High prevalence of Helicobacter pylori in liver cirrhosis: relationship with clinical and endoscopic features and the risk of peptic ulcer

Helicobacter pylori infection and peptic ulcer disease in cirrhotic patients: An updated meta-analysis

BACKGROUND

Peptic ulcer (PU) is more prevalent in patients with liver cirrhosis. The role of Helicobacter pylori (H. pylori) infection in the pathogenesis of PU in patients with cirrhosis is still not elucidated.

AIM

To perform a meta-analysis on the prevalence of H. pylori infection and PU and their association in liver cirrhosis patients.

METHODS

We searched PubMed, EMBASE, Web of Science, Cochrane, CNKI, Wangfang, and CQVIP databases from inception to July 10, 2020. Odds ratio (OR) and 95% confidence interval (CI) were pooled using a random-effects model. The statistical heterogeneity among studies (I²-index), subgroup analyses, regression analysis, sensitivity analysis, and the possibility of publication bias were assessed.

RESULTS

A total of 14 studies (13 cross-sectional studies; 1 cohort study) involving 2775 individuals (611 cases with PU and 2164 controls) were included in our meta-analysis. The prevalence of PU in patients with cirrhosis was 22%. The prevalence of H. pylori infection was 65.6% in cirrhotic patients with PU, and 52.5% in those without. The pooled overall OR was 1.73 (95%CI: 1.16-2.56, I² = 66.2%, P < 0.001, Z = 2.7, P_z < 0.05). We did not find the cause of heterogeneity in the subgroup analyses and meta-regression analysis except for one study. Funnel plot did not show significant publication bias. The results of Begg’s test and Egger’s test indicated no evidence of substantial publication bias (P_Begg = 0.732, P_Egger = 0.557).

CONCLUSION

There is a weakly positive association between H. pylori infection and PU in patients with liver cirrhosis. It is suggested that H. pylori infection may play a role in the pathogenesis of PU in liver cirrhotic patients.

Endoscopic findings unrelated to portal hypertension in patients with liver cirrhosis undergoing a varicose vein screening programme

AIM

To determine the prevalence of endoscopic lesions unrelated with portal hypertension in patients with cirrhosis.

PATIENTS AND METHODS

Cross-sectional study including a consecutive cohort of patients with liver cirrhosis enrolled in a screening program of oesophageal varices who underwent an upper gastrointestinal endoscopy from November, 2013, to November, 2018. Clinical predictors of endoscopic lesions unrelated to portal hypertension were analyzed by univariate and multivariate logistic regression.

RESULTS

A total of 379 patients were included. The most frequent aetiology of liver disease was alcohol consumption (60.4%). The prevalence of endoscopic lesions unrelated with portal hypertension was 39.6% (n=150). Among 96 patients with peptic lesions, urease was obtained in 56.2% of patients (positive in 44.4% of them). The prevalence of endoscopic lesions unrelated to portal hypertension was not associated with age, gender, liver function or ultrasound findings of portal hypertension. The prevalence of endoscopic lesions unrelated to portal hypertension was not associated with age, gender, liver function or ultrasound findings of portal hypertension. Smokers had a trend to increased prevalence of endoscopic lesions unrelated to portal hypertension (43.2% vs. 34.6%; p=0.09), particularly peptic ulcer (6.4% vs. 0.6%; p=0.05) and peptic duodenitis (17.3% vs. 6.3%; p=0.002). Active smoking was the only independent predictor of peptic ulcer or duodenitis (OR=2.56; p=0.017).

CONCLUSION

Active smoking is a risk factor for endoscopic lesions unrelated to portal hypertension. This finding should be further investigated to reassess endoscopic screening programs in cirrhotic smokers.

Identification and Analysis of Human Microbe-Disease Associations by Matrix Decomposition and Label Propagation

Studies have shown that microbes exist widely in the human body and are closely related to human complex diseases. Predicting potential associations between microbes and diseases is conducive to understanding the mechanisms of complex diseases and can also facilitate the diagnosis and prevention of human diseases. In this paper, we put forward the Matrix Decomposition and Label Propagation for Human Microbe-Disease Association prediction (MDLPHMDA) on the basis of the dataset of known microbe-disease associations collected from the database of HMDAD and the Gaussian interaction profile kernel similarity for diseases and microbes, disease symptom similarity. Moreover, the performance of our model was evaluated by means of leave-one-out cross validation and five-fold cross validation, and the corresponding AUCs of 0.9034 and 0.8954 ± 0.0030 were gained, respectively. In case studies, 10, 9, 9, and 8 out of the top 10 predicted microbes for asthma, colorectal carcinoma, liver cirrhosis, and type 1 diabetes were confirmed by literatures, respectively. Overall, evaluation results showed that MDLPHMDA has good performance in potential microbe-diseasepositive free parameter, which associations prediction.

Helicobacter pylori Infection as a Risk Factor for Hepatocellular Carcinoma: A Case-Control Study in Ethiopia

Background and Aims. Hepatocellular carcinoma is a major cause of cancer death worldwide, accounting for over half a million deaths per year. Its incidence varies with geographic locations and the type of etiologic factors. In Ethiopia, unidentified causes of liver disease are of sizeable proportion. Recent studies have shown an association of H. pylori infection with different spectrums of chronic liver disease. This study was conducted at St. Paul's Hospital Millennium Medical College in Ethiopia and assesses liver cancer and the association with H. pylori infection. Method. A prospective case-control study conducted on patients with chronic liver disease presenting with a suspicious liver lesion and diagnosed to have HCC in the Gastrointestinal (GI) Clinic of St. Paul's Hospital MMC from Dec 30, 2016, to Nov 1, 2017 G.C. Descriptive surveys on clinical history and physical examination and laboratory profiles were obtained, and the clinical course of the patients including the type of treatment was followed prospectively. Control cases were taken from adult patients without evidence of liver disease in the internal medicine clinic coming for routine evaluation. After collection data were analyzed using SPSS version 23 and associations were assessed using chi-square test. Binary logistic regression was used to assess the association of HCC with different variables and H. pylori infection. All variables with p-value <0.05 were considered as statistically significant. Results. One hundred twenty patients were analyzed with equal representation of cases and controls. The majority of patients with HCC were male with a mean age of 36 years. Older age adjusted Odds Ratio (AOR) (95%CI, p-value) 1.07(1.03-1.09, <0.001), viral hepatitis B (AOR) (95%CI, p-value) 6.19 (1.92-19.93, 0.002), and H. pylori infection (AOR) (95%CI, p-value) 5.22 (2.04-13.31, <0.001) were statistically significantly associated with HCC. Conclusion. H. pylori infection is associated with HCC in this case-control study. This study supports the emerging evidence of H. pylori association with other extra-gastric manifestations.

Association between Severity of Liver Disease, Frequency of Helicobacter pylori Infection, and Degree of Gastric Lesion in Egyptian Patients with Hepatitis B Virus Infection

The relationship between hepatitis B virus (HBV) infection, severity of liver disease, frequency of Helicobacter pylori infection, and degree of gastric lesions was not yet fully investigated in Egyptian patients. The present work was performed on 100 Egyptian patients with HBV from the National Hepatology and Tropical Medicine Institute and 70 healthy volunteers as control group. The participants were subjected to full medical history taking, clinical examination, and laboratory investigations. All patients were positive for HBV surface antigen (HBV sAg), HBV DNA, and negative for hepatitis C virus antibodies. The severity of the liver disease was assessed using Child-Pugh scoring system. Screening of all participants for H. pylori Ag in stool was performed. Biopsy specimens were taken from the gastric lesions of H. pylori-infected patients for histopathological examination. The mean age of the patients and control group were 34.9 and 33.4 years, respectively. The levels of the liver enzymes were statistically higher in HBV patients than the control group. Helicobacter pylori Ag in stool was detected in 45.7% of the control group, and a higher percentage (60%) was detected in the patients group. Chronic gastritis with glandular atrophy and metaplasia was found in 15.6% of patients of Child-Pugh A, 70% of Child-Pugh B, and 100% of Child-Pugh C. It could be concluded that the prognosis of the liver disease significantly influences the severity of the gastric pathology in H. pylori infection.

First-line Helicobacter pylori eradication among patients with chronic liver diseases in Taiwan

Helicobacter pylori eradication in patients with chronic liver diseases (CLDs) and liver cirrhosis is seldom reported. This study aimed to assess the efficacy of 7-day standard triple therapy in patients with CLD including cirrhosis and to investigate the clinical factors influencing the success of eradication. A total of 592 H. pylori-infected patients, who received 7-day standard first-line triple therapy between January 1, 2014, and December 31, 2014, were recruited. Patients were divided into two groups: CLD group (N=136) and non-CLD group (N=456). The eradication rates attained by the CLD and non-CLD groups were 86.0% and 84.2%, respectively, in the per-protocol analysis (p=0.606). The eradication rates of liver cirrhosis and noncirrhosis CLD were 88.5% and 84.3%, respectively (p=0.783). The adverse events were similar between the two groups (8.8% vs. 9.2%, p=0.891). Compliance between the two groups was good (99.3% vs. 99.6%, p=0.670). The univariate analysis showed male sex to be the significant clinical factor in the non-CLD group (p=0.001) and alcohol consumption to be the significant clinical factor influencing H. pylori eradication rate in patients with CLD (p=0.022). Alcohol consumption was the only significant factor influencing H. pylori eradication in multivariate analysis (odds ratio=3.786, p=0.031). The results of this study suggest that H. pylori eradication rates in patients with CLD may be comparable with non-CLD patients. Alcohol consumption was the significant factor influencing H. pylori eradication in patients with CLD.

Distinctive aspects of peptic ulcer disease, Dieulafoy's lesion, and Mallory-Weiss syndrome in patients with advanced alcoholic liver disease or cirrhosis

AIM: To systematically review the data on distinctive aspects of peptic ulcer disease (PUD), Dieulafoy’s lesion (DL), and Mallory-Weiss syndrome (MWS) in patients with advanced alcoholic liver disease (aALD), including alcoholic hepatitis or alcoholic cirrhosis.

METHODS: Computerized literature search performed via PubMed using the following medical subject heading terms and keywords: “alcoholic liver disease”, “alcoholic hepatitis”,“ alcoholic cirrhosis”, “cirrhosis”, “liver disease”, “upper gastrointestinal bleeding”, “non-variceal upper gastrointestinal bleeding”, “PUD”, ‘‘DL’’, ‘‘Mallory-Weiss tear”, and “MWS’’.

RESULTS: While the majority of acute gastrointestinal (GI) bleeding with aALD is related to portal hypertension, about 30%-40% of acute GI bleeding in patients with aALD is unrelated to portal hypertension. Such bleeding constitutes an important complication of aALD because of its frequency, severity, and associated mortality. Patients with cirrhosis have a markedly increased risk of PUD, which further increases with the progression of cirrhosis. Patients with cirrhosis or aALD and peptic ulcer bleeding (PUB) have worse clinical outcomes than other patients with PUB, including uncontrolled bleeding, rebleeding, and mortality. Alcohol consumption, nonsteroidal anti-inflammatory drug use, and portal hypertension may have a pathogenic role in the development of PUD in patients with aALD. Limited data suggest that Helicobacter pylori does not play a significant role in the pathogenesis of PUD in most cirrhotic patients. The frequency of bleeding from DL appears to be increased in patients with aALD. DL may be associated with an especially high mortality in these patients. MWS is strongly associated with heavy alcohol consumption from binge drinking or chronic alcoholism, and is associated with aALD. Patients with aALD have more severe MWS bleeding and are more likely to rebleed when compared to non-cirrhotics. Pre-endoscopic management of acute GI bleeding in patients with aALD unrelated to portal hypertension is similar to the management of aALD patients with GI bleeding from portal hypertension, because clinical distinction before endoscopy is difficult. Most patients require intensive care unit admission and attention to avoid over-transfusion, to correct electrolyte abnormalities and coagulopathies, and to administer antibiotic prophylaxis. Alcoholics should receive thiamine and be closely monitored for symptoms of alcohol withdrawal. Prompt endoscopy, after initial resuscitation, is essential to diagnose and appropriately treat these patients. Generally, the same endoscopic hemostatic techniques are used in patients bleeding from PUD, DL, or MWS in patients with aALD as in the general population.

CONCLUSION: Nonvariceal upper GI bleeding in patients with aALD has clinically important differences from that in the general population without aALD, including: more frequent and more severe bleeding from PUD, DL, or MWS.

Association between cirrhosis and Helicobacter pylori infection: a meta-analysis

Cirrhosis is a severe threat to public health. Some studies have suggested that cirrhosis is associated with Helicobacter pylori infection, but the results remain controversial. This meta-analysis was conducted to quantify the association between cirrhosis and H. pylori infection. Published articles on H. pylori prevalence in patients with cirrhosis were collected to assess the potential associations between H. pylori infection and cirrhosis risk. Twenty-one eligible studies were included for the analysis. Data on publication year, geographic region, and etiology were summarized. Metaregression models and subgroup analyses were established to screen the factors for heterogeneity. Of the 322 articles retrieved, 21 met the inclusion criteria. These studies involved 6135 cases, with a total H. pylori infection rate of 52.26%. This meta-analysis showed significant difference in H. pylori infection between patients with cirrhosis and controls [odd ratio (OR)=2.05, 95% confidence interval (CI): 1.33-3.18, P<0.0001]. The subgroup analysis revealed, in contrast to Asia (OR=0.90, 95% CI: 0.48-1.66, P<0.0001), Europe (OR=2.98, 95% CI: 2.02-4.39, P<0.0001), and America (OR=4.75, 95% CI: 1.42-15.95, P=0.249), a significantly higher prevalence of H. pylori infection in patients with cirrhosis. On the basis of etiology, there was a higher prevalence of H. pylori infection due to primary biliary cirrhosis (OR=1.75, 95% CI: 1.15-2.64, P=0.147) and viral cirrhosis (OR=2.66, 95% CI: 1.24-5.71, P<0.0001) compared with alcohol cirrhosis (OR=0.77, 95% CI: 0.04-16.59, P<0.0001). The pooled data suggest that there is a significantly high prevalence of H. pylori infection in patients with cirrhosis. Large-scale and multicenter studies are needed to further investigate the relation between cirrhosis and H. pylori infection.

Peptic ulcer disease in liver cirrhosis and chronic hepatitis: impact of portal hypertension

OBJECTIVE

The pathophysiology of peptic ulcer disease (PUD) in liver cirrhosis (LC) and chronic hepatitis has not been established. The aim of this study was to assess the role of portal hypertension from PUD in patients with LC and chronic hepatitis.

MATERIALS AND METHODS

We analyzed the medical records of 455 hepatic vein pressure gradient (HVPG) and esophagogastroduodenoscopy patients who had LC or chronic hepatitis in a single tertiary hospital. The association of PUD with LC and chronic hepatitis was assessed by univariate and multivariate analysis.

RESULTS

A total of 72 PUD cases were detected. PUD was associated with LC more than with chronic hepatitis (odds ratio [OR]: 4.13, p = 0.03). In the univariate analysis, taking an ulcerogenic medication was associated with PUD in patients with LC (OR: 4.34, p = 0.04) and smoking was associated with PUD in patients with chronic hepatitis (OR: 3.61, p = 0.04). In the multivariate analysis, taking an ulcerogenic medication was associated with PUD in patients with LC (OR: 2.93, p = 0.04). However, HVPG was not related to PUD in patients with LC or chronic hepatitis.

CONCLUSION

According to the present study, patients with LC have a higher risk of PUD than those with chronic hepatitis. The risk factor was taking ulcerogenic medication. However, HVPG reflecting portal hypertension was not associated with PUD in LC or chronic hepatitis (Clinicaltrial number NCT01944878).

Multiple infections and cancer: implications in epidemiology

Approximately 18% of the global cancer burden has been attributed to infectious agents, with estimates ranging from 7% in developed countries to about 22% in developing countries. Chronic infections caused by the hepatitis B and C viruses, human papilloma viruses (HPV), and Helicobacter pylori (H. pylori) are reported to be responsible for approximately 15% of all human cancers. Interestingly, although many of the infectious agents that have been associated with cancer--such as HPV, Epstein-Barr virus (EBV), and H. pylori--are highly prevalent in the world, most infected individuals do not develop cancer but remain lifelong carriers. Malignancies associated with infectious agents may result from prolonged latency as a result of chronic infections. Pathogenic infections are necessary but are not sufficient for cancer initiation or progression. Cancer initiation may require additional cofactors, including secondary infections. Therefore, in patients with chronic infection with one agent, secondary co-infection with another agent may serve as an important co-factor that may cause cancer initiation and progression. Additionally, opportunistic co-infections could significantly inhibit response to cancer treatment and increase cancer mortality. Co-infections are relatively common in areas with a high prevalence of infectious agents, especially in developing countries. These co-infections can cause an imbalance in the host immune system by affecting persistence of and susceptibility to malignant infections. Several articles have been published that focus on infectious agents and cancer. In this article, we discuss the role of infectious agents in malignancies, highlight the role of multiple/co-infections in cancer etiology, and review implications for cancer epidemiology.

Helicobacter pylori is not the predominant etiology for liver cirrhosis patients with peptic ulcer disease

OBJECTIVES

Patients with liver cirrhosis (LC) often develop peptic ulcers. The differentiation of Helicobacter pylori etiology in LC patients from that of peptic ulcers in non-LC patients is critical. This study aimed to determine whether H. pylori plays a central role in LC patients with peptic ulcers.

METHODS

LC was defined by International Classifications of Diseases, Revision 9, and Clinical Modification (ICD-9-CM) codes 571.2, 571.5, and 571.6. To be defined as non-LC, we did not identify patients in an inpatient setting or by one or more ambulatory care claims containing the International Classifications of Diseases, Revision 9, and Clinical Modification codes 571.2, 571.5, and 571.6. The sample included 9465 H. pylori-positive patients and 3418 H. pylori-negative patients. A logistic regression model was used to calculate the odds ratio (OR) and a 95% confidence interval was used to determine whether LC was an independent factor of lower H. pylori infection rates in peptic ulcer patients.

RESULTS

This study included 102 decompensated LC patients with peptic ulcers, 39 H. pylori-positive and 63 H. pylori-negative. There were 360 compensated LC patients with peptic ulcers, 193 H. pylori-positive and 167 H. pylori-negative. Among the non-LC patients with peptic ulcers, 9233 were H. pylori-positive and 3188 were H. pylori-negative. On the basis of logistic regression analysis, decompensated LC patients (OR=0.23, P<0.001) and compensated LC patients (OR=0.48, P<0.001) had lower H. pylori infection rates.

CONCLUSION

H. pylori is not the predominant etiology for LC, especially the decompensated type, either with peptic ulcer disease or with recurrent ulcer disease.

Non-variceal gastrointestinal bleeding in patients with liver cirrhosis: a review

BACKGROUND

Non-variceal gastrointestinal (NVGI) bleeding in cirrhosis may be associated with life-threatening complications similar to variceal bleeding.

AIM

To review NVGI bleeding in cirrhosis.

METHODS

MEDLINE, Scopus, and ISI Web of Knowledge were searched, using the textwords "portal hypertensive gastropathy," "gastric vascular ectasia," "peptic ulcer," "Dieulafoy's," "Mallory-Weiss syndrome," "portal hypertensive enteropathy," "portal hypertensive colopathy," "hemorrhoids," and "cirrhosis."

RESULTS

Portal hypertensive gastropathy (PHG) and gastric vascular ectasia (GVE) are gastric lesions that most commonly present as chronic anemia; acute upper GI (UGI) bleeding is a rare manifestation. Management of PHG-related bleeding is mainly pharmacological, whereas endoscopic intervention is favored in GVE-related bleeding. Shunt therapies or more invasive techniques are restricted in refractory cases. Despite its high incidence in cirrhotic patients, peptic ulcer accounts for a relatively small proportion of UGI bleeding in this patient population. However, in contrary to general population, the pathogenetic role of Helicobacter pylori infection remains questionable. Finally, other causes of UGI bleeding include Dieulafoy's lesion, Mallory-Weiss syndrome, and portal hypertensive enteropathy. The most common non-variceal endoscopic findings reported in patients with lower gastrointestinal bleeding are portal hypertensive colopathy and hemorrhoids. However, the vast majority of studies are case reports and, therefore, the incidence, diagnosis, and risk of bleeding remain undefined. Endoscopic interventions, shunting procedures, and surgical techniques have been described in this setting.

CONCLUSIONS

The data on NVGI bleeding in liver cirrhosis are surprisingly scanty. Large, multicenter epidemiological studies are needed to better assess prevalence and incidence and, most importantly, randomized studies should be performed to evaluate the success rates of therapeutic algorithms.

Cirrhotic patients at increased risk of peptic ulcer bleeding: a nationwide population-based cohort study

BACKGROUND

Few large population-based studies have compared the occurrence of peptic ulcer bleeding (PUB) in cirrhotic and noncirrhotic patients.

AIMS

To investigate if cirrhotic patients have higher risk of PUB than the general population and to identify possible risk factors of PUB in cirrhotic patients.

METHODS

Using the National Health Insurance Research Database, a nationwide population-based dataset in Taiwan and matching age, gender, comorbidities and ulcerogenic medication by propensity score, 4013 cirrhotic patients, 8013 chronic hepatitis patients and 7793 normal controls were compared. The log-rank test was used to analyse differences in accumulated PUB-free survival rates between the groups. Cox proportional hazard regressions were performed to evaluate independent risk factors for PUB in all patients and identified risk factors of PUB in cirrhotic patients.

RESULTS

During the 7-year follow-up, cirrhotic patients had significantly higher incidences of PUB than chronic hepatitis patients and controls, respectively (P < 0.001 by log-rank test). By Cox proportional hazard regression analysis, cirrhosis was independently associated with increased risk of PUB (hazard ratio: 4.22; 95% CI 3.37-5.29, P < 0.001) after adjusting for age, gender, economic status, underlying comorbidities and ulcerogenic medication. Age, male, diabetes, chronic renal disease, history of gastro-oesophageal variceal bleeding and use of nonsteroidal anti-inflammatory drugs were risk factors for PUB in cirrhotic patients.

CONCLUSION

Cirrhotic patients have a significantly higher risk of peptic ulcer bleeding after adjustments for possible confounding factors like age, gender, economic status, underlying comorbidities and ulcerogenic medication.

Divergent effects of irritants on the gastric mucosa in rats during various stages after bile duct ligation

BACKGROUND AND AIM

Controversy exists as to whether rats after bile duct ligation (BDL) are more susceptible to gastric mucosal damage (GMD) induced by irritants. In the present study we characterize GMD after intragastric instillation of either ethanol or hydrochloric acid (HCL), 3 and 21 days after the surgical procedure.

METHODS

Bile duct ligation and sham operated (SO) rats were studied.

RESULTS

Three days after surgery, BDL rats exhibited a reduction in gastric mucosal nitric oxide synthase (NOS) activity but an increase in ethanol-induced GMD. Twenty-one days after surgery gastric mucosal prostaglandin (PG) E(2) generation in BDL rats was increased while NOS activity in both groups was similar. Ethanol-induced GMD in SO rats was higher. Pretreatment with NG-nitro-L-arginine methyl ester, prior to ethanol administration was associated with an increase in gastric mucosal PGE(2) generation: (147% in SO and 104% in BDL rats) and in GMD (176% in SO and 303% in BDL rats). HCL induced GMD was of similar magnitude in both groups in both time periods.

CONCLUSIONS

The gastric resistance to damage by irritants in rats with BDL is not a static phenomenon. This may result from sequential changes that occur in the gastric mucosal defense mechanisms during the evolution of liver disease.

Correlation of CYP2C19 genetic polymorphisms with helicobacter pylori eradication in patients with cirrhosis and peptic ulcer

BACKGROUND

To investigate whether or not CYP2C19 genotype status is associated with cure rate for Helicobacter pylori infection in patients with cirrhosis and peptic ulcer, achieved with 2 weeks of triple therapy with rabeprazole, amoxicillin and clarithromycin.

METHODS

We prospectively studied 95 consecutive patients with cirrhosis and H. pylori-infected active peptic ulcers. H. pylori infection was confirmed if any 2 of the following were positive: H. pylori DNA, histology, and rapid urease test. Patients were assigned to an open-label 2-week course of oral amoxicillin 1,000 mg b.i.d., rabeprazole 20 mg b.i.d. and clarithromycin 500 mg b.i.d. Subsequently, all patients received oral rabeprazole 20 mg once daily until week 8. Three months and 1 year after therapy, all patients with cirrhosis were followed up endoscopically for peptic ulcer, rapid urease test, and (13)C-urea breath test. The CYP2C19 genotype status for 2 mutations associated with the extensive metabolizer phenotype was determined by polymerase chain reaction and restriction fragment length polymorphism analysis.

RESULTS

Cure rates for H. pylori infection were 80.9% (95% CI, 22.8-88.6%), 89.8% (95% CI, 50.8-90.2%), and 100% (95% CI, 62.8-100%) in the rapid-, intermediate-, and poor-metabolizer groups, respectively. Healing rates for duodenal and gastric ulcer in the 3 groups were roughly parallel with cure rates for H. pylori infection.

CONCLUSION

The results of the genotyping test for CYP2C19 seem to predict cure of H. pylori infection and peptic ulcer in patients with cirrhosis who receive triple therapy with rabeprazole, amoxicillin, and clarithromycin.

Helicobacter pylori and Hepatitis C Virus Coinfection in Egyptian Patients

INTRODUCTION

Chronic hepatitis C virus (HCV) infection is a leading cause of end-stage liver disease worldwide. It has been shown that Helicobacter pylori (H. pylori) plays an important role in chronic gastritis, peptic ulcer disease and gastric malignancies, and its eradication has been advocated. The association between H. pylori infection and liver cirrhosis in patients with hepatitis C virus has been documented in different parts of the world; nevertheless, no conclusive data is available in Egypt.

MATERIALS AND METHODS

In the present study, the status of H. pylori infection was sought in 90 patients with chronic HCV infection and in 66 HCV-free healthy controls.

RESULTS

The study showed that the H. pylori positivity was increased significantly (P = 0.03) in the HCV-infected patients when compared to that in healthy controls, where H. pylori infection was found in 50 (55.6%) out of 90 of the HCV-infected patients versus 26 (39.4%) out of 66 of the healthy controls. In HCV-infected patients, the prevalence of H. pylori infection was increased significantly (P = 0.04) from chronic active hepatitis to cirrhosis. H. pylori infection was present in 6/18 (33.3%), 10/21 (47.6%), 16/27 (59.3%), 18/24 (75.0%) patients with chronic active hepatitis, Child-Pugh score A, Child-Pugh score B and Child-Pugh score C, respectively. More importantly, the prevalence of H. pylori infection in HCV-infected patients was increased very significantly (P = 0.003) with increasing Meld (model for end-stage liver disease) score. The prevalence of H. pylori was documented in 9/28 (32.1%) patients with Meld score >10 and in 41/62 (66.1%) patients with Meld score >10.

CONCLUSION

It may be stated that our results collectively reflect a remarkable increase in H. pylori prevalence with advancing hepatic lesions, and the eradication treatment may prove beneficial in those patients with chronic hepatitis C.

Inadequate use of proton-pump inhibitors in patients with liver cirrhosis

OBJECTIVES

Patients with liver cirrhosis have a high prevalence of gastrointestinal symptoms. The use of antiacid therapy (AAT) in these patients is unexplored. We aimed to assess the use of AAT in cirrhotic patients.

METHODS

A total of 128 consecutive cirrhotic patients were evaluated for the use of and indications for acid-suppressive agents. Upper endoscopy findings and concomitant medications were registered. A validated questionnaire was used to measure the gastrointestinal symptom burden. Adequate indications for AAT were those strongly supported by the medical literature.

RESULTS

Forty percent (n=51) of patients with cirrhosis were on AAT. Thirty-seven percent (n=19) of these had adequate and 63% (n=32) inadequate indications for AAT. The major inadequate indication was previous variceal bleeding (34%). Patients with inadequate indications for AAT had increased severity of symptoms of indigestion compared with patients without AAT (P<0.05). Multivariate analysis revealed that inadequate use of AAT was independently related only to previous variceal bleeding and the number of concomitant medications.

CONCLUSION

AAT is used by a large proportion of patients with cirrhosis. In the majority, therapy is based on inadequate indications, mainly continuous long-term therapy after previous variceal bleeding. Patients with an inadequate indication for acid-suppressive medications have increased severity of symptoms of indigestion, indicating that gastrointestinal symptoms might be a factor contributing to proton-pump inhibitor consumption in these patients.

Proton pump inhibitors in cirrhosis: Tradition or evidence based practice?

Proton Pump Inhibitors (PPI) are very effective in inhibiting acid secretion and are extensively used in many acid related diseases. They are also often used in patients with cirrhosis sometimes in the absence of a specific acid related disease, with the aim of preventing peptic complications in patients with variceal or hypertensive gastropathic bleeding receiving multidrug treatment. Contradicting reports support their use in cirrhosis and evidence of their efficacy in this condition is poor. Moreover there are convincing papers suggesting that acid secretion is reduced in patients with liver cirrhosis. With regard to Helicobacter pylori (H pylori) infection, its prevalence in patients with cirrhosis is largely variable among different studies, and it seems that H pylori eradication does not prevent gastro-duodenal ulcer formation and bleeding. With regard to the prevention and treatment of oesophageal complications after banding or sclerotherapy of oesophageal varices, there is little evidence for a protective role of PPI. Moreover, due to liver metabolism of PPI, the dose of most available PPIs should be reduced in cirrhotics. In conclusion, the use of this class of drugs seems more habit related than evidence-based eventually leading to an increase in health costs.

Helicobacter pylori infection and peptic ulcer disease in patients with liver cirrhosis

BACKGROUND/AIMS

We investigated the prevalence and relationship of peptic ulcer disease and Helicobacter pylori infection to liver cirrhosis.

METHODS

We examined 288 patients with liver cirrhosis, 322 patients with non-ulcer dyspepsia, and 339 patients with peptic ulcer disease. Rapid urease test and Wright-Giemsa staining were used for diagnosis of H. pylori infection.

RESULTS

The prevalence of peptic ulcer disease in patients with cirrhosis was 24.3%. The prevalence of peptic ulcer disease in patients with cirrhosis divided into Child-Pugh classes A, B, and C was 22.3%, 21.0%, and 31.3%, respectively (p > 0.05). The prevalence of H. pylori infection in the patients with cirrhosis, non-ulcer dyspepsia, and peptic ulcer without chronic liver disease were 35.1%, 62.4%, and 73.7%, respectively (p < 0.001). The prevalence of H. pylori infection did not differ depending on whether there was peptic ulcer (35.6%) or not (34.9%) in patients with liver cirrhosis (p > 0.05). The prevalence of H. pylori infection in patients with hepatitis virus-related liver cirrhosis and in the patients with alcohol-related liver cirrhosis was 42.5% and 22.0%, respectively (p < 0.001). The prevalence of H. pylori infection in patients with Child-Pugh classes A, B, and C liver cirrhosis was 51.5%, 30.5%, and 20.0%, respectively (p < 0.001).

CONCLUSIONS

Factors other than H. pylori may be involved in the pathogenesis of peptic ulcer disease in the setting of liver cirrhosis.

Low frequency of Helicobacter DNA in benign and malignant liver tissues from Baltimore, United States

Helicobacter DNA has been reported in hepatocellular carcinoma tissues in several studies from varying geographic locations, raising the possibility that Helicobacter infection may contribute to the pathogenesis of hepatocellular carcinoma. Other known risk factors for hepatocellular carcinoma show significant geographic variability, but whether the same holds for Helicobacter is unknown. We studied the prevalence of Helicobacter DNA in a US cohort of hepatocellular carcinoma, where the prevalence of Helicobacter infection is low in the general population. Liver tissues from 57 individuals were examined. Thirty-five individuals had paired tumor/nontumor samples, including 21 cases of hepatocellular carcinoma, for a total of 92 samples studied. Both Helicobacter genus and Helicobacter pylori species-specific polymerase chain reaction was performed. Helicobacter DNA was detected in 5 (9%) of 57 cases, all in nonneoplastic cirrhotic liver tissues from individuals with hepatitis C infection (n = 4) or alcohol liver disease (n = 1). Tissues from 22 hepatocellular carcinomas and 10 cholangiocarcinomas were all negative as were tissues from 8 benign primary hepatic tumors. In conclusion, Helicobacter DNA was detectable in 9% of liver tissues in this cohort but was not found in primary benign or malignant liver tumors. These findings indicate that Helicobacter infection is unlikely to be etiologically associated with hepatocellular carcinoma in this cohort. If Helicobacter infection does contribute to the development of hepatocellular carcinoma in general, then significant regional variability must exist.

Gastric tissue oxidative changes in portal hypertension and cirrhosis

Gastric mucosal lesions are very common in portal hypertension and cirrhosis. The aim of this study was to assess for oxidative gastric tissue damage in cirrhosis and evaluate relations with portal hypertension and cirrhosis parameters. The study included 30 patients with cirrhosis and 30 controls. Each patient's history, physical examination, and laboratory findings were recorded, and multiple biopsies of the gastric antrum were obtained at endoscopy. A set of antral biopsies was also collected from each control subject. Each tissue specimen was analyzed for levels of glutathione peroxidase (GPX), superoxide dismutase (SOD), and catalase (CAT) activity and level of malondialdehyde (MDA). Patients' gastric GPX, SOD, and CAT levels were significantly lower, and MDA levels were higher, than in the control group. The GPX activity level in the specimens was moderately negatively correlated with portal vein diameter (P<0.05, r=-0.45) and spleen length (P<0.05, r=-0.45). In this study gastric tissue oxidative markers showed that antral oxidative factors worsen in cirrhosis. Oxidative stress may not be a clinical condition but it obviously shows gastric tissue damage and may explain many patients' gastric lesions and hemorrhage.

[Influence of nonsteroidal antiinflammatory drugs in gastrointestinal bleeding due to gastroduodenal ulcers or erosions in patients with liver cirrhosis]

INTRODUCTION

Peptic ulcer disease, with or without complications, is more common in patients with liver cirrhosis than in the general population. Factors associated with portal hypertension are involved in its pathogenesis. The prevalence of Helicobacter pylori infection in patients with liver cirrhosis and the general population is similar. The aim of the present study was to determine the influence of nonsteroidal antiinflammatory drugs (NSAIDs) in the etiology of bleeding peptic ulcer disease in patients with liver cirrhosis.

PATIENTS AND METHODS

We studied 35 patients with liver cirrhosis and gastrointestinal bleeding due to gastroduodenal ulcers or erosions (group A), 125 noncirrhotic patients with gastrointestinal bleeding due to gastroduodenal ulcers or erosions (group B), and 70 patients with liver cirrhosis who were admitted to hospital without gastrointestinal bleeding (group C). All patients were questioned about NSAID consumption, including aspirin, during the week prior to hospital admission.

RESULTS

NSAID consumption was reported by 15 patients (42.8%) in group A, 102 patients (58.2%) in group B, and 6 patients (8.5%) in group C. Statistically significant differences were obtained when the results for group A were compared with those for group C.

CONCLUSIONS

NSAID consumption in patients with liver cirrhosis without gastrointestinal bleeding was low (8.5%) and was much lower than that observed in patients with cirrhosis admitted to hospital for bleeding due to gastroduodenal ulcers or erosions (42.8%). As occurs in the general population, NSAIDs play a significant role in the pathogenesis of bleeding due to peptic ulcer disease in patients with liver cirrhosis and portal hypertension.

Association between Helicobacter pylori infection and cirrhosis in patients with chronic hepatitis C virus

We evaluated, employing a logistic regression model, the association between Helicobacter pylori infection and cirrhosis in a cohort of 106 patients (57 males; mean age, 52.9 years; range, 20-78 years) with chronic hepatitis C virus (HCV) from Rosario, Argentina. HCV was confirmed by ELISA and PCR. H. pylori status was determined by ELISA. Of the 106 patients evaluated, 47 (44.3%) had cirrhosis. A total of 70.2% (33/47) of cirrhotic patients and 47.5% (28/59) of noncirrhotic patients were H. pylori-positive. In univariate analyses, cirrhosis was associated with age (P = 0.016) and H. pylori-positive status (P = 0.019) but not with gender (P = 0.28) or length of infection (P = 0.35). In multivariate analysis, H. pylori infection (P = 0.037; OR = 2.42; 95% CI = 1.06-5.53) and age (P = 0.033; OR = 1.04; 95% CI = 1.00-1.07) of patients remained significant and independently associated with cirrhosis. In conclusion, our results demonstrate an association between H. pylori infection and cirrhosis in patients with hepatitis C virus.

Helicobacter pylori and hepatocellular carcinoma: correlated or uncorrelated?

Helicobacter pylori can be detected in liver tissue resected from patients with hepatocellular carcinoma. Conflicting reports regarding the relationship between H. pylori and hepatocellular carcinoma mean it is uncertain whether H. pylori acts as a troublemaker, co-risk factor or innocent bystander to the development of hepatocellular carcinoma. Clinical studies in patients without known causes of hepatocellular carcinoma are important to discover whether H. pylori is involved in the carcinogenesis of hepatocellular carcinoma. High quality prospective studies in patients with hepatocellular carcinoma, hepatitis C virus infection and no cirrhosis are needed to determine whether H. pylori is a co-risk factor for hepatocellular carcinoma.

The effects of eradication of Helicobacter pylori on the recurrence of duodenal ulcers in patients with cirrhosis

BACKGROUND

The role of Helicobacter pylori in patients with cirrhosis and increased prevalence of peptic ulcers is still poorly defined. The objective is to evaluate the effect of H pylori eradication on ulcer recurrence in patients with cirrhosis.

METHODS

The study was conducted at a single, tertiary, referral hospital with 1200 beds. Patients with cirrhosis and duodenal ulcers were tested for H pylori and were enrolled in the study. Patients with positive H pylori received eradication therapy. Patients with duodenal ulcers received antisecretory therapy and regular endoscopic examinations. Main outcome measurements were the recurrence of duodenal ulcers within 1 year.

RESULTS

A total of 104 patients with cirrhosis and duodenal ulcers were enrolled. Fifty-four patients (52%) were H pylori positive, and 50 patients (48%) were H pylori negative. Forty-four patients received antimicrobial treatment and 36 patients achieved eradication of H pylori. Recurrent duodenal ulcers within 1 year were noted in 21 of 36 patients (58%) who achieved H pylori eradication. Recurrent duodenal ulcers also were noted in 8 of the 18 patients (44%) who remained H pylori positive and in 24 of the patients (48%) who were H pylori negative since their enrollment in the study (p = 0.53). The limitation was a relatively small sample size.

CONCLUSIONS

The results of our study showed that the prevalence of H pylori in patients with cirrhosis and duodenal ulcers was only 52%. Eradication of H pylori in patients with cirrhosis and duodenal ulcers did not effectively reduce the recurrence of ulcers.

Helicobacter pylori seroprevalence in patients with cirrhosis of the liver and hepatocellular carcinoma

BACKGROUND

Infection by Helicobacter hepaticus causes chronic hepatitis and hepatocellular carcinoma (HCC) in mice, and Helicobacter pylori (H. pylori) genomic sequences have been demonstrated in the liver of patients with HCC. H. pylori infection reportedly occurs with high frequency in patients with cirrhosis but none of the studies has investigated it in subjects with cirrhosis and superimposed HCC. In this case-control study, we searched for the seroprevalence of H. pylori infection in patients with HCC.

PATIENTS AND METHOD

Forty-six patients (30 males, 16 females, mean age 69 years) with HCC and hepatitis C virus (HCV)-related cirrhosis were compared to 46 sex and age (+/-1 year) matched patients presenting consecutively to the Emergency Department of Molinette Hospital of Torino. All subjects were tested for presence in serum of IgG antibodies against H. pylori and the result was analyzed using the chi-square test.

RESULTS

H. pylori seropositivity was more prevalent among patients with HCC (36/46, 78.2%) than in controls (25/46, 54%) (P<0.05) (OR 3.02, 95% confidence interval ). Twenty-five out of 30 (83.3%) male patients showed seropositivity at a variance with 16/30 (53%) in the controls (P<0.05); 11 out of 16 (68.7%) female patients were seropositive versus 9 out of 16 (56.2%) control subjects (P=n.s.).

CONCLUSION

Seroprevalence of antibodies to H. pylori was found to be higher in patients with HCC than in controls.

Helicobacter species sequences in liver samples from patients with and without hepatocellular carcinoma

AIM: Only a minority of patients carrying a defined viral aetiologic agent develop cirrhosis and ultimately hepatocellular carcinoma (HCC), the mechanism underlying the worsening is still undefined. Experimental infection by Helicobacter hepaticus in mice causes chronic hepatitis and HCC and recently, more Helicobacter species (Helicobacter spp.) have been detected in the liver of patients suffering from cholestatic diseases and HCC arising from non-cirrhotic liver. We investigated whether Helicobacter spp. sequences could be detected in the liver of patients with cirrhosis and HCC compared to subjects with metastasis to liver from colon cancer.

METHODS: Twenty-three liver samples from patients operated upon for HCC superimposed on hepatitis C virus (HCV)-related cirrhosis and 6 from patients with resected metastases from colorectal cancer, were tested by polymerase chain reaction for presence of genomic 16S rRNA of Helicobacter genus using specific primers. DNA sequencing and cag A gene analysis were also performed.

RESULTS: Genomic sequences of Helicobacter spp. were found in 17 of 20 (85%) liver samples from patients with HCC and in 2 of 6 samples from patients with liver metastasis. In three samples of the first group the result was uncertain. H pylori was revealed in 16 out of 17 positive samples and Helicobacter pullorum in the other.

CONCLUSION: Helicobacter spp., carcinogenic in mice, were found at a higher frequency in the liver of patients with HCV-related cirrhosis and HCC than those in patients without primary liver disease.

Detection of identical Helicobacter DNA in the stomach and in the non-cirrhotic liver of patients with hepatocellular carcinoma

OBJECTIVES

Studies have implied the presence of Helicobacter species in the human liver. The possible relationship between the presence of Helicobacter species in the non-cirrhotic liver of patients with hepatocellular carcinoma (HCC) and the detection of Helicobacter species in their stomach was explored.

PATIENTS AND METHODS

A 16S rDNA-based polymerase chain reaction (PCR) followed by DNA sequence analysis of the obtained PCR fragments was performed on 51 surgically obtained non-cirrhotic liver specimens and 14 gastric samples.

RESULTS

Analysis indicated a significant difference in the presence of Helicobacter-species-specific DNA in the liver of patients with HCC compared with controls. Sequence analysis of these PCR products obtained from HCC patients indicated that they were related most closely to the 16S rDNA sequence of Helicobacter pylori but that they always differed at the same two positions. This same aberrant Helicobacter-species-specific 16S rDNA could be isolated in gastric samples of patients with HCC.

CONCLUSION

These data suggest that gastric colonization with a specific subset of Helicobacter strains is associated with the induction of HCC, either directly via colonization of the liver or indirectly, e.g. via secretion of specific toxins by Helicobacter residing in the stomach.

Gastric cancer prevalence in patients with liver cirrhosis

An increased risk for gastric cancer in patients with liver cirrhosis has recently been reported in epidemiological studies. The present endoscopic study was performed to further evaluate whether people with cirrhosis are at increased risk for gastric cancer development. We reviewed the medical records of all cirrhotic patients referred to our Endoscopic Service for portal hypertension screening and, therefore, cases of latent gastric cancer were observed. For a comparison, the prevalence (age and sex standardized) of latent gastric cancer in the general population was estimated hypothesizing a latency period of 5 years. Overall, 1379 patients with cirrhosis were selected from a total of 15 791 endoscopically examined different patients observed during the period 1982-1997. Histological assessment revealed the presence of gastric cancer in 10 patients (9 males and 1 female). There was a significant 2.6-fold (P<0.01) increase in prevalence of gastric cancer compared with that expected in our cirrhotic patients. In conclusion, our findings confirm that liver cirrhosis would seem to be a risk factor for the development of gastric cancer. Other studies are needed to evaluate the pathogenic mechanisms involved.

Helicobacter pylori infection in patients with liver cirrhosis: facts and fictions

Helicobacter pylori infection could play a role in different clinical alterations observed in cirrhosis, from gastroduodenal lesions to hepatic encephalopathy. Although its prevalence in cirrhotics is similar to that in controls, H. pylori infection is responsible for the increased prevalence of peptic ulcer observed in these patients. The ammonia production by H. pylori urease does not seem to increase blood ammonia levels during cirrhosis, indicating that its role in hepatic encephalopathy could be marginalized in clinical practice. Dual and triple therapies have been shown to be equally effective for H. pylori eradication in these patients.

Helicobacter pylori is a risk factor for peptic ulcer disease in cirrhotic patients. A meta-analysis

BACKGROUND

Peptic ulcer disease is highly prevalent in cirrhosis, and ulcer complications are a major cause of morbidity in these patients. Helicobacter pylori infection is considered the chief aetiological factor of ulcer disease. However, in cirrhotic patients the role of H. pylori in the pathogenesis of peptic ulcer remains uncertain.

AIM

To evaluate the evidence of the pathogenic role of H. pylori infection in peptic ulcer disease in patients with cirrhosis.

MATERIALS AND METHODS

An extensive MEDLINE search of the literature was performed. Studies reporting the prevalence of H. pylori infection in cirrhotic patients with and without ulcers were selected. Meta-analysis was conducted using RevMan 4.0.3. Pooled odds ratios were calculated for each comparison, using a fixed model analysis.

RESULTS

The search identified seven studies with a total of 976 patients with cirrhosis (275 cases with ulcer disease and 701 controls). The prevalence of H. pylori infection in patients with peptic ulcer disease was higher than in those without. The pooled odds ratio was 2.70 (95% CI, 1.91-3.82). H. pylori infection was associated more or less equally with duodenal and gastric ulcers.

CONCLUSION

H. pylori infection increases the risk of peptic ulcer disease in patients with cirrhosis.

Review article: Helicobacter species and hepatobiliary diseases

Helicobacter species, which may colonize the biliary tract, have been implicated as a possible cause of hepatobiliary diseases ranging from chronic cholecystitis and primary sclerosing cholangitis to gall-bladder carcinoma and primary hepatic carcinomas. Research in this area has been limited by the lack of a gold standard in the diagnosis of these organisms in bile. Most published data to date have been based on molecular techniques that detect the DNA of Helicobacter species in bile, rather than evidence of viable organisms in bile. Helicobacter species have not been shown to induce histological injury to the biliary epithelium or liver parenchyma. The strongest association of the presence of these organisms in bile is with cholestatic conditions. This article reviews the literature on this newly developing field as it has evolved historically, taking pertinent methodological issues into account.

Impairment of cytochrome P-450-dependent liver activity in cirrhotic patients with Helicobacter pylori infection

BACKGROUND

Helicobacter pylori gastric infection has been associated with various digestive and extra-digestive diseases. The systemic influence of gastric H. pylori infection seems to be mediated by the release of various cytokines. In liver disease, bacterial infections have been associated with the impairment of liver metabolic function.

AIMS

To evaluate the influence of H. pylori infection on liver function as assessed by means of the monoethylglycinexylidide test, which depends upon liver blood flow and cytochrome P-450 activity, and the 13C-galactose breath test, which depends on cytosolic enzymatic activity and is correlated with hepatic functional mass. Moreover, to evaluate whether H. pylori-associated modifications of liver function may be related to tumour necrosis factor-alpha serum levels.

PATIENTS AND METHODS

Thirty-five patients with liver cirrhosis of various aetiologies, who underwent monoethylglycinexylidide and 13C-galactose breath tests, were retrospectively evaluated for H. pylori infection by means of anti-H. pylori immunoglobulin G. The main clinical, biochemical and functional characteristics of the patients as well as their tumour necrosis factor-alpha serum levels were then analysed on the basis of the presence of H. pylori infection.

RESULTS

Twenty-one patients tested positive for H. pylori infection (60%), and 11 tested negative (31.4%). No clinical or biochemical differences were observed between H. pylori-infected and non-infected patients. H. pylori infection showed no difference in distribution according to Child-Pugh classes (A, 55%; B and C, 67%). The monoethylglycinexylidide test results were significantly lower at each sampling time in H. pylori-positive patients compared to H. pylori-negative patients (MEGX15, P=0.027; MEGX30, P=0.014; MEGX60, P=0.028), while 13C-galactose breath test showed no significant differences considering both cumulative percentage dose and percentage dose/h. The median tumour necrosis factor-alpha serum levels were no different between H. pylori-positive (16.1 pg/mL, 95% confidence interval, 8.7-28.7) and H. pylori-negative (12.3 pg/mL, 95% confidence interval, 8.7-23.4) patients.

CONCLUSIONS

In cirrhotic patients, H. pylori infection seems to selectively affect cytochrome P-450 liver activity, while hepatic functional mass does not seem to be impaired. Tumour necrosis factor-alpha does not seem to be the mediator of this impairment. Further studies are needed to evaluate the impact of H. pylori eradication on parameters of liver function.

Role of Helicobacter pylori in cirrhotic patients with dyspepsia: a 13C-urea breath test study

The role of Helicobacter pylori in dyspeptic, cirrhotic patients remains unclear. This prospective outpatient study, conducted to assess the relationship of gastroduodenal disease and H. pylori as determined by the (13C) urea breath test, enrolled 109 consecutive cirrhotic patients with dyspepsia. All patients underwent upper-gastrointestinal endoscopy, which revealed respective prevalences of peptic ulcer, gastric ulcer, and duodenal ulcer of 41.3%, 23.9%, and 22.9%; H. pylori infection was found in 52.3%. The rate of peptic ulcer disease in the H. pylori-positive (45.6%) and -negative (36.5%) groups was not significantly different; neither was the prevalence of H. pylori in patients with or without portal hypertensive gastropathy and with or without esophageal varices. The relationship between peptic ulcer disease and H. pylori in dyspeptic patients with cirrhosis appears to be weak. Likewise, no significant relationship was evident between H. pylori and portal hypertensive gastropathy or esophageal varices. This organism may not be a major pathogenetic factor in gastroduodenal diseases in dyspeptic patients with cirrhosis.

Helicobacter pylori seroprevalence in hepatitis C virus positive patients with cirrhosis

BACKGROUND/AIMS

Liver cirrhosis is a significant cause of death in Italy and one of the most frequent causes of hospitalization. Acute peptic ulcer and upper gastrointestinal bleeding reportedly occur in over one-third of cirrhotic patients. Since Helicobacter pylori (H. pylori) infection strongly correlates with peptic ulcer, we sought to ascertain the prevalence of H. pylori infection in cirrhotic patients.

METHODS

In a case-control study, we examined 254 consecutive patients (127 male and 127 female, age range 30-82 years) suffering from hepatitis C virus (HCV)-related cirrhosis and 463 sex- and age-matched patients admitted to the Department of Emergency Care of our hospital (254 male, 209 female, age range 30-79 years) resident in the same area.

RESULTS

Antibodies to H. pylori were present in 226/254 (89%) cirrhotic patients and in 275/463 (59%) controls (p<0.0001). The difference was significant both in males and in females.

CONCLUSIONS

The very high prevalence of H. pylori infection may explain the frequent occurrence of gastroduodenal ulcer in cirrhotic patients and may possibly determine the prognosis of those who are also infected with HCV.

Helicobacter pylori. One bacterium and a broad spectrum of human disease! An overview

Since the historical rediscovery of gastric spiral Helicobacter pylori in the gastric mucosa of patients with chronic gastritis by Warren and Marshall in 1983, peptic ulcer disease has been largely viewed as being of infectious aetiology. Indeed, there is a strong association between the presence of H. pylori and chronic active gastritis in histology. The bacterium can be isolated in not less than 70% of gastric and in over 90% of duodenal ulcer patients. Eradication of the organism has been associated with histologic improvement of gastritis, lower relapse rate and less risk of bleeding from duodenal ulcer. The bacterium possesses several virulence factors enabling it to survive the strong acid milieu inside the stomach and possibly damaging host tissues. The sequence of events by which the bacterium might cause gastric or duodenal ulcer is still not fully elucidated and Koch's postulates have never been fulfilled. In the majority of individuals, H. pylori infection is largely or entirely asymptomatic and there is no convincing data to suggest an increase in the prevalence of peptic ulcer disease among these subjects. An increasingly growing body of literature suggests an association between colonization by H. pylori in the stomach and a risk for developing gastric mucosa-associated lymphoid tissue (MALT), MALT lymphoma, gastric adenocarcinoma and even pancreatic adenocarcinoma. The bacterium has been implicated also in a number of extra-gastrointestinal disorders such as ischaemic heart disease, ischaemic cerebrovascular disease, atherosclerosis, and skin diseases such as rosacea, but a causal role for the bacterium is missing. Eradication of H. pylori thus seems to be a beneficial impact on human health. Various drug regimens are in use to eradicate H. pylori involving the administration of three or four drugs including bismuth compounds, metronidazole, clarithromycin, tetracyclines, amoxycillin, ranitidine, omeprazole for 1-2 weeks. The financial burden, side effects and emergence of drug resistant strains due to an increase in the use in antibiotics for H. pylori eradication therapy need further reconsideration.

Identification of Helicobacter pylori and other Helicobacter species by PCR, hybridization, and partial DNA sequencing in human liver samples from patients with primary sclerosing cholangitis or primary biliary cirrhosis

Helicobacter pylori was identified in human liver tissue by PCR, hybridization, and partial DNA sequencing. Liver biopsies were obtained from patients with primary sclerosing cholangitis (n = 12), primary biliary cirrhosis (n = 12), and noncholestatic liver cirrhosis (n = 13) and (as controls) normal livers (n = 10). PCR analyses were carried out using primers for the Helicobacter genus, Helicobacter pylori (the gene encoding a species-specific 26-kDa protein and the 16S rRNA), Helicobacter bilis, Helicobacter pullorum, and Helicobacter hepaticus. Samples from patients with primary biliary cirrhosis and primary sclerosing cholangitis (11 and 9 samples, respectively) were positive by PCR with Helicobacter genus-specific primers. Of these 20 samples, 8 were positive with the 16S rRNA primer and 9 were positive with the 26-kDa protein primer of H. pylori. These nine latter samples were also positive by Southern blot hybridization for the amplified 26-kDa fragment, and four of those were verified to be H. pylori by partial 16S rDNA sequencing. None of the samples reacted with primers for H. bilis, H. pullorum, or H. hepaticus. None of the normal livers had positive results in the Helicobacter genus PCR assay, and only one patient in the noncholestatic liver cirrhosis group, a young boy who at reexamination showed histological features suggesting primary sclerosing cholangitis, had a positive result in the same assay. Helicobacter positivity was thus significantly more common in patients with cholestatic diseases (20 of 24) than in patients with noncholestatic diseases and normal controls (1 of 23) (P = <0.00001). Patients positive for Helicobacter genus had significantly higher values of alkaline phosphatases and prothrombin complex than Helicobacter-negative patients (P = 0.0001 and P = 0.0003, respectively). Among primary sclerosing cholangitis patients, Helicobacter genus PCR positivity was weakly associated with ulcerative colitis (P = 0.05). Significant differences related to blood group or HLA status were not found.