2 groups except for the GSRS pain subscore, which decreased more in the study group than the control group (-0.59 vs. -0.10; P < 0.001). With regard to reflux, the RSS decreased by -0.34 in the study group and -0.14 in controls (P = 0.27), while the GSRS reflux subscore decreased by -0.32 in the study group and -0.05 in controls (P = 0.12). GSRS diarrhea and constipation subscores decreased slightly after surgery, to the same extent in both groups.

CONCLUSIONS

This large prospective controlled study, the only one using validated reflux symptom questionnaires, shows that cholecystectomy does not lead to an increase in reflux symptoms. As expected, GSRS pain subscores were decreased in the cholecystectomy group but not the controls.

H pylori exist in the gallbladder mucosa of patients with chronic cholecystitis

AIM: To study whether H pylori locate in the gallbladder mucosa of patients with chronic cholecystitis.

METHODS: Using Warthy-Starry (W-S) silver stain and immunohistochemistry stain with anti-H pylori antibodies, we screened paraffin specimens in 524 cases of cholecystitis. H pylori urease gene A (HPUA) and H pylori urease gene B (HPUB) were analyzed by polymerase chain reaction (PCR) in the fresh tissue specimens from 81 cases of cholecystitis.

RESULTS: H pylori-like bacteria were found in 13.55% of the gallbladders of the cholecystitis patients using W-S stain. Meanwhile, bacteria positive for H pylori antibodies were also found in 7.1% of the gallbladders of patients with cholecystitis by immunohistochemistry. Of 81 gallbladders, 11 were positive for both HPUA and HPUB, 4 were positive for HPUA only and 7 were positive for HPUB only.

CONCLUSION: H pylori exist in the gallbladders of patients with chronic cholecystitis.

Câncer de coto gátrico em ratos: papel da associação de Helicobacter pylori e refluxo êntero-gástrico

OBJETIVOS: Avaliar a relação entre o refluxo êntero-gástrico e Helicobacter pylori na gênese de neoplasias epiteliais e seus precursores, no rato submetido a gastrectomia subtotal com reconstrução a Billroth II. MÉTODO: Foram operados 20 ratos machos da raça Wistar, divididos igualmente em dois grupos: um grupo controle submetido à laparotomia exploradora e outro submetido à gastrectomia subtotal a BII. Após nove meses de operados, os animais foram mortos e seus estômagos estudados quanto à quantificação de H. pylori por glândula gástrica e à alterações epiteliais neoplásicas ou pré-neoplásicas. RESULTADOS: Os animais gastrectomizados tiveram percentual maior de colonização por H. pylori, assim como de alterações epiteliais que variaram do aumento do número de mitoses ao carcinoma invasor. CONCLUSÃO: O comprometimento glandular por H. pylori aumenta com o refluxo êntero-gástrico proporcionado pela gastectomia parcial, e está associado ao desenvolvimento de adenocarcinoma de coto gástrico em ratos.

Gastro-oesophageal reflux and duodenogastric reflux before and after eradication in Helicobacter pylori gastritis

OBJECTIVE

Helicobacter pylori and duodenogastric reflux (DGR) are both associated with chronic gastritis, peptic ulcer and gastric cancer. The nature of their interrelationship remains unclear. H. pylori eradication has also been reported to result in new or worsening acid gastro-oesophageal reflux (GOR). The aim of this study was to investigate the relationship between GOR, DGR and H. pylori infection.

METHOD

25 patients with H. pylori gastritis underwent ambulatory 24-hour oesophageal and gastric pHmetry and gastric bilirubin monitoring before and 12 weeks after H. pylori eradication, confirmed by 14C urea breath testing (UBT). Ten healthy subjects served as a control group.

RESULTS

There were no differences between patient and control groups for gastric alkaline exposure or gastric bilirubin exposure (P> 0.25 in all categories). Oesophageal acid reflux was higher in the study group (P< 0.02). No differences were detected in oesophageal acid reflux, gastric alkaline exposure, or gastric bilirubin exposure (P = 0.35, 0.18 and 0.11, respectively) before and after eradication.

CONCLUSIONS

Acid GOR is not increased by H. pylori eradication. DGR in patients with H. pylori gastritis is similar to that in healthy, non-infected subjects. H. pylori eradication produces no change in GOR or DGR. In patients with chronic gastritis, H. pylori infection and DGR appear to be independent of each other.

Effect of cholecystectomy on gastroesophageal and duodenogastric reflux

OBJECTIVE

The majority of patients experience resolution of their symptoms after cholecystectomy, but a minority either find their symptoms unchanged or complain of new upper GI symptoms. It has been suggested that the effect of cholecystectomy on upper GI motility, sphincter function, or bile delivery may account for these postoperative symptoms. We aimed to determine whether cholecystectomy affects gastroesophageal reflux or duodenogastric reflux by using 24-h ambulatory pH and gastric bilirubin monitoring before and after surgery.

METHODS

Seventeen symptomatic patients with gallstones underwent 24-h ambulatory esophageal and gastric pH-metry and gastric bilirubin monitoring. Helicobacter pylori status was ascertained in all patients by 14C urea breath test and serology. Combined pH and bilirubin monitoring was repeated 3 months after cholecystectomy. Eleven healthy subjects served as a control group.

RESULTS

Three (17%) patients complained of persistent or new symptoms after surgery, whereas 14 (83%) patients were asymptomatic. Two patients (12%) underwent open cholecystectomy, and (88%) had the operation performed laparoscopically. No significant differences were detected in esophageal acid exposure (pH < 4), gastric alkaline shift (pH > 4), or gastric bilirubin exposure (absorbance > 0.14) after surgery. Three (17%) patients tested positive for Helicobacter pylori; the presence of infection did not appear to affect pre- or postoperative values.

CONCLUSIONS

Cholecystectomy does not result in increased bile reflux into the stomach or increased gastroesophageal acid reflux. Those patients who had increased postoperative duodenogastric reflux were entirely asymptomatic. The symptoms of postcholecystectomy syndrome are unlikely to be related to increased duodenogastric reflux after surgery.

Cholecystectomy, peptic ulcer disease and the risk of adenocarcinoma of the oesophagus and gastric cardia

BACKGROUND

Gastro-oesophageal reflux is a strong risk factor for oesophageal adenocarcinoma. Bile and pancreatic enzymes may be particularly carcinogenic. Cholecystectomy causes an increased gastric level of these constituents. A decreased risk of oesophageal adenocarcinoma has been observed in persons infected with cagA-positive Helicobacter pylori. There is a strong correlation between ulcer disease and Helicobacter pylori infection. The aim of this study was to determine whether previous cholecystectomy or peptic ulcer disease affects the risk of oesophageal carcinoma.

METHODS

Data were collected as a nationwide population-based case-control study in Sweden between 1995 and 1997. Multivariate adjusted odds ratios (ORs) were calculated with logistic regression.

RESULTS

There was no statistically significant association between cholecystectomy and the risk of oesophageal carcinoma. Among persons with previous peptic ulcer, the adjusted OR for oesophageal adenocarcinoma was below unity (OR = 0.6, 95 per cent confidence interval 0.3-1.1). The relative risk estimates for cardia adenocarcinoma and oesophageal squamous cell carcinoma were close to unity.

CONCLUSION

Cholecystectomy, despite its effect on the composition of gastric juice, does not appear to increase the risk of adenocarcinoma of the oesophagus or gastric cardia. While the data do not contradict a protective effect of H. pylori, the results are also consistent with absence of such an effect.

Hepatic Helicobacter species identified in bile and gallbladder tissue from Chileans with chronic cholecystitis

BACKGROUND & AIMS

Cancer of the gallbladder is the number one cause of cancer mortality in Chilean women. Incidence rates for this tumor vary widely on a worldwide basis, being approximately 30 times higher in high-risk than in low-risk populations, suggesting that environmental factors such as infectious microorganisms, carcinogens, and nutrition play a role in its pathogenesis. Because several Helicobacter sp. colonize the livers of animals and induce hepatitis, the aim of this study was to determine whether Helicobacter infection was associated with cholecystitis in humans.

METHODS

Bile or resected gallbladder tissue from 46 Chileans with chronic cholecystitis undergoing cholecystectomy were cultured for Helicobacter sp. and subjected to polymerase chain reaction (PCR) analysis using Helicobacter-specific 16S ribosomal RNA primers.

RESULTS

Recovery of Helicobacter sp. from frozen specimens was unsuccessful. However, by PCR analysis, 13 of 23 bile samples and 9 of 23 gallbladder tissues were positive for Helicobacter. Eight of the Helicobacter-specific PCR amplicons were sequenced and subjected to phylogenetic analysis. Five sequences represented strains of H. bilis, two strains of "Flexispira rappini" (ATCC 49317), and one strain of H. pullorum.

CONCLUSIONS

These data support an association of bile-resistant Helicobacter sp. with gallbladder disease. Further studies are needed to ascertain whether similar Helicobacter sp. play a causative role in the development of gallbladder cancer.

Gastroesophageal reflux and tracheal contamination during laparoscopic cholecystectomy and diagnostic gynecological laparoscopy

Laparoscopy causes an increase in intraabdominal pressure and may lead to an increase in gastroesophageal reflux (GER). We designed this study to assess and compare the frequency of GER and tracheal contamination in patients undergoing laparoscopic cholecystectomy (LC) and gynecological laparoscopy (LG). We studied 20 LC and 17 LG patients. The pH was measured using monocrystalline antimony pH electrodes positioned in the middle to upper esophagus and on the posterior wall of the trachea distal to the tip of the endotracheal tube. Acid reflux was defined as a decrease in esophageal pH to 4.0 or less. Alkaline reflux was defined as an abrupt increase in esophageal pH of more than 1.0, not associated with previous acid reflux. More than 80% of all patients at baseline had a gastric pH < or = 2. Overall, acid GER alone occurred in 47% patients in the LG group and in 15% patients in the LC group. During recovery, a larger proportion of patients had acid reflux in the LG group (47%) than in the LC group (10%). In contrast, alkaline reflux occurred in 75% of LC patients and 11.7% of LG patients. After cholecystectomy, there is an acute increase in the incidence of alkaline reflux. This alkaline reflux may be due to duodenogastric reflux resulting in an alkaline gastric shift.

IMPLICATIONS

We studied the incidence of reflux of stomach contents in patients undergoing laparoscopic (keyhole) surgery for cholecystectomy or gynecology, using pH probes in the esophagus (gullet) and the trachea (windpipe). Acid reflux was very common but did not pass into the trachea. After gallbladder removal, the refluxed material became alkaline.

Symptoms of oesophageal reflux are more common following laparoscopic cholecystectomy than in a control population

Previous studies have shown that up to 40 per cent of patients have symptoms after cholecystectomy or laparoscopic cholecystectomy (LC). There are concerns, however, that these symptoms reflect those of the general population and are not a specific post-operative phenomenon. Abdominal symptoms of 212 patients following LC were compared to a healthy acalculous control population (n = 62). Patients and controls were assessed by questionnaire. Age and sex profiles were similar in both groups. There was no significant difference in the incidence of abdominal pain, bloating or nausea between the 2 groups. Frequent heartburn was a symptom in 19.3 per cent of patients following LC as compared to 3.2 per cent of control patients (p = 0.004, chi-squared 9.39, 1 d.f.). Furthermore 11.3 per cent of post-operative patients complained of dysphagia versus 6.4 per cent of the control group (p = 0.08, chi-squared 1.245, 1 d.f.). One hundred and twenty (57.1 per cent) patients judged their operation to be a complete success, while 9 (4.3 per cent) were dissatisfied. Five of the latter group cited frequent heartburn as the cause of their dissatisfaction. We conclude that abdominal pain, bloating and nausea occur as frequently in the general population as in patients following LC. Patients are more likely to suffer from heartburn and dysphagia following LC than a normal population supporting a link between cholecystectomy and lower oesophageal dysfunction.