Combining the serum pepsinogen level and Helicobacter pylori antibody test for predicting the histology of gastric neoplasm

Assessing Serum Pepsinogen and Helicobacter pylori Tests for Detecting Diffuse-Type Gastric Cancer: Insights from a Large-Scale and Propensity-Score-Matched Study in Republic of Korea

The incidence of cancer and its associated mortality have increased over the past several decades [...].

Diagnostic value of combined detection of three gastric functions and Helicobacter pylori typing in chronic gastritis and gastric cancer

This research attempted to clarify the clinical diagnostic value of combined detection of gastric function and Helicobacter pylori (Hp) serotyping in chronic gastritis and gastric cancer (GC). The 80 chronic non atrophic gastritis (CNAG) patients treated in our hospital from October 2021 to October 2022 received selection as the CNAG group. The 96 chronic atrophic gastritis (CAG) patients diagnosed by gastroscopy and pathology in the same period received selection as CAG group. During the same period, 50 patients diagnosed with GC received inclusion in GC group. Pepsin I (PG I), PG II (PG II), gastrin-17 (G-17) and Hp serotyping received detection and comparison in three groups. The diagnostic efficacy of PG Ⅰ, PG Ⅱ, G-17, the ratio of serum PG I to PG II (PGR), and Hp serotyping in chronic gastritis and GC received evaluation by receiver operating characteristic (ROC). Relative to in the CNAG group, PG I and PGR levels in the other two groups exhibited depletion (P < 0.05); no statistical significance was observed in the PG II level among the three groups (P > 0.05); relative to the CNAG group, the G-17 level in the other two groups exhibited elevation (P < 0.05). Total Hp positive rate was 61.06 %, among which GC group exhibited the highest positive rate (72.00 %), and type I Hp positive rate also exhibited the highest in GC group (60.00 %). The type II Hp positive rate exhibited the highest in CNAG group (15.00 %). The PG I and PGR levels in type I Hp positive patients exhibited depletion relative to those in type II Hp positive patients, whereas PG II and G-17 levels exhibited elevation. When testing each indicator alone, the area under the curve (AUC) of PG I exhibited the highest in CNAG group, which was 0.874. When testing each indicator alone, AUC of Hp typing exhibited the highest in CAG group, which was 0.515. When testing each indicator alone, AUC of G-17 exhibited the highest in GC group, which was 0.787. The performance of combined detection was better than that of individual detection, with AUCs greater than 0.9 in three groups. In conclusion, changes in PG I, PG II, PGR and G-17 levels and Hp serotyping can receive application as screening indicators for chronic gastritis and GC, which can reflect relevant status of gastric mucosa to varying degrees. Combined detection of indicators has higher diagnostic performance and can receive application as an auxiliary diagnostic indicator in addition to gastroscopy biopsy, providing a reference basis for the formulation of clinical diagnosis and treatment plans.

Helicobacter pylori Infection Status and Gastric Tumor Incidence According to the Year of Birth

Background/Aims

: The prevalence of Helicobacter pylori-naive status is increasing. Nonetheless, biennial gastroscopy is recommended for all Koreans aged 40 to 75 years. This study aimed to determine whether gastric cancer screening guidelines could be changed according to H. pylori infection status and year of birth.

Methods

: Koreans who underwent serum assays and gastroscopy for gastric cancer screening between 2010 and 2016 were included if screening tests were followed up for ≥3 times. H. pylori infection was confirmed when invasive tests or 13C-urea breath tests were positive. In the case of negative test findings, eradication history, serologically detected atrophy, and intestinal metaplasia/atrophy were checked for past infection. If all were absent, H. pylori-naive status was confirmed.

Results

: Two-thousand and two (256 H. pylori-naive, 743 past-infected, and 1,003 infected) Koreans underwent screening tests for 95.5±28.4 months. The mean year of birth in the naive group (1969±7) differed from those of the past-infected (1957±10, p<0.001) and infected (1958±10, p<0.001) groups. H. pylori-naive status was correlated with recent year of birth (r=0.368, p<0.001). No gastric tumors were observed among the naive participants (p=0.007), whereas 23 adenomas, 18 adenocarcinomas, and two neuroendocrine tumors were detected in 1.9% (14/743) of past-infected and 2.5% (25/1,003) of infected participants, including four infected participants with metachronous tumors.

Conclusions

: The prevalence of H. pylori-naive status is increasing in young Koreans, and gastric tumors are rare in this population. Hence, biennial gastroscopy could be waived after the confirmation of naive status.

Useful Serum Pepsinogen Levels for Detecting Ongoing Helicobacter pylori Infection in Asymptomatic Subjects: A Cross-Sectional Study Based on 13C-urea Breath Test Findings

BACKGROUND /AIMS

The serum pepsinogen (PG) assay is used to screen subjects at high risk for gastric cancer. Currently, there are few studies on the PG levels for the detection of Helicobacter pylori infection. This study aimed to determine the PG assay findings for detecting ongoing infection.

METHODS

Asymptomatic subjects who underwent a ¹³C-urea breath test (¹³C-UBT) on the day of gastroscopy and serum assay for cancer screening were included. Subjects with a recent intake of acid suppressants or antibiotics, gastrectomy, or renal failure were excluded. H. pylori infection was defined as a positive ¹³C-UBT result.

RESULTS

Among the 500 included subjects, 167 (33.4%) had current infection. The serum PG II levels of > 12.95 ng/mL (area under the curve [AUC] = 0.930, sensitivity 86.5%, specificity 90.7%) and PG I/II ratios of < 4.35 (AUC = 0.875, sensitivity 86.8%, specificity 79.6%) were related to infection. The PG I/II ratios were inversely correlated with age (r = -0.160, p = 0.039). The cutoff values of PG I/II ratios were lower in older subjects aged ≥ 50 years (< 4.05; AUC = 0.875, sensitivity 80.7%, specificity 88.2%) than in younger subjects aged < 50 years (< 4.35; AUC = 0.873, sensitivity 77.4%, specificity 88.9%).

CONCLUSIONS

Serum PG II levels > 12.95 ng/mL and PG I/II ratios < 4.35 suggest ongoing infection in asymptomatic subjects; therefore, H. pylori confirmation tests (i.e., ¹³C-UBT) should be considered under these conditions. Stricter criteria are required in older subjects aged ≥ 50 years (PG I/II ratio < 4.05) to detect ongoing infection than younger subjects.

Prognosis of Seronegative Subjects with a Helicobacter pylori-infected Spouse

Background/Aims: Helicobacter pylori (H. pylori) can disseminate between couples. The present study compared the findings of gastric cancer screening between seronegative subjects according to the presence of an infected spouse.Materials and Methods: Follow-up data of seronegative subjects were analyzed among married couples who underwent gastric cancer screening via gastroscopy, serum pepsinogen, and anti-H. pylori IgG assays between January 2010 and May 2016. New detection rates of H. pylori infection and gastric neoplasm at the follow-up screening were compared between seronegative subjects according to the H. pylori-infected status of spouse.Results: Among 246 seronegative subjects with an H. pylori-infected spouse, 92 underwent follow-up tests (case group). Among 278 seronegative subjects with seronegative spouse, 94 underwent follow-up tests (control group). The past infection rate was higher in the case group than in the control group (52/92 vs. 34/94; P=0.005). New H. pylori infection was diagnosed in three of the 92 cases and two of the 94 controls (3.2% vs. 2.1%; P=0.681). During the mean follow-up of 67.9±36.0 months, three adenocarcinomas and two adenomas (5/184) were newly detected among the cases and their spouses, whereas none (0/188) were detected among the controls and their spouses (2.7% vs. 0%; P=0.029).Conclusions: Gastric neoplasm occurred more frequently in couples with an H. pylori-infected spouse. Because the past infection rate is higher among seronegative subjects with an infected spouse, gastric cancer screening is recommended in both partners when the spouse is infected.

Serum Assay Findings after Successful Helicobacter pylori Eradication

Serum pepsinogen (PG), anti-Helicobacter pylori (H. pylori) immunoglobulin G (IgG), and gastrin-17 (G-17) are plasma biomarkers for gastritis. H. pylori serology titers and PG levels increase during active H. pylori infection; moreover, elevated PG II levels indicate a high risk for diffuse-type gastric cancer in East Asian populations. Serum PG I/II ratios and PG I levels decrease with the progression of gastric corpus atrophy; thus, a combination of serum PG I levels ≤70 ng/mL and a PG I/II ratio ≤3 (serologic atrophy) indicates a high risk of intestinal-type gastric cancer. Serum G-17 is often not used as an indicator in H. pylori-seroprevalent populations because it is usually elevated in subjects with H. pylori infections. When H. pylori is eradicated, most patients show a rapid decrease in serum PG II levels and anti-H. pylori IgG titers within a few months. Seroreversion is required for several months to years after regression of H. pylori. Moreover, seroreversion may not always be achieved in all eradicated cases. The serum PG I/II ratio starts to increase after eradication; therefore, serologic atrophy improves accordingly, unless severe atrophy is present. Thus, some eradicated patients may show normal serum assay findings but have a higher risk for developing gastric cancer than H. pylori-naive subjects. Furthermore, serum PG levels decrease after gastrectomy and increase with the intake of certain drugs (e.g., aspirin or acid suppressants) or in renal failure patients. Due to such wide variations, serum assays are inadequate for the confirmation of H. pylori eradication. It is useful when interpreted with gastroscopy and other H. pylori test findings.

The Diagnostic Value of Serum Gastrin-17 and Pepsinogen for Gastric Cancer Screening in Eastern China

Objective

To evaluate the diagnostic value of gastrin-17 (G-17) and pepsinogen (PG) in gastric cancer (GC) screening in China, especially eastern China, and to determine the best diagnostic combination and threshold (cutoff values) to screen out patients who need gastroscopy.

Methods

The serum concentrations of G-17 and pepsinogen I and II (PGI and PGII) in 834 patients were analyzed, and the PGI/PGII ratio (PGR) was calculated. According to pathological results, patients can be divided into chronic nonatrophic gastritis (NAG)/chronic atrophic gastritis (CAG)/intraepithelial neoplasia (IN)/GC groups. The differences in G-17, PG, and PGR in each group were analyzed, and their values in GC diagnosis were evaluated separately and in combination.

Results

There were differences in serum G-17, PGII, and PGR among the four groups (NAG/CAG/IN/GC) (P ≤ 0.001). In total, 54 GC cases were diagnosed, of which 50% were early GC. There was no significant difference in the PGI levels among the four groups (P = 0.377). NAG and CAG composed the chronic gastritis (CG) group. The G-17 and PGII levels in the IN and GC groups were higher than those in the CG group (both P ≤ oth C), while the PGR levels were lower (P ≤ lower). When distinguishing NAG from CAG, the best cutoff value for G-17 was 9.25 pmol/L, PGII was 7.06 μg/L, and PGR was 12.07. When distinguishing CG from IN, the best cutoff value for G-17 was 3.86 pmol/L, PGII was 11.92 μg/L, and PGR was 8.26. When distinguishing CG from GC, the best cutoff value for G-17 was 3.89 pmol/L, PGII was 9.16 μg/L, and PGR was 14.14. The sensitivity, specificity, accuracy, and positive and negative predictive values of G-17/PGII/PGR for GC diagnosis were 83.3%/70.4%/79.6%, 51.8%/56.3%/47.8%, 53.8%/57.2%/49.9%, 10.7%/10.9%/9.6%, and 97.8%/96.5%/97.1%, respectively. The sensitivity, specificity, accuracy, and positive predictive and negative predictive values of PGII/G-17 vs. PGR/G-17 vs. PGR/PGII in the diagnosis of GC were 63.0% vs. 70.4% vs. 64.8%, 70.5% vs. 70.1% vs. 60.4%, 70.0% vs. 70.1% vs. 60.7%, 12.9% vs. 14.0% vs. 10.2%, and 96.5% vs. 97.2% vs. 96.1%, respectively.

Conclusion

The PGII and G-17 levels in patients with gastric IN and GC were significantly increased, while the serum PGR level was significantly decreased. Serological detection is effective for screening GC. The combination of different markers can improve the diagnostic efficiency. The highest diagnostic accuracy was G-17 combined with PGR, and the best cutoff values were G − 17 > 3.89 pmol/L and PGR < 14.14.

Incidence of Infection among Subjects with Helicobacter pylori Seroconversion

Background/Aims

Helicobacter pylori (H. pylori) seroconversion may occur during screening for gastric cancer. Our study aimed to assess the number of seroconverted subjects with H. pylori and their results in follow-up tests.

Methods

Data were consecutively collected on subjects who were H. pylori-seronegative and presented for gastric cancer screening. Subjects who were followed up using the same serology test and pepsinogen (PG) assays on the day of endoscopy were included in the study.

Results

During the follow-up of 57.7 ± 21.4 months, 61 (15.0%) of 407 seronegative subjects showed seroconversion. H. pylori infection was detected in six (9.8%) of 61 seroconverted subjects. A diffuse red fundal appearance, with a significant increase in the Kyoto classification scores for gastritis, was observed in the infected subjects (p<0.001). Compared to the false-seropositive subjects, infected subjects showed higher serology titers (p<0.001) and PG II levels (p<0.001), and lower PG I/II ratios (p=0.002), in the follow-up tests.

Conclusions

Seroconversion occurred in 3.3% of seronegative subjects per year; however, only 9.8% had H. pylori infection. The majority (90.2%) of the seroconverted subjects showed false seropositivity without significant changes in the follow-up test results. The diffuse red fundal appearance could be an indicator of H. pylori infection.

ABC Classification Is Less Useful for Older Koreans Born before 1960

Background/Aims

In the ABC classification system, group A consists of seronegative subjects without gastric corpus atrophy. This study aimed to determine the prevalence and characteristics of pseudo group A subjects.

Methods

Group A subjects were identified among consecutive Korean adults who underwent a serum anti-Helicobacter pylori immunoglobulin G (IgG) test and pepsinogen (PG) assay on the day of endoscopy. Past infection was defined as the presence of either eradication history or endoscopic findings suggesting past infection (i.e., gastric xanthoma, metaplastic gastritis, or advanced atrophy >closed-type 1).

Results

Among 2,620 group A subjects, 448 (17.1%) had eradication history, and 133 (5.1%) showed endoscopic findings suggesting past infection. Older age (odds ratio [OR], 1.148; 95% confidence interval [CI], 1.067 to 1.236) and earlier year of birth (OR, 1.086; 95% CI, 1.009 to 1.168) were independent risk factors for classification into pseudo group A, with cutoff points at 50.5 years and birth year of 1959.5, respectively. Positive H. pylori test findings were found in 22 subjects (3.1%) among the 715 subjects who underwent the urea breath test or Giemsa staining on the same day. Current infection was positively correlated with PG I and PG II levels (p<0.001) but not with age, anti-H. pylori IgG titer, or classification into pseudo group A.

Conclusions

Among the group A subjects, 22.2% had past infection. The risk was higher in subjects older than 50 years, especially those born before 1960. Furthermore, current infection was found in 3.1% of the subjects and was correlated with increased gastric secretory ability.

[Advances in serum biomarkers for early diagnosis of gastric cancer]

Early diagnosis is the key to improve the prognosis of gastric cancer. How to screen out high-risk subjects of gastric cancer in population is a hot spot. Serum-based early detection of gastric cancer is suitable for high-risk population screening, which is more convenient and safer. This article reviews the diagnostic value of serum biomarkers for gastric cancer, including serum DNA methylation, various RNAs, pepsinogen, gastrin, osteopontin, MG7-Ag and CA724. Until now, there is still lack of ideal biomarkers for gastric cancer, and searching for specific RNAs may be promising for early diagnosis and screening of gastric cancer.

Clinical significance of serum markers reflecting gastric function and H. pylori infection in colorectal cancer

Purpose: The study was conducted to investigate the relationship of serum pepsinogens PGI, PGII, gastrin-17, and Hp-IgG with colorectal cancer (CRC), aiming to explore the clinical significance of serum markers reflecting gastric function and H. pylori infection in CRC. Methods: A total of 569 CRC cases and 569 age and sex-matched controls were enrolled in this study between June 2012 and April 2016 from The First Hospital of China Medical University. The serum markers reflecting gastric function and H. pylori infection were detected using ELISA, including PGI, PGII, PGI/II ratio, G-17 and Hp-IgG. Information of clinicopathological parameters and tumor biomarkers was collected from the medical records of inpatients, including CEA, CA199, CA125, CA153 and AFP. Results: Serum PGII, G-17 levels and Hp-IgG were increased in CRC, while PGI and PGI/II ratio appeared no significant difference between CRC and controls. In subgroup analysis, PGII was more significant in males (P=0.014). Hp-IgG was demonstrated higher in age<60y (P=0.001). With respect to the association with serum tumor biomarkers, G-17 level was associated with the rise of CA125 (P=0.005, OR (95%CI): 4.89 (1.90-12.57)), Hp-IgG increasing was associated with the rise of CA125 (P=0.024, OR (95%CI): 4.10 (1.54-10.93)). Conclusions: Serum PGII, G-17 and Hp-IgG were associated with CRC risk. The serum levels of G-17 and Hp-IgG were associated with the rise of CA125 in patients with CRC.

Prediction of Chronic Atrophic Gastritis and Gastric Neoplasms by Serum Pepsinogen Assay: A Systematic Review and Meta-Analysis of Diagnostic Test Accuracy

Serum pepsinogen assay (sPGA), which reveals serum pepsinogen (PG) I concentration and the PG I/PG II ratio, is a non-invasive test for predicting chronic atrophic gastritis (CAG) and gastric neoplasms. Although various cut-off values have been suggested, PG I ≤70 ng/mL and a PG I/PG II ratio of ≤3 have been proposed. However, previous meta-analyses reported insufficient systematic reviews and only pooled outcomes, which cannot determine the diagnostic validity of sPGA with a cut-off value of PG I ≤70 ng/mL and/or PG I/PG II ratio ≤3. We searched the core databases (MEDLINE, Cochrane Library, and Embase) from their inception to April 2018. Fourteen and 43 studies were identified and analyzed for the diagnostic performance in CAG and gastric neoplasms, respectively. Values for sensitivity, specificity, diagnostic odds ratio, and area under the curve with a cut-off value of PG I ≤70 ng/mL and PG I/PG II ratio ≤3 to diagnose CAG were 0.59, 0.89, 12, and 0.81, respectively and for diagnosis of gastric cancer (GC) these values were 0.59, 0.73, 4, and 0.7, respectively. Methodological quality and ethnicity of enrolled studies were found to be the reason for the heterogeneity in CAG diagnosis. Considering the high specificity, non-invasiveness, and easily interpretable characteristics, sPGA has potential for screening of CAG or GC.

[Identification of Nodular Gastritis among Patients Diagnosed with Lymphofollicular Gastritis on a Gastric Biopsied Specimen]

Background/Aims

Nodular gastritis (NG) is a well-known endoscopic finding observed in patients with a Helicobacter pylori infection, which may lead to invasive gastric cancer. Lymphofollicular gastritis consists of lymphoid follicles or lymphoid cell aggregates, and is common in children. The aim of this study was to identify patients with NG from those in whom gastric biopsied specimens showed lymphoid follicles and lymphoid cell aggregates.

Methods

Subjects, whose gastric biopsy specimens showed lymphoid follicles or lymphoid cell aggregates, were included in this study. The inclusion criterion was that they underwent a serum pepsinogen assay on the day of upper gastrointestinal endoscopy. NG was diagnosed if the endoscopy findings revealed regular-sized, multiple, colorless subepithelial nodules.

Results

Among 108 subjects who showed lymphoid follicles or lymphoid cell aggregates, 13 (12.0%) revealed NG on endoscopy, and all these subjects showed positive Giemsa staining. Patients diagnosed with NG were younger (p=0.012) and showed a female predominance (p=0.001) compared to those without NG. The mean serum pepsinogen levels were higher (p=0.001) and lymphoid follicle-dominant subjects were more common (p<0.001) in the NG subjects than in those without NG. Logistic regression analysis revealed a younger age (p=0.041) and female gender (p=0.002) to be significant independent risk factors for NG.

Conclusions

NG should be distinguished from lymphofollicular gastritis because only 12% of patients showing gastric biopsy findings of lymphoid follicles and lymphoid cell aggregates demonstrated NG on endoscopy. NG is an endoscopic finding that is more common in women and in the younger population, irrespective of the biopsy findings and gastric secretory ability.

Gastric Cancer Screening by Combined Determination of Serum Helicobacter pylori Antibody and Pepsinogen Concentrations: ABC Method for Gastric Cancer Screening

Objective:

Gastroscopy combined with gastric mucosa biopsies is currently regarded as a gold standard for diagnosis of gastric cancer. However, its application is restricted in clinical practice due to its invasive property. A new noninvasive population screening process combining the assay of anti-Helicobacter pylori antibody and serum pepsinogen (PG) (ABC method) is adopted to recognize the high-risk patients for further endoscopy examination, avoiding the unnecessary gastroscopy for most population and saving the cost consumption for mass screening annually. Nevertheless, controversies exist for the grouping of ABC method and the intervals of gastroscopy surveillance for each group. In this review, we summarized these popular concerned topics for providing useful references to the healthcare practitioner in clinical practice.

Data Sources:

The PubMed databases were systematically searched from the inception dates to November 22, 2017, using the keywords “Helicobacter pylori,” “Pepsinogens,” and “Stomach Neoplasms.”

Study Selection:

Original articles and reviews on the topics were selected.

Results:

Anti-H. pylori antibody and serum PG concentration showed significant changes under the different status of H. pylori infection and the progression of atrophic gastritis, which can be used for risk stratification of gastric cancer in clinic. In addition, anti-H. pylori antibody titer can be used for further risk stratification of gastric cancer contributing to determine better endoscopy surveillance interval.

Conclusions:

The early detection and diagnosis of gastric cancer benefit from the risk stratification, but the cutoff values for H. pylori antibody and serum PG concentration require further modification.

Long-term outcome of group D patients with negative serum anti-Helicobacter pylori antibody and positive serum pepsinogen test in healthy Koreans

OBJECTIVE

The aim of this study was to assess the clinical characteristics and long-term outcomes of group D patients (negative H. pylori antibodies and positive pepsinogen level).

METHODS

Group D patients were divided into two groups, that is, the limited endoscopic atrophic gastritis (EAG) group with EAG confined to the antrum and angle (C1 and C2) and the advanced EAG group with gastric body-involved EAG (C3 to O3). We compared the progression of precursor lesions and the occurrence of gastric neoplasms between the two groups.

RESULTS

Among 107 group D patients, the advanced EAG group (n = 60) was elder and had a lower pepsinogen I level and a lower pepsinogen I to II ratio (PGI/II) than the limited EAG group (n = 47). Among the 52 patients who underwent a follow-up endoscopy, three gastric neoplasms were detected (one in the limited and two in the advanced EAG groups). During a median follow-up of 44 months, 10 (43.5%) patients in the limited and 13 (52.0%) in the advanced EAG groups showed EAG progression or newly occurred intestinal metaplasia. A family history of GC (odds ratio [OR] 44.974, 95% confidence interval [CI] 1.360-1487.087), a lower PGI/II (OR 0.247, 95% CI 0.085-0.717) and a longer follow-up duration (OR 1.832, 95% CI 1.200-2.796) increased the risk of progression.

CONCLUSION

A family history of GC and low baseline PGI/II were independently associated with an increased risk of progression of precursor lesions of GC.

Characteristics of Helicobacter pylori-seropositive subjects according to the stool antigen test findings: a prospective study

BACKGROUND/AIMS

In countries with a higher risk of gastric atrophic gastritis, noninvasive tests are helpful for a more reliable diagnosis of Helicobacter pylori infection. The aim of this study was to evaluate the characteristics of seropositive subjects according to their stool H. pylori antigen test, serum pepsinogen (PG) assay, and endoscopic findings.

METHODS

Consecutive subjects who visited Konkuk University Medical Center for upper gastrointestinal endoscopy for a regular check-up were included in a prospective setting if the serum anti-H. pylori immunoglobulin G assay was positive. A H. pylori antigen stool test was measured using a stool H. pylori antigen enzyme-linked immunosorbent assay kit on the same day as a serum PG assay and endoscopy.

RESULTS

Of 318 seropositive subjects, 256 (80.5%) showed positive stool test findings. Subjects with a negative stool test result showed lower serum PG I (p < 0.001) and PG II (p < 0.001) levels and higher PG I/II ratio (p < 0.001) than those with a positive stool test. Chronic atrophic gastritis was more common in the positive stool test group than the negative stool test group on endoscopic finding (p = 0.009). A higher serum PG I level (p = 0.001) and a lower serum PG I/II ratio (p = 0.001) were independent risk factors for the presence of H. pylori antigen in stool.

CONCLUSION

A high serum PG level denotes an ongoing current H. pylori infection with positive stool H. pylori antigen test findings. Seropositive subjects with increased gastric secreting ability tend to have H. pylori in their fecal material as reflected by a positive stool H. pylori antigen test finding.

Predicting the Development of Gastric Neoplasms in a Healthcare Cohort by Combining Helicobacter pylori Antibodies and Serum Pepsinogen: A 5-Year Longitudinal Study

Background

Helicobacter pylori (HP) and gastric atrophy are risk factors for gastric cancer. We evaluated whether the combination of serum HP antibody and pepsinogen (PG), which is indicative of gastric atrophy, could serve as a predictive marker for the development of gastric neoplasms in a Korean population.

Methods

The subjects who had undergone health-screening examination with endoscopic follow-ups were classified into the following 4 groups according to serum PG status and HP antibody at baseline: group A (HP (-), normal PG), group B (HP (+), normal PG), group C (HP (+), atrophic PG), and group D (HP (-), atrophic PG). We compared the development of gastric neoplasms among the groups.

Results

Of the 3297 subjects, 1239 (37.6%) were categorized as group A, 1484 (45.0%) as group B, 536 (16.3%) as group C, and 38 (1.2%) as group D. During the 5.6 years of mean follow-up period, the annual incidence of gastric neoplasms increased gradually by 0.06% in group A, 0.16% in group B, 0.38% in group C, and 0.49% in group D. A Cox proportional hazard model showed increased development of gastric neoplasms according to group (P for trend = 0.025). Compared to group A, the hazard ratio was 8.25 for group D (95% confidence interval 0.2-74.24), 5.35 for group C (1.68-17.05), and 2.65 for group B (0.86-8.14).

Conclusion

The combination of serum PG and HP antibody is useful for predicting the development of gastric neoplasms, including cancer and adenoma, in a Korean population using endoscopic surveillance.

The histologic detection of Helicobacter pylori in seropositive subjects is affected by pathology and secretory ability of the stomach

BACKGROUND

Helicobacter pylori is unevenly distributed in hypochlorhydric environments. The study aim was to elucidate the risk factors for a negative Giemsa staining finding in seropositive subjects by measuring the secretory ability of the stomach.

METHODS

Subjects aged over 18 years were included consecutively after endoscopic biopsy at gastric lesions with color or structural changes. Blood was sampled for the serum pepsinogen (PG) assay and H. pylori serology test. After excluding the subjects with past H. pylori eradication, the risk factors for a negative Giemsa staining finding in seropositive subjects were analyzed.

RESULTS

Among 872 included subjects, a discrepancy between the serum anti-H. pylori IgG and Giemsa staining findings was found in 158 (18.1%) subjects, including 145 Giemsa-negative, seropositive subjects. Gastric adenocarcinoma/adenoma (OR = 11.090, 95% CI = 3.490-35.236) and low serum PG II level (OR = 0.931, 95% CI = 0.899-0.963) were the independent risk factors for a negative Giemsa staining finding in seropositive subjects. The cutoff value of serum PG II level was 7.45 ng/mL (area under curve [AUC] = 0.904, 95% CI = 0.881-0.927). Follow-up studies of Giemsa staining at different sites of the stomach revealed that 75% of the Giemsa-negative seropositive subjects with adenocarcinoma are positive, whereas none of those with low serum PG II level of <7.45 ng/mL revealed positive findings.

CONCLUSIONS

The risk of a negative Giemsa staining finding in seropositive subjects is increased in gastric adenocarcinoma/adenoma specimens and in subjects with a diminished gastric secretory ability with low serum PG II level of <7.45 ng/mL. A false-negative Giemsa staining finding is common in subjects with adenocarcinoma, and therefore, additional biopsies at different sites should be performed in these subjects.

The serum pepsinogen levels for risk assessment of gastric neoplasms: New proposal from a case-control study in Korea

To decrease the gastric cancer related mortality rate, endoscopic screening is widely performed in Korea. However, a precise method for identifying those at a high risk of gastric neoplasms has not been established. This study aims to evaluate serum pepsinogen (PG) levels for risk assessment of gastric neoplasms. Between August 2014 and March 2016, a total of 398 subjects, including 87 with gastric neoplasms, were enrolled in this study. On the basis of the serum PG I/II ratio, the enrolled subjects were classified into 4 groups: group A, PG I/II ratio >4; group B, >3 and ≤4; group C, >2 and ≤3; group D, ≤2. Compared with group A, a stepwise increase in the risk of gastric neoplasm was observed from group B [odds ratio (OR) = 9.9, 95% confidence interval (95% CI) = 4.0-24.4] to group C (OR = 20.9, 95% CI = 8.7-50.5) to group D (OR = 37.3, 95% CI = 14.3-97.4). The optimal cutoff value of the serum PG I/II ratio for predicting gastric neoplasms was 4.5, with a sensitivity of 97.7% and a specificity of 57.6%. A decrease in the serum PG I/II ratio was strongly associated with an increased risk of gastric neoplasms. The serum PG I/II ratio can be used to identify those at a high risk of gastric neoplasms in Korean population.

Factors Related to Upper Gastrointestinal Symptom Generation in 2275 Helicobacter pylori Seroprevalent Adults

BACKGROUND AND AIM

Upper gastrointestinal (UGI) symptoms are common; however, the role of Helicobacter pylori and gastric corpus atrophy in the generation of these symptoms is controversial. The aim of this study was to determine the risk factors for UGI symptoms in adults in an endemic area of H. pylori infection.

METHODS

Korean adults who completed questionnaires on the day of serum anti-H. pylori IgG and pepsinogen (PG) assays before UGI endoscopy were included. Gastric corpus atrophy was based on the criteria of a serum PG I/II ratio <3.0 and a PG I <70 ng/ml.

RESULTS

Of the 2275 included subjects, 723 (31.8%) had at least one UGI symptom. A total of 374 (16.4%) subjects had multiple symptoms without significant correlations between the symptoms (λ < 0.2). The H. pylori serology assay was positive in 1382 (60.7%) subjects, and gastric corpus atrophy was present in 291 (12.8%). Neither H. pylori seropositivity (p = 0.077) nor gastric corpus atrophy (p = 0.138) was related to the presence of UGI symptoms. Female gender and smoking were independent risk factors for heartburn and upper abdominal pain (all p < 0.001). Furthermore, female gender was the only independent risk factor for multiple UGI symptoms (p < 0.001), globus sensation (p < 0.001), early satiety (p < 0.001), epigastric soreness (p = 0.001), and chest discomfort (p = 0.003).

CONCLUSIONS

In an H. pylori seroprevalent population, female gender is the most common risk factor followed by smoking for UGI symptom generation. Neither H. pylori seropositivity nor gastric corpus atrophy is an independent risk factor for UGI symptom generation.

Link between Serum Pepsinogen Concentrations and Upper Gastrointestinal Endoscopic Findings

The serum pepsinogen (PG) assay findings are correlated with the status of Helicobacter pylori infection, but there are controversies on the link with upper gastrointestinal (UGI) endoscopic findings. The aim of this study was to determine the significance of a serum PG assay for correlating with endoscopic findings in H. pylori-seroprevalent adult population. Korean adults who visited for a health check-up were included consecutively. Subjects after gastrectomy or H. pylori eradication were excluded. After completing the serum PG assay and anti-H. pylori immunoglobulin G (IgG) titer on the same day of UGI endoscopy, subjects with equivocal serology test finding or gastric neoplasm were excluded. Of the 4,830 included subjects, 3,116 (64.5%) were seropositive for H. pylori. Seropositive finding was related to high serum PG I (P < 0.001) and PG II (P < 0.001) concentrations, low PG I/II ratio (P < 0.001), old age (P < 0.001), and male gender (P = 0.006). After adjusting age and gender, the serum PG I and II concentrations were positively correlated with the presence of nodular gastritis (NG) (all P = 0.003). The serum PG I was positively correlated with gastric ulcer (P = 0.003), and it was correlated with duodenal ulcer in seropositive subjects (P = 0.008). The PG I/II ratio was positively correlated with erosive esophagitis, while it was inversely related to chronic atrophic gastritis and metaplastic gastritis (all P < 0.001). Our findings suggest that the serum PG assay finding correlates well with the UGI endoscopic finding. A higher serum PG concentration in subjects with NG and peptic ulcer disease suggests that endoscopic findings reflect gastric secreting ability.

Risk Factors for the Presence of Symptoms in Peptic Ulcer Disease

BACKGROUND/AIMS

Peptic ulcer disease (PUD) is a common condition, but is difficult to detect in asymptomatic individuals. We aimed to investigate the prevalence of symptomatic and asymptomatic PUD during screening endoscopy and to identify risk factors for the presence of symptoms in patients with PUD.

METHODS

We investigated subjects who underwent a health inspection, including endoscopy of the upper gastrointestinal (GI) tract and a serum anti-Helicobacter pylori IgG assay, and who completed a self-report questionnaire about their symptoms.

RESULTS

Of the 12,852 subjects included in the study, 124 (1.0%) had symptomatic PUD and 309 (2.4%) had asymptomatic PUD. Old age, current smoking, and H. pylori infection were independent risk factors for symptomatic and asymptomatic PUD. Use of non-steroidal anti-inflammatory drugs (NSAIDs) was an independent risk factor only for symptomatic PUD (p=0.040). Compared to subjects with asymptomatic PUD, subjects with symptomatic PUD were more likely to have active-stage ulcers (p=0.002) and to drink more heavily (p=0.005).

CONCLUSIONS

Use of NSAIDs is a risk factor for symptomatic PUD, but not for asymptomatic PUD. Excessive alcohol consumption and active-stage ulcers in patients with PUD are related to the presence of gastroduodenal symptoms.

Engineering bioinspired bacteria-adhesive clay nanoparticles with a membrane-disruptive property for the treatment of Helicobacter pylori infection

We present a bioinspired design strategy to engineer bacteria-targeting and membrane-disruptive nanoparticles for the effective antibiotic therapy of Helicobacter pylori (H. pylori) infection. Antibacterial nanoparticles were self-assembled from highly exfoliated montmorillonite (eMMT) and cationic linear polyethyleneimine (lPEI) via electrostatic interactions. eMMT functions as a bioinspired 'sticky' building block for anchoring antibacterial nanoparticles onto the bacterial cell surface via bacteria-secreted extracellular polymeric substances (EPS), whereas membrane-disruptive lPEI is able to efficiently lyse the bacterial outer membrane to allow topical transmembrane delivery of antibiotics into the intracellular cytoplasm. As a result, eMMT-lPEI nanoparticles intercalated with the antibiotic metronidazole (MTZ) not only efficiently target bacteria via EPS-mediated adhesion and kill bacteria in vitro, but also can effectively remain in the stomach where H. pylori reside, thereby serving as an efficient drug carrier for the direct on-site release of MTZ into the bacterial cytoplasm. Importantly, MTZ-intercalated eMMT-lPEI nanoparticles were able to efficiently eradicate H. pylori in vivo and to significantly improve H. pylori-associated gastric ulcers and the inflammatory response in a mouse model, and also showed superior therapeutic efficacy as compared to standard triple therapy. Our findings reveal that bacterial adhesion plays a critical role in promoting efficient antimicrobial delivery and also represent an original bioinspired targeting strategy via specific EPS-mediated adsorption. The bacteria-adhesive eMMT-lPEI nanoparticles with membrane-disruptive ability may constitute a promising drug carrier system for the efficacious targeted delivery of antibiotics in the treatment of bacterial infections.

Mass Eradication of Helicobacter pylorito Prevent Gastric Cancer: Theoretical and Practical Considerations

Although the age-adjusted incidence of gastric cancer is declining, the absolute number of new cases of gastric cancer is increasing due to population growth and aging. An effective strategy is needed to prevent this deadly cancer. Among the available strategies, screen-and-treat for Helicobacter pylori infection appears to be the best approach to decrease cancer risk; however, implementation of this strategy on the population level requires a systematic approach. The program also must be integrated into national healthcare priorities to allow the limited resources to be most effectively allocated. Implementation will require adoption of an appropriate screening strategy, an efficient delivery system with a timely referral for a positive test, and standardized treatment regimens based on clinical efficacy, side effects, simplicity, duration, and cost. Within the population, there are subpopulations that vary in risk such that a "one size fits all" approach is unlikely to be ideal. Sensitivity analyses will be required to identify whether the programs can be utilized by heterogeneous populations and will likely require adjustments to accommodate the needs of subpopulations.

Helicobacter pylori Infection, Gastric Cancer and Gastropanel

Gastric cancer (GC) is one of the most widespread types of cancer worldwide. Helicobacter pylori infection has been clearly correlated with gastric carcinogenesis. At present and in the near future, the most important challenge is and will be the significant reduction of mortality due to GC. That goal can be achieved through the identification of higher-risk patients, such as those with atrophic gastritis, intestinal metaplasia and dysplasia. In this review we intend to discuss the importance of diagnosing H. pylori infection and chronic atrophic gastritis in preventing gastric cancer, using a new non-invasive test called GastroPanel. This test is a classification algorithm including four biochemical parameters pepsinogen I and II (PGI and PGII), gastrin-17 (G17), and anti-Helicobacter pylori antibodies (Ig G anti-Hp) measured in fasting sera, which allows to classify patients as having atrophic or non-atrophic gastritis and to find whether gastritis is associated or not with H. pylori infection. GastroPanel is not a "cancer test", but it can and should be used in the screening and diagnosis of subjects with a high cancer risk; still, a careful diagnostic made by superior digestive endoscopy is compulsory to find possible precancerous or cancerous lesions at an early and curable stage.

Endoscopic gastritis, serum pepsinogen assay, and Helicobacter pylori infection

Endoscopic findings of the background gastric mucosa are important in the Helicobacter pylori-seroprevalent population. It is strongly correlated not only with the risk of gastric cancer, but also with the excretion ability of gastric mucosa cells. In noninfected subjects, common endoscopic findings are regular arrangement of collecting venules, chronic superficial gastritis, and erosive gastritis. In cases of active H. pylori infection, nodularity on the antrum, hemorrhagic spots on the fundus, and thickened gastric folds are common endoscopic findings. The secreting ability of the gastric mucosa cells is usually intact in both noninfected and actively infected stomachs, and the intragastric condition becomes hyperacidic upon inflammation. Increased serum pepsinogen II concentration correlates well with active H. pylori infection, and also indicates an increased risk of diffuse-type gastric cancer. In chronic inactive H. pylori infection, metaplastic gastritis and atrophic gastritis extending from the antrum (closed-type chronic atrophic gastritis) toward the corpus (open-type chronic atrophic gastritis) are common endoscopic findings. The intragastric environment is hypoacidic and the risk of intestinal-type gastric cancer is increased in such conditions. Furthermore, there is a decrease in serum pepsinogen I concentration when the secreting ability of the gastric mucosa cells is damaged. Serologic and endoscopic changes that occur upon H. pylori infection are important findings for estimating the secreting ability of the gastric mucosa cells, and could be applied for the secondary prevention of gastric cancer.

Does the antibody production ability affect the serum anti-Helicobacter pylori IgG titer?

AIM: To investigate the relationship between serum titers of anti-Helicobacter pylori (H. pylori) immunoglobulin G (IgG) and hepatitis B virus surface antibody (HBsAb).

METHODS: Korean adults were included whose samples had positive Giemsa staining on endoscopic biopsy and were studied in the hepatitis B virus surface antigen (HBsAg)/HBsAb serologic assay, pepsinogen (PG) assay, and H. pylori serologic test on the same day. Subjects were excluded if they were positive for HBsAg, had a recent history of medication, or had other medical condition(s). We analyzed the effects of the following factors on serum titers of HBsAb and the anti-H. pylori IgG: Age, density of H. pylori infiltration in biopsy samples, serum concentrations of PG I and PG II, PG I/II ratio, and white blood cell count.

RESULTS: Of 111 included subjects, 74 (66.7%) exhibited a positive HBsAb finding. The serum anti-H. pylori IgG titer did not correlate with the serum HBsAb titer (P = 0.185); however, it correlated with the degree of H. pylori infiltration on gastric biopsy (P < 0.001) and serum PG II concentration (P = 0.042). According to the density of H. pylori infiltration on gastric biopsy, subjects could be subdivided into those with a marked (median: 3.95, range 0.82-4.00) (P = 0.458), moderate (median: 3.37, range 1.86-4.00), and mild H. pylori infiltrations (median: 2.39, range 0.36-4.00) (P < 0.001). Subjects with a marked H. pylori infiltration on gastric biopsy had the highest serological titer, whereas in subjects with moderate and mild H. pylori infiltrations titers were correspondingly lower (P < 0.001). After the successful eradication, significant decreases of the degree of H. pylori infiltration (P < 0.001), serum anti-H. pylori IgG titer (P < 0.001), and serum concentrations of PG I (P = 0.028) and PG II (P = 0.028) were observed.

CONCLUSION: The anti-H. pylori IgG assay can be used to estimate the burden of bacteria in immunocompetent hosts with H. pylori infection, regardless of the HBsAb titer after HBV vaccination.

Validation of western Helicobacter pylori IgG antibody assays in Korean adults

Helicobacter pylori infection is endemic in Korea, and serology testing is widely performed. The aim of this study was to validate and compare the diagnostic accuracy of Korean and Western serological assays for H. pylori detection in Korean adults. The 114 Korean adults who visited our centre over a 6-month period for the evaluation of H. pylori infection using the urea breath test (UBT) were enrolled in this prospective study. Anti-H. pylori IgG was measured using three commercially available immunoassays: Genedia H. pylori ELISA (Green Cross Medical Science), Chorus helicobacter IgG (DIESSE Diagnostica Senese) and Vidas H. pylori IgG (bioMérieux). Positive UBT findings were obtained in 40.6% of included subjects. The sensitivities and the specificities of Vidas, Chorus and Genedia were 89.7%, 100% and 100% and 85.5%, 75.4% and 80.7%, respectively. We found no differences in sensitivity between the Vidas and Chorus (P=0.125), Chorus and Genedia (P=0.125) and Vidas and Genedia (P=1.000) assays. There were also no differences in specificity between the Vidas and Chorus (P=0.070), Chorus and Genedia (P=0.508) and Vidas and Genedia (P=0.549) assays. In Korean adults, the Genedia H. pylori ELISA, Chorus helicobacter IgG and Vidas H. pylori IgG assays exhibited a high concurrence rate with similar diagnostic accuracy. Thus, both the Korean and Western non-invasive assays are reliable for serodiagnosis of H. pylori in Korean individuals.

Anti-Helicobacter pylori activities of FEMY-R7 composed of fucoidan and evening primrose extract in mice and humans

Helicobacter pylori-eliminating effects of FEMY-R7, composed of fucoidan and evening primrose extract, were investigated in mice and humans. Male C57BL/6 mice were infected with the bacteria by intragastric inoculation (1×10(9) CFU/mouse) 3 times at 2-day intervals, and simultaneously, orally treated twice a day with 10 or 100 mg/kg FEMY-R7 for 2 weeks. In Campylobcter-like organism-detection test, FEMY-R7 markedly reduced the urease-positive reactivity. In a clinical sudy, human subjects, confirmed to be infected with Helicobacter pylori, were orally administered twice a day with a capsule containing 150 mg FEMY-R7 for 8 weeks. FEMY-R7 significantly decreased both the Delta over baseline-value in urea breath test and the serum pepsinogens I and II levels. The results indicate that FEMY-R7 not only eliminates H. pylori from gastric mucosa of animals and humans, but also improves gastric function.