Helicobacter pylori infection and peptic ulcer disease in children

Where are we today with Helicobacter pylori infection among healthy children in Saudi Arabia?

BACKGROUND/AIMS

The available studies on Helicobacter pylori (H. pylori) prevalence among healthy asymptomatic population across Saudi Arabia suffers from significant limitations. We conducted this large population-based study to estimate the H. pylori seropositivity rate among apparently healthy children in Saudi Arabia, using anti-H. pylori immunoglobulin A (IgA) and IgG serology tests, and to study the influence of H. pylori infection on growth.

MATERIALS AND METHODS

We conducted a cross-sectional study to screen apparently healthy school aged Saudi children (aged 6-15 years), attending primary and intermediate schools in Riyadh between 2014 and 2016, for H. pylori seropositivity by checking for the presence of anti-H. pylori IgG and IgA antibodies in serum specimens.

RESULTS

Out of 3551 serum specimens, 1413 cases tested seropositive for H. pylori organism (40%): 430 (12.2%) were both IgG and IgA positive, 212 (6%) and 771 (21.7%) cases showed isolated positivity for IgG or IgA, respectively. Male gender, older age, lower levels of socioeconomic status (SES), and family members >10 were significantly associated with H. pylori seropositivity. The proportion of participants with short stature was significantly more in the H. pylori seropositive group than the seronegative group (OR1.249, confidence interval [1.020-1.531], P= 0.033). There was no significant association between H. pylori seropositivity and gastrointestinal symptoms.

CONCLUSION

The prevalence of H. pylori seropositivity among apparently healthy Saudi children (40%) is intermediate compared with that in developed and developing countries. The Saudi pediatric population shows a predominant IgA-type immunological response to H. pylori infection.

Helicobacter pylori antimicrobial resistance in a pediatric population

BACKGROUND

The increasing prevalence of Helicobacter pylori (H. pylori) antimicrobial resistance, primarily for clarithromycin decreases the success of treatment. The aim of this study is to determine the local pattern of first-line antimicrobials resistance and the eradication rate.

MATERIAL AND METHODS

Prospective cohort study of H. pylori infected patients (positive histological or cultural exams) treated at Centro Materno-Infantil do Norte from January of 2013 to October of 2017. Susceptibility to 4 antibiotics: amoxicilin, metronidazole, clarithromycin, and levofloxacin were analyzed by E-test (phenotypic resistance). The E-test was chosen because it is simple and cost-effective for routine susceptibility testing. Point mutations that confer clarithromycin resistance were surveyed (genotypic resistance). Eradication of H. pylori infection was defined by a negative urea breath test or fecal antigen 6-8 weeks after the end of treatment.

RESULTS

Of a total of 74 H. pylori infected patients, 16 were excluded because they had previous H. pylori treatment or severe systemic disease. Median age of infection cases was 15 years (3-17 years). Eradication regimen used in all patients combined the use of 3 antibiotics (amoxicillin and metronidazole or clarithromycin) and proton pump inibhitor for 14 days and was tailored according antimicrobial susceptibility. 79.5% of the patients completed the treatment. The resistance rate for metronidazole and clarithromycin was 3.3% and 23.3%, respectively. There was no resistance for amoxicilin and levofloxacin. The rate of genotypic resistance to clarithromycin was 37.2%. The eradication rate was 97.8%.

CONCLUSIONS

The authors found a high resistance rate of H. pylori for clarithromycin in this northern portuguese pediatric center. This factor should determine a change in local current treatment, contraindicating the use of clarithromycin as a first-line treatment for H. pylori infection in children. The high eradication rate maybe explained for the eradication treatment tailored according antimicrobial susceptibility.

Nontraditional therapies to treat Helicobacter pylori infection

The Gram-negative pathogen Helicobacter pylori is increasingly more resistant to the three major antibiotics (metronidazole, clarithromycin and amoxicillin) that are most commonly used to treat infection. As a result, there is an increased rate of treatment failure; this translates into an overall higher cost of treatment due to the need for increased length of treatment and/or the requirement for combination or sequential therapy. Given the rise in antibiotic resistance, the complicated treatment regime, and issues related to patient compliance that stem from the duration and complexity of treatment, there is clearly a pressing need for the development of novel therapeutic strategies to combat H. pylori infection. As such, researchers are actively investigating the utility of antimicrobial peptides, small molecule inhibitors and naturopathic therapies. Herein we review and discuss each of these novel approaches as a means to target this important gastric pathogen.

Meta-analysis: Helicobacter pylori eradication treatment efficacy in children

BACKGROUND

Several meta-analyses assessing the efficacy of anti-Helicobacter pylori treatment in adults have been published but a comparable meta-analysis in children is lacking.

AIMS

To summarize the efficacy of treatments aimed at eradicating H. pylori in children and to identify sources of variation in treatment efficacy across studies.

METHODS

We searched Medline, reference lists from published study reports, and conference proceedings for anti-H. pylori treatment trials in children. Weighted meta-regression models were used to find sources of variation in efficacy.

RESULTS

Eighty studies (127 treatment arms) with 4436 children were included. Overall, methodological quality of these studies was poor with small sample sizes and few randomized-controlled trials. The efficacy of therapies varied across treatment arms, treatment duration, method of post-treatment assessment and geographic location. Among the regimens tested, 2-6 weeks of nitroimidazole and amoxicillin, 1-2 weeks of clarithromycin, amoxicillin and a proton pump inhibitor, and 2 weeks of a macrolide, a nitroimidazole and a proton pump inhibitor or bismuth, amoxicillin and metronidazole were the most efficacious in developed countries.

CONCLUSIONS

Before worldwide treatment recommendations are given for eradication of H. pylori, additional well-designed randomized placebo-controlled paediatric trials are needed, especially in developing countries where both drug resistance and disease burden is high.

Helicobacter pylori stool antigen test

OBJECTIVE

Helicobacter pylori ( H.pylori ) infection is usually acquired in early childhood. Invasive techniques used for diagnosis of H.pylori infection require endoscopic examination which is expensive and inconvenient and may cause complications. The aim of this study was to evaluate the performance of a new noninvasive diagnostic method, stool antigen test for H.pylori in untreated children with recurrent abdominal pain.

METHODS

Eighty children (35 female, 45 male) who have undergone upper gastrointestinal endoscopy due to recurrent abdominal pain were included in the study. The H.pylori stool antigen test (HpSA) is based on a sandwich enzyme immunoassay with antigen detection. HpSA sensitivity, specificity, and positive and negative predictive values were determined with reference to the results of both histology and rapid urease test as a gold standard ( H. pylori status).

RESULTS

While 49 of the 80 children (61%) tested were positive for H.pylori according to the results of both histology and rapid urease test, 28 children had negative H.pylori status. Among those 49 children, 48 were found to be positive by HpSA. Of 28 patients with negative H.pylori status, 28 were H.pylori -negative also in the stool test. The sensitivity, specificity, and positive and negative predictive values of HpSA were found to be 98%, 100%, 100%, and 96.5%, respectively.

CONCLUSION

These findings have demonstrated that HpSA as a relatively simple, inexpensive and time saving noninvasive test is a reliable method for detection of H.pylori infections in children.

Helicobacter pylori and recurrent pain abdomen

OBJECTIVE

Pain abdomen is a common problem in childhood. Many factors i.e., organic changes in the gut, psychological and environment contribute to recurrent pain abdomen (RAP) in children. Helicobacter pylori infects children very early in childhood and stays indefinitely in the gut without its eradication. It may be responsible for pain abdomen and peptic ulcers in children. This study was done to assess the HP status in children with RAP diagnosed and evaluate the effects of eradication of HP infection in them.

METHODS

76 children were included in the study.

RESULT

Out of 76 children studied 14.8% had evidence of a secondary cause for pain abdomen and responded to appropriate therapy. 65.45% of children who had undergone UGIE, had evidence of HP infection in the upper gastrointestinal tract. Most of these children responded to HP eradication therapy by becoming free of abdominal pain after the eradication therapy with OCA or OMA regimen. We could not do repeated endoscopies in all of them to prove the eradication due to parents' refusal and this is the main drawback of this study.

CONCLUSION

However, in view of clinical response to HP eradication therapy in almost all the cases, we strongly advocate this therapy for those children with RAP, in whom HP infection of the upper gastrointestinal tract can be established beyond doubt.

Expression of cytokeratins 7 and 20 in Helicobacter pylori-associated chronic gastritis in children

Helicobacter pylori gastric infection induces structural changes in the gastric epithelium. Among them, variations in the expression of cytokeratins have been reported in adult patients. In the present study, we describe the expression of CK7 and CK20 in gastric samples taken from the antrum in three groups of pediatric patients: (A) Helicobacter pylori-associated chronic gastritis (mean age: 11.4 years); (B) previous H. pylori chronic gastritis patients (mean age: 9.4 years); and (C) controls (mean age: 8.8 years). In all, the presence of sulfomucins was assessed with Alcian blue-periodic acid-Schiff pH 1.0. Immunoreactivity was graded as absent (0), weak (1+), moderate (2+), or intense (3+), in accordance with the intensity of the staining, and its distribution as focal or diffuse. CK7 reactivity was 2+ either focal or diffuse in all group A biopsies. The reactivity was more evident in the cells at the neck of the glands, in the areas with more inflammatory infiltrates, decorating long vertical segments of epithelium. In groups B and C, CK7 reactivity was also focal and 1+ at the cells of the necks of the glands. However, group B presented longer vertical segments of positive cells as compared to group C, and shorter than those of group A. The deeper glandular structures were focally 1+ in both groups. CK20 expression was comparable in all three groups, depicting a 2+ diffuse reactivity at the surface epithelium and interposed pits with absence or focal reactivity at the neck and coiled gland areas. Ki-67 immunostaining paralleled that of the CK7. Staining for sulfated mucosubstances was positive in two of five cases of groups A and B, and in none of the cases of group C. We conclude that: (1) the long segments of CK7-positive glandular necks in H. pylori cases most probably indicate intense regenerative activity during active inflammation; (2) eradication of H. pylori does not warrant ad integrum restitution since long segments of Ki-67+, CK7+ cells at the germinative compartment of the glands (as well as cells with sulfomucins) were still recognizable in ex- H. pylori patients; (3) finally, differing from what happens in adults, children somehow manage to maintain fully differentiated CK20+ superficial epithelium while the H. pylori is in action.

A population-based survey on gastrointestinal tract symptoms and Helicobacter pylori infection in children and adolescents

BACKGROUND

Helicobacter pylori infection is a frequent infection mainly acquired in childhood. Even if the infection is almost invariably associated with mild to severe gastro-duodenal lesions, no specific clinical picture has been identified. The aim of this study was to evaluate the presence of dyspeptic symptoms and their relationship with the presence of H. pylori infection in the first two decades of life.

MATERIALS AND METHODS

A school-population sample size of 808 subjects from 6- to 19-year-olds was investigated for the presence of gastrointestinal tract symptoms and evaluated by a 13C-urea breath test for H. pylori infection. The relationship between clinical findings and H. pylori infection was evaluated by chi2 statistic or Fisher's exact test, as appropriate.

RESULTS

Symptoms of dyspepsia were identified in 45% of subjects, while the picture of ulcer-like and dysmotility-like forms were present in 3-4%. H. pylori infection was demonstrated in 95 (11.8%) subjects, 49.5% of them without symptoms. Severe epigastric pain and ulcer-like dyspepsia were significantly associated with H. pylori infection, while recurrent abdominal pain or dysmotility-like dyspepsia were not.

CONCLUSIONS

Dyspeptic symptoms are frequent in children, and its association with H. pylori infection is more evident than with recurrent abdominal pain. The age at which the infection is acquired seems to be under 6 years of age.

Accuracy of office-based immunoassays for the diagnosis of Helicobacter pylori infection in children

BACKGROUND

Rapid non-invasive diagnostic tests that can reliably document the presence or absence of Helicobacter pylori infection are urgently required. The aim of this study was to determine the accuracy of two immunoassays (Flex-Sure and MedMira), developed for use outside the laboratory setting by practitioners, in the setting of a low prevalence of H. pylori infection.

METHODS

Serum samples collected in four previous studies (n = 349) were employed to detect the presence of H. pylori-specific immunoglobulin G, compared to previous results obtained using endoscopic biopsies, serology, flow cytometry, and urease breath testing. Serum samples included 52 obtained from adults (parents and grandparents of symptomatic children), 123 sera collected from children and adolescents undergoing diagnostic upper endoscopy for upper gastrointestinal tract symptoms, and 174 samples drawn from children in the primary care setting with or without recurrent abdominal pain.

RESULTS

Overall, 16% of subjects were infected by the gastric pathogen. Both the specificity (%) and negative predictive value (%) of the two tests were high (FlexSure: 91 and 92; Medmira: 97 and 94, respectively). In adults, both tests also demonstrated high sensitivity (83% and 86%) and positive predictive values (79% and 83%, respectively). However, in children where the prevalence of infection was 12% (37 of 297 subjects), the sensitivity (59% and 71%) and positive predictive values (55% and 88%, respectively) of the immunoassays were lower.

CONCLUSIONS

These findings indicate that, in the setting of a low prevalence of H. pylori infection, the MedMira office-based test provides satisfactory results and utility. However, the low positive-predictive value of the FlexSure kit may limit applicability of this test in children.

[Epidemiological aspects of Helicobacter pylori infection in childhood and adolescence]

The scope of the review is to study the epidemiological aspects of Helicobacter pylori infection and its importance during childhood and adolescence, focusing on incidence, prevalence, transmission and risk factors. The study's references included the following databases: LILACS (PAHO/ Bireme), MEDLINE, the US's National Library of Medicine and the thesis developed at University of São Paulo for the period 1983 to 1999. It was noted that Helicobacter pylori infection is mainly acquired during childhood, age-related prevalence, main risk factors are associated to low socioeconomic status, and its transmission mechanism remains unclear.

Helicobacter pylori infection in patients with idiopathic short stature

BACKGROUND

Some investigators have recently described an association between Helicobacter pylori infection and children with short stature. In the present study, we aimed to evaluate children with short stature with different etiologies.

METHODS

This study evaluated short patients aged from 1 to 16 years. These patients were divided into a growth hormone deficient short stature group (n = 27) and an idiopathic short stature group (n = 14). A control group included children with normal growth and no abdominal pain (n = 47). Anti-H. pylori antibodies were measured in each group (total of 88).

RESULTS

The antibody positivity rates for each group were as follows: growth hormone deficient short stature group, 7.4%; idiopathic short stature group, 28.6%; and control group, 6.4%. The H. pylori antibody positivity rate in the idiopathic short stature group was significantly higher than in the control group.

CONCLUSION

Our findings suggest an association between H. pylori infection and idiopathic short stature.

[Prevalence of Helicobacter pylori infection in children evaluated at "Hospital de Clínicas de Porto Alegre", RS, Brazil]

OBJECTIVES

To determine prevalence of Helicobacter pylori infection in a group of symptomatic patients between 2 and 18 years old who were submitted to gastric biopsy during upper endoscopy done in the period of 1990-97. To correlate the histological findings with clinical and endoscopical data.

METHODS

A cross-sectional study done after review of clinical and histopathological data. Histopathological sections were reviewed by a pathologist, who did not know the clinical information and the previous histopathological reports.

RESULTS

Among 181 patients evaluated, prevalence of Helicobacter pylori infection was 24.86% (45 positive cases). In pathological analysis, gastritis was found in 38/45 of the positive Helicobacter pylori patients and in 45/136 negative Helicobacter pylori. Gastric ulceration was found in 6/45 positive Helicobacter pylori and in 3/136 negative Helicobacter pylori.

CONCLUSION

This study stated a significative association between Helicobacter pylori infection and pathological abnormalities in children evaluated in the "Hospital de Clínicas de Porto Alegre", RS, Brazil.

A comprehensive review of the natural history of Helicobacter pylori infection in children

Across populations of children, Helicobacter pylori prevalence ranges from under 10% to over 80%. Low prevalence occurs in the U.S., Canada, and northern and western Europe; high prevalence occurs in India, Africa, Latin America, and eastern Europe. Risk factors include socioeconomic status, household crowding, ethnicity, migration from high prevalence regions, and infection status of family members. H. pylori infection is not associated with specific symptoms in children; however, it is consistently associated with antral gastritis, although its clinical significance is unclear. Duodenal ulcers associated with H. pylori are seldom seen in children under 10 years of age. H. pylori-infected children demonstrate a chronic, macrophagic, and monocytic inflammatory cell infiltrate and a lack of neutrophils, as compared with the response observed in adults. The effect of H. pylori infection on acid secretion in children remains poorly defined. The events that occur during H. pylori colonization in children should be studied more thoroughly and should include urease activity, motility, chemotaxis, adherence, and downregulation of the host response. The importance of virulence determinants described as relevant for disease during H. pylori infection has not been extensively studied in children. Highly sensitive and specific methods for the detection of H. pylori in children are needed, especially in younger pediatric populations in which colonization is in its early phases. Criteria for the use of eradication treatment in H. pylori-infected children need to be established. Multicenter pediatric studies should focus on the identification of risk factors, which can be used as prognostic indicators for the development of gastroduodenal disease later in life.

Is Helicobacter pylori a cause of infantile hypertrophic pyloric stenosis?

My hypothesis is that infantile hypertrophic pyloric stenosis (IHPS) is caused in some cases by Helicobacter pylori (HP) a bacterium commonly found in the human stomach. IHPS is an idiopathic condition of infancy. It occurs at about 5 weeks of age in 3 per 1000 newborns. Children with IHPS have structurally normal pylori at birth and do not resemble children with congenital anomalies. Some nonspecific evidence (temporal distribution, seasonality, familial clustering, leukocytic infiltrates, and increased risk with bottle feeding) are compatible with an infectious etiology. Some other epidemiologic features of IHPS, such as its strong male predominance, its racial and social class variation, and a possible drop in its incidence, are also features of HP infection. Clinical features of IHPS, such as vomiting, hematemesis, and esophagitis, are also consistent with HP. Finally, children with IHPS appear to be more likely to develop chronic conditions, such as peptic ulcers, now known to be caused by HP.

Sulfomucins in Helicobacter pylori-associated chronic gastritis in children: is this incipient intestinal metaplasia?

BACKGROUND

Little is known about early stages of intestinal metaplastic in chronic gastritis. The purpose of this study was to determine the presence of sulfated mucosubstances hence most probably intestinal metaplasia, in isolated cells of surface gastric pits, and glands in pediatric patients with Helicobacter pylori-associated chronic gastritis.

METHODS

Participants were nine patients (nine different biopsies; mean age 11.5 years, range 3-16 years) with sulfomucin-containing cells evident in the gastric biopsy specimen. Eight of the patients were selected from a group of 15 patients with histologically documented H. pylori-associated chronic gastritis in whom the utility of the Sydney system was being tested.

RESULTS

Symptoms and endoscopic findings of H. pylori-associated chronic gastritis were the same regardless of the presence or absence of sulfomucin-containing cells. On hematoxylin and eosin stained tissues, neither intestinal metaplasia nor atrophy was apparent. However, periodic acid-Schiff (PAS)-alcian blue (pH 1.0) stain revealed the presence of sulfated mucosubstances in isolated cells of gastric pits and glands in the nine patients.

CONCLUSIONS

This finding may represent a "minimal" form of incomplete intestinal metaplasia (type III). Because the nine patients had been untreated, the change is probably reversible. Two follow-up biopsies in patients in whom H. pylori had been treated and eradicated showed absence of sulfated mucins. Although these findings cannot be regarded as fully developed type III intestinal metaplasia, it is possible that left untreated, the alteration may persist and evolve into some other complication. This conclusion justifies follow-up of these patients.

Helicobacter pylori seropositivity in patients with severe neurologic impairment

The objective of this study was to assess the prevalence of Helicobacter pylori seropositivity in institutionalized patients with severe neurologic impairment. Anti-H. pylori immunoglobulin G antibody in serum was measured in 196 institutionalized Japanese patients using enzyme linked immunosorbent assay, taking an antibody level >50 units/ml as evidence of H. pylori seropositivity. Patient age pattern and duration of institutionalization were examined for the relationships with H. pylori seropositivity. We also examined for seroconversion indicating new H. pylori infection in initially negative patients 1 year later. Positivity for H pylori infection among institutionalized patients was also compared with positivity among patients living at home. H. pylori seropositivity was present in 81.1% of subjects. Prevalence of H. pylori seropositivity increased with both age and duration of institutionalization. The serum level of anti-H. pylori immunoglobulin G antibody in patients over 20 years old was consistently high, approximately twice that of subjects less than 10 years of age. Of 38 patients initially negative for H. pylori infection, 18 (47.4%) had become positive at 1 year. H. pylori seropositivity was significantly more prevalent among institutionalized patients than among patients living at home (P < 0.0001). This study confirms that high H. pylori seropositivity rates are found among institutionalized patients with severe neurologic impairment. Our observations suggest person to person transmission, with fecal to oral, salivary secretion and respiratory droplet routes possibly being important pathways.

Peptic ulcer disease and exposure to domestic pets

OBJECTIVES

This study assessed whether an association exists between household pets and peptic ulcer disease.

METHODS

Canadian adults (n = 15,779) were asked about cats or dogs in their household and about history of peptic ulcer disease. Logistic regression was used to assess the association between pet ownership and a history of peptic ulcer disease, after adjustment for sociodemographic differences.

RESULTS

No relationship was observed between report of household pets and a history of peptic ulcer disease (adjusted odds ratio = 1.14, 95% confidence interval = 0.95, 1.36).

CONCLUSIONS

In a large sample of Canadian adults, no association was observed between pet ownership and a history of peptic ulcer disease.

Campylobacter upsaliensis: waiting in the wings

Despite strong epidemiological evidence supporting an important role for Campylobacter upsaliensis as a human enteropathogen, it remains relatively unknown in the realm of clinical microbiology. Clinical studies indicate that infection with this organism usually is associated with benign self-limiting diarrhea. However, more serious illnesses, including spontaneous abortion and hemolytic-uremic syndrome, recently have been associated with human infections. Understanding of the virulence properties and molecular biology of C. upsaliensis is beginning to evolve. There is now a pressing need for controlled, prospective epidemiologic studies in addition to further in-depth investigation of the pathogenesis of this enteric campylobacter to more precisely define its role in human disease. Furthermore, since C. upsaliensis is sensitive to the antibiotics routinely used in Campylobacter selective media, widespread appreciation of the importance of this organism will rely on the development of widely applicable, effective techniques for its isolation.

Macrolide antibiotics

This article is an extensive review of current information available on the macrolide antibiotics. This includes antimicrobial spectrum, pharmacology, complications and side effects, and pediatric use of these drugs. These are important antibiotics, but careful selection of patients must be made and the physician must be alert for evidence of drug-drug interactions, which are not uncommon with several members of this class.

Helicobacter pylori: challenges for the paediatrician

During the last 15 years, a great body of knowledge about Helicobacter pylori has been accumulated. Much, however, remains to be studied, particularly in relation to children. The vast majority of infections occur in childhood. It is towards children that any widespread screening, prevention or treatment strategies would need to be aimed. In this annotation, we discuss the epidemiology, symptomatology, diagnosis and treatment of H. pylori in children.

Health care of the internationally adopted child. Part 2: Chronic care long-term medical issues

Internationally adopted children remain at risk throughout their lives for medical sequelae related to their birth and residence in a foreign country. In the early period after placement the most important problems are the management of chronic infectious diseases and malnutrition. Over time, however, many children will have issues related to growth, age determination, timing of puberty, dental care, development, and language acquisition. Chronic disease and ethnic health considerations pose some special problems for the adopted child without a personal or family history. Part 1 of this series addressed the initial evaluation for the newly arrived internationally adopted child, whereas part 2 discusses the long-term management problems. J Pediatr Health Care.

Capsaicin as an inhibitor of the growth of the gastric pathogen Helicobacter pylori

Capsaicin, the active ingredient in chili, has been implicated as both a cytoprotective and a detrimental agent to the gastric mucosa. The effect of capsaicin on Helicobacter pylori has not been investigated previously. Therefore, we performed in vitro time- and concentration-dependent studies to examine the growth of H. pylori in the presence of capsaicin. Capsaicin specifically inhibited growth of H. pylori dose-dependently at concentrations greater than 10 micrograms ml-1 (P < 0.05) but did not inhibit the growth of a human fecal commensal Escherichia coli strain. Bactericidal activity was observed within 4 h. Capsaicin continued to exhibit bactericidal activity when incubated at pH values as low as 5.4. Ingestion of chili, therefore, could have a protective effect against H. pylori-associated gastroduodenal disease. This effect deserves further study in animal models.