Helicobacter pylori infection in Finland

Thirty-Year Incidence and Mortality Trends in Upper and Lower Gastrointestinal Bleeding in Finland

IMPORTANCE

Epidemiological data on lower gastrointestinal bleeding (GIB) in the general population are sparse.

OBJECTIVE

To describe the incidence, recurrence, mortality, and case fatality rates of major upper GIB and lower GIB in the general population of Finland between 1987 and 2016.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study used data from the 1987 to the 2012 cycles of the National FINRISK Study, a health examination survey that was conducted every 5 years in Finland. Survey participants were adults aged 25 to 74 years who were recruited from a population register by random sampling; those with a history of hospitalization for GIB were excluded. Participants were followed up from survey enrollment to onset of GIB that led to hospitalization, death from any cause, or study end (December 31, 2016). Follow-up was performed through linkage with national electronic health registers. Data were analyzed from February 1, 2019, to January 31, 2020.

MAIN OUTCOMES AND MEASURES

Incidence, recurrence, mortality, and case fatality rates for all, upper, lower, and unspecified GIB. Outcome measures were stratified by sex and age group.

RESULTS

Among the 39 054 participants included in the study, 494 (1.3%) experienced upper GIB (321 men [65.0%]; mean [SD] age, 52.8 [12.1] years) and 645 (1.7%) had lower GIB (371 men [57.5%]; mean [SD] age, 54.0 [11.7] years). The age-standardized incidence rate was 0.94 per 1000 person-years (95% CI, 0.85-1.04) for upper GIB and 1.26 per 1000 person-years (95% CI, 1.15-1.38) for lower GIB; the incidence was higher in men than in women. Between 1987 and 2016 the incidence rate of upper GIB remained mostly stable, ranging from 0.40 to 0.66 per 1000 person-years, whereas constant increases occurred in the incidence of lower GIB until the rate stabilized. The proportion of recurrent GIB events showed an increasing trend from 1987 to 2016. The upper GIB-specific mortality was higher (0.07 per 1000 person-years; 95% CI, 0.04-0.09) than the lower GIB-specific mortality (0.01 per 1000 person-years; 95% CI, 0.001-0.03). Case fatality was high for those with upper GIB (7.0%; 95% CI, 4.7-10.1) compared with those with lower GIB (0.4%; 95% CI, 0.1-1.3). Case fatality remained stable over the years but was higher in men (between 5% and 10%) than women (<2%) with GIB.

CONCLUSIONS AND RELEVANCE

This study found that the overall incidence rate of upper GIB was lower than the incidence of lower GIB, but the recurrence, mortality, and 28-day case fatality were higher in participants with upper GIB. These data can serve as a reference when putting into context the rates of drug-associated GIB and can inform efforts to improve GIB care and outcome and to prevent rebleeding or death for patients with major GIB.

Outcomes of patients hospitalized with peptic ulcer disease diagnosed in acute upper endoscopy

OBJECTIVES

The incidence and complications of peptic ulcer disease (PUD) have declined, but mortality from bleeding ulcers has remained unchanged. The aims of the current study were to evaluate the significance of PUD among patients admitted for acute upper endoscopy and to evaluate the survival of PUD patients.

PATIENTS AND METHODS

In this prospective, observational cohort study, data on 1580 acute upper endoscopy cases during 2012-2014 were collected. A total of 649 patients were included with written informed consent. Data on patients' characteristics, living habits, comorbidities, drug use, endoscopy and short-term and long-term survival were collected.

RESULTS

Of all patients admitted for endoscopy, 147/649 (23%) had PUD with the main symptom of melena. Of these PUD patients, 35% had major stigmata of bleeding (Forrest Ia-IIb) in endoscopy. Patients with major stigmata had significantly more often renal insufficiency, lower level of blood pressure with tachycardia and lower level of haemoglobin, platelets and ratio of thromboplastin time. No differences in drug use, Charlson comorbidity class, BMI, smoking or alcohol use were found. Of the PUD patients, 31% were Helicobacter pylori positive. The 30-day mortality was 0.7% (95% confidence interval: 0.01-4.7), 1-year mortality was 12.9% (8.4-19.5) and the 2-year mortality was 19.4% (13.8-26.8), with no difference according to major or minor stigmata of bleeding. Comorbidity (Charlson>1) was associated with decreased survival (P=0.029) and obesity (BMI≥30) was associated with better survival (P=0.023).

CONCLUSION

PUD is still the most common cause for acute upper endoscopy with very low short-term mortality. Comorbidity, but not the stigmata of bleeding, was associated with decreased long-term survival.

Increased short- and long-term mortality in 8146 hospitalised peptic ulcer patients

BACKGROUND

Incidence and complications of peptic ulcer disease (PUD) have declined, but mortality from peptic ulcer bleeding has remained unchanged. The few recent studies on mortality associated with both uncomplicated and complicated patients with peptic ulcer disease provide contradictory results.

AIMS

To evaluate short- and long-term mortality, and the main causes of death in peptic ulcer disease.

METHODS

In this retrospective epidemiologic cohort study, register data on 8146 adult patients hospitalised with peptic ulcer disease during 2000-2008 were collected in the capital region of Finland. All were followed in the National Cause of Death Register until the end of 2009. The data were linked with the nationwide Drug Purchase Register of the Finnish Social Insurance Institution.

RESULTS

Mean follow-up time was 4.9 years. Overall mortality was substantially increased, standardised mortality ratio 2.53 (95% CI: 2.44-2.63); 3.7% died within 30 days, and 11.8% within 1 year. At 6 months, the survival of patients with perforated or bleeding ulcer was lower compared to those with uncomplicated ulcer; hazard ratios were 2.06 (1.68-2.04) and 1.32 (1.11-1.58), respectively. For perforated duodenal ulcers, both the short- and long-term survival was significantly impaired in women. The main causes of mortality at 1 year were malignancies and cardiovascular diseases. Previous use of statins was associated with significant reduction in all-cause mortality.

CONCLUSIONS

One-year mortality in patients hospitalised with peptic ulcer disease remained high with no change. This peptic ulcer disease cohort had a clearly decreased survival rate up to 10 years, especially among women with a perforated duodenal ulcer, most likely explained by poorer survival due to underlying comorbidity.

Incidence and complications of peptic ulcer disease requiring hospitalisation have markedly decreased in Finland

BACKGROUND

The characteristics of peptic ulcer disease (PUD) are changing.

AIM

To evaluate time trends in the incidence of PUD and its complications in hospitalised patients at the beginning of the 21st century, drug therapies in out-patient care as a risk factor for recurrent PUD, and medication used by PUD patients compared with the background population.

METHODS

In this retrospective epidemiologic cohort study, data from the years 2000-2008 came from The Hospital District of Helsinki and Uusimaa, and the Finnish Care Register. All hospitalised adult patients with PUD in the capital region of Finland were included. The data were linked with nationwide Prescription Register of the Finnish Social Insurance Institution allowing detailed individual medicine purchase data.

RESULTS

A total of 9951 peptic ulcers were detected among 8146 individual patients during the study period. The mean annual incidence of all peptic ulcers decreased from 121/100,000 (95% CI: 117-125) in 2000-2002, to 79 (95% CI: 76-82) in 2006-2008 [Incidence rate ratio = 0.62 (95% CI: 0.58-0.64), P < 0.001 after age and sex adjustment]. Decrease in incidence was seen in all age groups and in both sexes. The overall rate of severe complications of PUD was reduced. One-year cumulative incidence of recurrent ulcers was 13%. Use of several drugs was associated with increased risk for recurrence. The purchases of various drugs were more common among PUD patients compared with background population.

CONCLUSIONS

Both the incidence and complication rates have markedly decreased during the study period. Recurrent peptic ulcer disease was associated with polypharmacy.

Helicobacter pylori and gastrointestinal symptoms in diagnostics and adjuvant chemotherapy of colorectal cancer

5-Fluorouracil (5-FU)-based chemotherapy is the mainstay of adjuvant treatment for colorectal cancer (CRC). Few studies have explored Helicobacter pylori (H. pylori)-associated gastrointestinal symptoms in the diagnosis of CRC, and the association between H. pylori infection and gastrointestinal toxicity during adjuvant chemotherapy in CRC. Seventy-nine CRC patients were randomised in a prospective clinical trial to receive 5-FU and leucovorin administered as bolus injection (Mayo regimen) or continuous infusion (simplified de Gramont regimen). H. pylori antibodies were analysed at baseline, twice monthly during treatment and after treatment up to 12 months. Thirty-seven patients (47%) were H. pylori-seronegative at baseline. There was no significant association between baseline H. pylori seropositivity (n=42; 53%) and oro-gastrointestinal toxicity during chemotherapy. The median time from symptom onset of CRC to surgery was significantly longer in patients with H. pylori infection (median time, 6 vs. 5 months; P=0.012). Functional dyspeptic symptoms at presentation significantly delayed diagnosis (median time, 7.5 vs. 5 months; P=0.035), whereas anaemia, bowel symptoms, occlusion, blood in the stool, infection and hypolactasia did not. We conclude that there is no association between H. pylori status and gastrointestinal toxicity in CRC patients during chemotherapy. Dyspeptic symptoms and presence of H. pylori may delay the diagnosis of CRC. (www.controlled-trials.com/ISRCTN98405441).

Significant decrease in prevalence of Helicobacter pylori in the Czech Republic

AIM: To study possible decrease in prevalence of Helicobacter pylori (H. pylori) infection in the Czech Republic within a 10-year period.

METHODS: A total of 22 centres entered the study. The catchment areas of these centres covered cities and towns with more than 20 000 inhabitants, smaller towns (≤ 20 000 inhabitants) with surrounding villages and rural areas, and were spread over the whole country, corresponding well to the geographical distribution of the Czech population. A total of 1 837 subjects (aged 5-98 years) took part in the study, randomly selected out of 38 147 people from the general population. H. pylori infection was investigated by means of a ¹³C-urea breath test. Breath samples in duplicates were analysed using isotope ratio mass spectrometry. The cut-off point was 3.5. Social and demographic characteristics were based on data from self-completed questionnaires.

RESULTS: The overall prevalence of H. pylori infection was 23.5% (430/1826), and 4.8% (20/420) in children aged 15 or less. There was no statistically significant difference in prevalence between males (24.3%; 208/857) and females (22.9%, 222/969, P = 0.494). H. pylori infection was strongly associated with higher age, among subjects aged 55+ years, prevalence of H. pylori infection was 39.8% (252/633, P < 0.001). The highest prevalence of H. pylori infection was found among persons aged 55-64 years (43.9%, 97/221) and 75+ years (37.9%, 58/153). Among study subjects aged 15+ years, prevalence of H. pylori infection was significantly increased in those with lowest education (odds risk 3.19, 95% CI 1.87-5.47). Compared to never married (14.1%), the prevalence of H. pylori infection was statistically significantly higher among married (35.4%, 246/694, P < 0.001), divorced (36.8%, 49/133, P < 0.001) and widowed study subjects (40.2%, 45/112, P < 0.001), both in minimally and fully adjusted analysis. There was no significant difference in the prevalence of H. pylori infection between married and widowed subjects (35.4%, 246/694 vs 40.2%, 45/112, P = 0.389). There was little variation in smoking prevalence across categories of smoking and there was no evidence of an increased risk of H. pylori infection among current or past smokers in our data (odds risk 1.04 with 95% CI 0.78-1.40 for current smokers; odds ratio 0.83 with 95% CI 0.60-1.16 for former smokers). The current prevalence of H. pylori in 2011 was significantly lower compared to the prevalence reported from identical geographical areas in 2001 (23.5% vs 41.7%, P < 0.001).

CONCLUSION: The overall prevalence of H. pylori infection in the general population has fallen substantially in the Czech Republic over the past 10 years.

Gastric cancers in Finnish patients after cure of Helicobacter pylori infection: A cohort study

Helicobacter pylori infection is associated with gastric cancer. A total of 97% of the infected subjects have elevated levels of H. pylori antibodies. The antibody titers have been shown to decline rapidly (40-60% within 4-12 months) only after successful eradication therapy. We allocated 26,700 consecutive patients tested during 1986-1998 for H. pylori antibodies to 3 subcohorts: seropositive patients with rapidly falling antibody titers (Hp+CURED, n = 3,650), seropositive patients where no serological information indicating cure was obtained (Hp+NoInfo, n = 11,638) and seronegative patients (Hp-, n = 11,422). In the subcohorts, the standardised incidence ratios (SIRs) with 95% confidence intervals (CI) were defined for subsequent cancers of stomach, pancreas, colon, rectum, breast and prostate separately and for all cancers except stomach combined. The mean follow-up time was 10.1 years and the number of gastric cancers was 72. For the Hp+CURED, the SIR for gastric cancers for the first 5 follow-up years was 1.62 but decreased from the sixth follow-up year thereon to 0.14 (CI: 0.00-0.75). Likewise, the risk ratio, defined in a Poisson regression analysis using the Hp+NoInfo group as the reference, decreased from 1.60 to 0.13 (CI: 0.02-1.00, p = 0.049). The SIR for Hp- was not significantly higher than that for Hp+NoInfo for any of the cancers analysed. To conclude, cured H. pylori infection led to a significantly decreased incidence of gastric cancers from the sixth follow-up year. Advanced atrophic gastritis would be a plausible contributor to the elevated SIR in elderly Hp- patients.

Helicobacter pylori eradication therapy: indications, efficacy and safety

BACKGROUND

Helicobacter pylori infects up to half of the world's population. It remains the major cause of peptic ulcer disease and is recognised as a carcinogen for its role in gastric carcinogenesis. Successful eradication of the bacteria is associated with improved health outcomes including fewer dyspeptic symptoms, reduced peptic ulcer recurrence and rebleeding, reduced peptic ulcer risk with NSAIDs and as a cure for low-grade gastric MALT lymphoma. The risk of gastric cancer is reduced in those without premalignant mucosal abnormalities at the time of eradication.

OBJECTIVE

This review outlines the current indications and options for therapy of H. pylori with particular reference to drug-induced adverse events associated with treatment.

METHODS

The indications for H. pylori eradication are evidence-based and in accordance with recent consensus statements and recommendations. The eradication treatment is based on numerous clinical trials and meta-analyses.

RESULTS/CONCLUSION

Eradication therapy, in general, is safe and well tolerated. Antibiotic therapy may be associated with significant drug adverse reactions, especially gastrointestinal symptoms.

Prevalence and distribution of gastric intestinal metaplasia and its subtypes

BACKGROUND AND STUDY AIMS

Intestinal metaplasia, especially type III intestinal metaplasia is considered to be a precursor of gastric cancer and because of this it is suggested that these patients should be followed up by gastroscopy. Our aim was to find out the prevalence of intestinal metaplasia and its subtypes, the appearance of intestinal metaplasia in different parts of the stomach, and the correlation of intestinal metaplasia with other histological and endoscopic findings.

PATIENTS AND METHODS

A total of 505 consecutive patients, with a mean age+/-S.D. of 54+/-16 years, had two biopsies taken from the antrum, two from the corpus, and, in 272 cases, two from the angulus of the stomach during routine upper gastrointestinal endoscopy. Histological specimens were examined according to the updated Sydney system and the ones with incomplete intestinal metaplasia were further stained for sulphomucin visualisation to divide these into types II and III.

RESULTS

The overall prevalence of intestinal metaplasia was 19%. The prevalence of type III intestinal metaplasia was 2.8%, type II intestinal metaplasia was 4.4%, and complete intestinal metaplasia was 11%. Intestinal metaplasia was found most frequently in the antrum and also in the angulus. There was no type III intestinal metaplasia in the corpus. Intestinal metaplasia was found more frequently in patients with atrophic gastritis than in other patients (p < 0.01). The patients with type III intestinal metaplasia were older than the patients without intestinal metaplasia (mean age of 73 versus 51 years). None of the patients with a totally normal appearing stomach in upper gastrointestinal endoscopy had type II or type III intestinal metaplasia.

CONCLUSION

The relatively high overall prevalence of intestinal metaplasia was found in patients referred for gastroscopy in a region of low prevalence of Helicobacter pylori infection and low incidence of gastric cancer. Intestinal metaplasia was most often found in the antrum and angulus. Type III intestinal metaplasia was more prevalent in older patients and intestinal metaplasia was more frequently found in patients with atrophic gastritis. Normal appearing endoscopic finding seems to exclude type II and III intestinal metaplasia.

Seroprevalence of Helicobacter pylori infection among schoolchildren and teachers in Taiwan

BACKGROUND

Helicobacter pylori are associated with chronic antral gastritis that is related to duodenal ulcer, gastric ulcer, and probably gastric adenocarcinoma. Infection of H. pylori during childhood is considered an important risk factor for gastric carcinoma in adult life.

MATERIALS AND METHODS

To examine the epidemiologic characteristics of H. pylori infection among schoolchildren in central Taiwan, a community-based survey was carried out using stratified sampling in 10 elementary schools and three junior high schools including students and theirs teachers. Serum specimens of 1950 healthy schoolchildren (aged 9-15 years old) and 253 teachers who were randomly sampled were screened for the H. pylori antibodies by enzyme-linked immunosorbent assay. Statistical analysis was performed by using the SPSS for Windows statistical software system.

RESULTS

A total of 332 subjects were H. pylori antibodies positive, giving an overall prevalence of 15.1%. The age-specific seropositive rates were 11.0% in 9-12 years age group, 12.3% in 13-15 years age group, and 45.1% in the teacher group. The older the age, the higher the seroprevalence (OR = 11.53; 95% CI = 6.73-19.74; p < .001 for children vs. teachers). There was no difference in the seroprevalence of H. pylori infection by gender, ethnicity, geographical area, socioeconomic level, parental education, sibship size, family members, and source of drinking water.

CONCLUSION

The teachers had a much higher prevalence of H. pylori antibodies. The finding suggests that these teachers (adults) might be infected in their early childhood and implies that the poor environmental and hygienic conditions might be responsible for it. It seemed that poor water supply system, sewage disposal, and other environmental hygiene in adult might play some roles in H. pylori infection in Taiwan (before early 1980s).

Epidemiology of Helicobacter pylori infection in the Czech Republic

BACKGROUND

Prevalence of Helicobacter pylori infection has been estimated to range from 60 to 95% in the former communist countries of Central and Eastern Europe. The aim of this study was to evaluate H. pylori infection prevalence in a representative sample of the Czech population. The second objective was to describe difference of H. pylori prevalence between different social groups of children and adults.

MATERIALS AND METHODS

A total of 2509 persons aged 5-100 years, randomly selected out of 30,012 persons of the general population, took part in the study. H. pylori infection was investigated by means of 13C-urea breath test. Breath samples were analyzed by isotope ratio mass spectrometry. Social and demographic characteristics were based on data from self-completed questionnaires.

RESULTS

Using the total Czech population as a standard, we estimated the age-standardized prevalence of H. pylori in males aged 5+ years at 41.9% (95% CI 39.0%, 44.8%) and in females aged 5+ years at 41.4% (95% CI 38.6%, 44.3%) in 2001. Prevalence of H. pylori increased with age but was not related to gender. Children of mothers with basic or lower education, living in crowded accommodations, without access to running warm water, and residing in smaller towns appear to be at the highest risk. Low education and heavy smoking are most strongly associated with prevalence of H. pylori positivity in adults and adolescents.

CONCLUSIONS

This is a unique study based on a representative sample of the general population in a Central European country. The overall prevalence of H. pylori is lower than previously assumed and could partly reflect a substantial recent decrease in H. pylori prevalence in the Czech Republic. Consistent with earlier studies, H. pylori infection is strongly influenced by socioeconomic conditions and childhood poverty.

Stool antigen tests in the diagnosis of Helicobacter pylori infection before and after eradication therapy

AIM

To evaluate two enzyme immunoassay-based stool antigen tests, Premier Platinum HpSA and Amplified IDEIA HpStAR, and one rapid test, ImmunoCard STAT! HpSA, in the primary diagnosis of Helicobacter pylori (H pylori) infection and after eradication therapy.

METHODS

Altogether 1 574 adult subjects were screened with a whole-blood H pylori antibody test and positive results were confirmed with locally validated serology and (13)C-urea breath test. All 185 subjects, confirmed to be H pylori positive, and 97 H pylori-negative individuals, randomly selected from the screened study population and with negative results in serology and UBT, were enrolled. After eradication therapy the results of 182 subjects were assessed.

RESULTS

At baseline, the sensitivity of HpSA and HpStAR was 91.9% and 96.2%, respectively, and specificity was 95.9% for both tests. ImmunoCard had sensitivity of 93.0% but specificity of only 88.7%. After eradication therapy, HpSA and HpStAR had sensitivity of 81.3% and 100%, and specificity of 97.0% and 97.6%, respectively. ImmunoCard had sensitivity of 93.8% and specificity of 97.0%. HpSA, HpStAR, and ImmunoCard had PPV 77%, 80%, and 75%, and NPV 98%, 100%, and 99%, respectively.

CONCLUSION

In primary diagnosis, the EIA-based tests performed well. After eradication therapy, negative results were highly accurate for all the three tests. HpStAR had the best overall performance.

Probiotic supplementation improves tolerance to Helicobacter pylori eradication therapy--a placebo-controlled, double-blind randomized pilot study

BACKGROUND

H. pylori is the major cause of chronic gastritis, and a risk factor for peptic ulcer and gastric cancer.

AIM

To investigate the effect of probiotic supplementation on the tolerance and efficacy of H. pylori eradication treatment in a randomized, double-blind, placebo-controlled trial.

METHODS

A total of 338 volunteers were screened for H. pylori infection. The eligibility criteria were met by 47 subjects whose H. pylori infection was verified at the outset and re-evaluated after the treatment by the 13C-urea breath test and by enzyme immunoassay serology. The subjects were randomized to receive probiotic therapy (Lactobacillus rhamnosus GG, L. rhamnosusLC705, Bifidobacterium breve Bb99 and Propionibacterium freudenreichii ssp. shermanii JS) or a placebo during H. pylori eradication and for 3 weeks following the treatment, and recorded their daily symptoms in a standardized diary.

RESULTS

When the frequencies of new or aggravated symptoms were evaluated, no significant differences were found between the two groups for individual symptoms. However, the probiotic group showed less treatment-related symptoms as measured by the total symptom score change (P = 0.038) throughout the H. pylori eradication therapy in contrast to the placebo group. The H. pylori eradication rate was non-significantly higher in the group receiving probiotic therapy (91% vs. 79%, P = 0.42). In this group the recovery of probiotic bacteria in the faeces increased significantly (P < 0.001).

CONCLUSIONS

In this pilot study, probiotic supplementation did not diminish significantly the frequency of new or aggravated symptoms during H. pylori eradication. However, our data suggest an improved tolerance to the eradication treatment when total symptom severity was taken into account. Furthermore, the results show that probiotic bacteria are able to survive in the gastrointestinal tract despite the intensive antimicrobial therapy.

First-line eradication therapy for Helicobacter pylori in primary health care based on antibiotic resistance: results of three eradication regimens

AIM

To determine the efficacy of three Helicobacter pylori eradication regimens and factors affecting the eradication results in Finland.

METHODS

A total of 342 H. pylori-positive adult patients from primary health care referred for gastroscopy at 23 centres in different parts of Finland were randomized to receive either (i) lansoprazole 30 mg b.d., amoxicillin 1 g b.d. and metronidazole 400 mg t.d.s. (LAM), (ii) lansoprazole 30 mg b.d., amoxicillin 1 g b.d. and clarithromycin 500 mg b.d. (LAC), or (iii) ranitidine bismuth citrate 400 mg b.d., metronidazole 400 mg t.d.s. and tetracycline 500 mg q.d.s. (RMT). A (13)C-urea breath test was performed 4 weeks after therapy.

RESULTS

The eradication result could be assessed in 329 cases. Intention-to-treat cure rates of LAM, LAC, and RMT were 78, 91 and 81%. The difference was significant between LAM and LAC (P = 0.01) and between LAC and RMT (P = 0.04). The eradication rates in cases with metronidazole-susceptible vs. -resistant isolates were for LAM 93% vs. 53% (P = 0.00001), for LAC 95% vs. 84%, and for RMT 91% vs. 67% (P = 0.002). Previous antibiotic use, smoking, and coffee drinking reduced the efficacy of therapy.

CONCLUSIONS

In unselected patients in primary health care, LAC was the most effective first-line eradication.