Helicobacter pylori and gastrointestinal symptoms

Endoscopic and histopathologic findings associated with H. pylori infection in very young children

Most of the individuals infected with H. pylori acquire the infection early in life. However, there is limited data regarding endoscopic and histopathologic findings of H. pylori infection when it is acquired during infancy. The aim of this study was to investigate the H. pylori-related endoscopic and histopathological findings in children younger than 2 years of age. One hundred and fifty-two infants who underwent upper gastrointestinal endoscopy were included in the study. The diagnosis of H. pylori infection was based on histopathology and a positive rapid urease test. Forty of 152 (26.3%) infants were infected with H. pylori, and 65% of the infected infants had histopathologic gastritis. There were no clinical or endoscopic findings suggestive of H. pylori infection. No correlation could be found between the density of H. pylori and the severity of gastritis. H. pylori infection is associated with various degrees of gastritis in more than half of the infected infants. Since the likelihood of normal histopathology is rare in H. pylori-infected infants, its long-term complications should be cautiously followed up in endemic areas.

Helicobacter pylori infection is not associated with specific symptoms in nonulcer-dyspeptic children

OBJECTIVES

To assess symptoms associated with Helicobacter pylori infection in children presenting with nonulcer dyspepsia (NUD).

STUDY DESIGN

A prospective double-blind study was conducted between March 2001 and April 2002 in children at least 6 years old with NUD who had been referred for upper gastrointestinal endoscopy for epigastric pain. A standardized questionnaire was administered blindly by a pediatric gastroenterologist. This questionnaire characterized epigastric pain and associated factors. Infection was confirmed by positive culture and histologic examination of the gastric mucosa.

RESULTS

From 100 children enrolled, 26 proved infected (12 female, 14 male; mean age: 11.4 +/- 2.6 years), and 74 were noninfected (44 female, 30 male; mean age: 10.4 +/- 3.1 years). There were no differences in age or symptom characteristics between groups except for epigastric pain during meals that was more frequent in noninfected than in infected children (25.6% vs 3.8%).

CONCLUSION

There were no specific characteristics of symptoms in nonulcer-dyspeptic H pylori-infected children as compared with noninfected children.

Acquired rectal fistula in human immunodeficiency virus-positive children: a causal or casual relationship?

Acquired rectal fistula in human immunodeficiency virus (HIV)-positive children is a new and worrisome entity. The aim of this paper is to highlight the relationship between HIV infection and acquired rectal fistula (RF) in children in order to create awareness among clinicians who attend to children. Over a 1-year period, 11 girls aged 4 weeks-11 months (median 5 months) with acquired RF were managed at our institution. Ten were HIV-positive by enzyme-linked immunosorbent assay and confirmed by Western blot test. One child defaulted before the test. All the mothers and three fathers of the 10 children were seropositive for HIV. Bronchopneumonia, otitis media, oral thrush, diarrhoea, and lymphadenopathy were common associations. Treatment was essentially conservative because the result of surgical intervention was disappointing. Two of the infants and one of the fathers are now dead from full-blown acquired immunodeficiency syndrome. Acquired RF seems to be a sign of HIV infection in children. It will be necessary to screen any child presenting with acquired RF for HIV infection.

Helicobacter pylori and gastrointestinal symptoms in school children in Russia

BACKGROUND AND AIMS

Helicobacter pylori is considered to be the major cause of chronic gastritis and duodenal ulcer disease recurrence in childhood. However, the association between H. pylori and recurrent abdominal pain (RAP) syndrome is still controversial. Therefore, the spectrum of clinical variants of gastrointestinal symptoms associated with H. pylori-positive status was studied in consecutive symptomatic children who were undergoing diagnostic endoscopy.

METHODS

A consecutive series of 225 school children from the Ural area of Russia (mean age 11.1 + 1.4 years, age range 7-15 years) who presented with RAP were investigated using esophagogastroduodenoscopy, including three antral biopsies for histology and polymerase chain reaction. Helicobacter pylori immunoglobulin G antibodies were found using a second-generation enzyme immunoassay. Information about the clinical symptoms was collected using a special questionnaire.

RESULTS

The authors found a high incidence of H. pylori infection (80%) and peptic ulcers (16%) in 225 school children from the Ural area of Russia who were referred for upper gastrointestinal (UGI) endoscopy for chronic abdominal pain. Of the overall 225 symptomatic children who underwent endoscopy, 182 (80,8%) were found to be H. pylori-positive. Duodenal ulcers were detected in 36 H. pylori-positive children. A family history of peptic ulcers was significantly more frequent in the children infected with H. pylori (P < 0.001). Symptom score and duration of symptoms were similar, but night-time pain (P < 0.0001) and fasting pain relieved by food (P < 0.001) were more frequent in the H. pylori-positive children as compared with the H. pylori-negative children.

CONCLUSIONS

The present results provide further evidence for a significant association between H. pylori and some patterns of gastrointestinal symptoms in children who underwent UGI endoscopy in order to exclude an organic cause of severe chronic gastrointestinal disorders.

Helicobacter pylori serology at diagnosis and follow-up of biopsy-verified infection in children

Data on the use of Helicobacter pylori serology in children are limited. We studied the serum antibodies of 105 H. pylori-infected children (median age 9.1 y, range 1.5-17.5 y) using an in-house enzyme immunoassay. At diagnosis of the biopsy-verified infection, IgG antibodies to H. pylori were elevated in 98/105 children (93%) but were at a normal level in 7 children, 5 of whom were < 5 y of age. Serum IgA antibodies to H. pylori were elevated in 40/105 children (38%). The levels of IgG and IgA antibody titers to H. pylori correlated with age (p < 0.001 and p < 0.02, respectively). IgG titers were reduced by > or = 50% in 85% (83/98; median follow-up 0.6 y) of children after therapy. In 56 such children eradication was verified by negative histology or urea breath test but I such child showed Helicobacters on histologic examination. Of the 15 children whose IgG titers dropped by < 50%, 7 were considered positive and 4 negative on the basis of histology or urea breath test. In 3 children, IgG titers returned to pretreatment levels 1 y after a 50% drop was seen. Serology is 1 alternative for monitoring H. pylori infection in children, although its sensitivity is lower in very young children. The length of follow-up needed after eradication, however, is unclear.

Childhood peptic ulcer in the Ural area of Russia: clinical status and Helicobacter pylori-associated immune response

BACKGROUND

The relation of between Helicobacter pylori and the symptoms in children is still controversial. Determination of specific immunoglobulin (Ig) G antibodies to H. pylori may represent a useful test to screen the patients with acid peptic disease in childhood. The aim of this study was to investigate the spectrum of clinical symptoms, endoscopic and histologic lesions, and clinical value of serum IgG response to H. pylori in school-aged children residing in the Ural area of Russia for the identification of Helicobacter -related acid-peptic disease.

METHODS

During 1998, 129 pediatric outpatients (mean age, 12.1 +/- 2.3 years; age range, 10-15 years; 41 boys, 88 girls) were undergoing gastroduodenal endoscopy for evaluation of chronic abdominal pain. H. pylori colonization was determined by histology, urease test, and polymerase chain reaction. H. pylori IgG antibodies were found by using an enzyme-linked immunosorbent assay.

RESULTS

There was a high prevalence of H. pylori infection (80%) and peptic ulcers (24%) among the study group. Duodenal ulcers were detected in 31 of the children; all of them were H. pylori positive. Family history of peptic ulcers, nighttime pain associated with nocturnal awakening, fasting pain relieved by food, pain associated with meals, postprandial pain, bitter taste, and heartburn were the clinical signs that helped to distinguish the ulcer-positive children from the ulcer-negative H. pylori group. Duodenal ulcer patients had higher anti- H. pylori IgG titers compared with the levels of IgG antibodies in the infected children without ulcers ( P < 0.001). Peptic ulcer disease was a more common finding in the Ural ethnic group of Asians (Bashkirs) compared with the pediatric population of Russian origin.

CONCLUSIONS

These results provide further evidence for a causal relation between H. pylori -associated peptic ulcer disease in childhood and relevant clinical symptoms. High titers of anti- H. pylori IgG might serve as a useful noninvasive indicator of ulcer disease.

Treatment of Helicobacter pylori in children with recurrent abdominal pain

BACKGROUND

The role of Helicobacter pylori remains unclear in children with recurrent abdominal pain (RAP). In this study children with RAP were included in a double blind treatment study to elucidate whether symptoms disappear in children with a H. pylori infection and RAP, if the bacteria are eradicated.

METHODS

Thirty-seven H. pylori-infected children aged 4.9-14.5 years (median 9.8 years) with RAP were included. H. pylori was identified by histology and culture. The children were treated with amoxicillin and metronidazole for 14 days. A re-endoscopy including biopsies for histology and culture was done at least one month after the end of treatment. Simple questions for symptoms were asked and blood for serology was repeated 3 and 6 months after the end of treatment. During the observation period the results of the re-endoscopy and the serology 3 and 6 months after the re-endoscopy were blinded for 23 patients and opened to 14 of the patients according to the choice of the families.

RESULTS

The eradication rates were 81% (30/37) in the total group and 74% (17/23) in the blinded group. The IgG antibodies to H. pylori decreased significantly 3 (p =.03) as well as 6 months after end of treatment (p <.001) in children with successful eradication. The number of children with RAP decreased after examination and treatment and the well-being improved after 6 months in almost 95% of the children. However, no correlation was seen between eradication of H. pylori and disappearance of RAP, neither after 3 nor after 6 months' observation in the total group of patients (p =.94 and p =.90) or in the blinded group (p =.42 and p =.65).

CONCLUSIONS

These results do not provide evidence for a causal relationship between RAP and H. pylori.

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.

Influence of age on 13C-urea breath test results in children

BACKGROUND

The 13C-urea breath test for diagnosis of Helicobacter pylori infection has not been validated in infants and young children. The influence of age on the test results was studied by conventional validation against invasive methods and by mathematical estimation in a large pediatric population.

METHODS

The breath test was performed in 1499 children aged 2 months to 18 years. After a fasting period of 4 hours or more, 75 mg 13C-urea was ingested with cold apple juice, breath samples were taken at baseline and at 15 and 30 minutes. The distribution of the natural logarithms of the delta-over baseline (DOB) values were calculated, and the optimal cutoff values between positive and negative test results and gray zones with a risk of misclassification more than 10% were determined for both time points. In a subgroup of 149 children results of the breath test were compared with concordant results of histology and rapid urease test; 53 of them were less than 6 years of age.

RESULTS

Logarithmic results of 1499 breath tests revealed two normally distributed subgroups with minimal overlap. The calculated optimal cutoff values were 4.7/1000 at 15 minutes and 5.0/1000 at 30 minutes. At 30 minutes, only 2.6% of all results were in the calculated gray zone (2.6-6.5/1000). Age was negatively correlated to DOB values of both negative (r = -0.223) and positive results (r = -0.291; P < 0.001). Breath test-negative and -positive children 6 or less years of age had significantly higher mean DOB values (P < 0.02) and a larger proportion of results within the gray zone than older children. Compared with biopsy-based results, the least discrepancies occurred at a cutoff of 5.0/1000: 0 of 61 infected (sensitivity 100%) and 6 of 88 noninfected children. Because five of the false-positive results were obtained in children less than 6 years of age, specificity and positive predictive values were lower in this age group than in older patients (88.1% vs. 97.8% and 68.8% vs. 98.0%, respectively).

CONCLUSIONS

Under the applied conditions, the 13C-urea breath test shows an excellent separation between positive and negative results. Because of some overlap and a strong age effect, definition of a gray zone appears more meaningful than a threshold value. Because infants and young children have a high risk for false-positive breath test results, the values for cutoff and gray zones may have to be adapted. Further validation studies against invasive methods are warranted in this age group.

Helicobacter pylori gastritis in children: efficacy of 2 weeks of treatment with clarithromycin, amoxicillin and omeprazole

Thirty-eight children with Helicobacter pylori gastritis diagnosed by histopathology, and/or bacteriological culture were treated with omeprazole, amoxicillin and clarithromycin. Follow-up endoscopy was performed in 34 children. Outcome was measured by negative histology and culture for H. pylori. Six patients were excluded. Of the 32 remaining children eradication was achieved in 75% (95% confidence interval 60-90%).

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.

Helicobacter pylori infection in children with celiac disease: prevalence and clinicopathologic features

BACKGROUND

Celiac disease is frequently associated with chronic gastritis. Helicobacter pylori is the main etiologic agent of chronic gastritis. The aim of this study was to assess the prevalence of H. pylori, the related symptoms, and the endoscopic and histologic gastric features in children with celiac disease.

METHODS

Eight-one (24 boys, 57 girls; age range: 1.4-17.7 years, median 6.8) children with celiac disease were studied. All children had a blood sample taken. In a subgroup of 30 children who underwent endoscopy, three gastric biopsy specimens were taken for histology (hematoxylin and eosin, Giemsa, immunohistochemistry) and urease quick test. Symptom complaints were recorded. Age- and sex-matched (one case, one control) children without celiac disease were used for comparison. Serum H. pylori IgG were measured by means of a locally validated commercial enzyme-linked immunoassay.

RESULTS

Overall, 15 of 81 (18.5%) children with celiac disease and 14 of 81 (17.3%) control children were positive for H. pylori. The percentage of H. pylori positivity was similar in children with untreated and treated celiac disease. Recurrent abdominal pain was the only symptom that helped to distinguish between H. pylori-positive and H. pylori-negative children. However, symptoms disappeared in patients with celiac disease after gluten withdrawal, irrespective of H. pylori status. All endoscopic (erythema, nodularity) and histologic (superficial-, interstitial-, lymphocytic-gastritis, activity, lymphoid follicles) findings did not differ between celiac and nonceliac H. pylori-positive children.

CONCLUSIONS

Prevalence and clinical expressivity of H. pylori infection is not increased in children with celiac disease. The clinicopathologic pattern of the infection is not specifically influenced in this condition.

Helicobacter pylori and abdominal symptoms: a population-based study among preschool children in southern Germany

OBJECTIVE

To determine the relation of Helicobacter pylori infection with gastrointestinal symptoms in a healthy population-based sample of children.

DESIGN

Population-based cross-sectional study of preschool children.

SETTING

Screening examination for school fitness by physicians of the Public Health Service in Ulm, a city with 100 000 inhabitants in southern Germany.

PARTICIPANTS

One thousand two hundred one preschool children.

MAIN OUTCOME MEASURES

Infection status was determined by 13C-urea breath test. Information on gastrointestinal symptoms was collected from children's parents by a standardized questionnaire and integrated into a symptom score. Results. Nine hundred forty-five children participated in the study (response rate, 79%). Overall, 127 children (13.4%) were infected. H pylori infection was not positively related to specific gastrointestinal symptomatology. Infected children had even fewer symptoms when compared with uninfected children.

CONCLUSIONS

Our results indicate that H pylori infection in children is mostly asymptomatic and not associated with specific gastrointestinal symptoms.

High risk of Helicobacter pylori infection associated with cow's milk antibodies in young diabetics

Antibody titres (IgA and IgG) for Helicobacter pylori were assayed in 69 insulin-dependent diabetes mellitus patients (42 males, age 1-20 years) and 310 healthy controls (171 males, age 1-20 years). A positive antibody titre for Helicobacter pylori was found in 18/69 diabetic subjects compared to 17/310 controls (p < 0.001). There was no difference between Helicobacter pylori positive and negative diabetic subjects as regards age, sex, duration of diabetes, diabetic control, insulin dose and SDS for weight and height. Gastroduodenoscopy revealed presence of Helicobacter pylori and evidence of gastric inflammation in 7/8 symptomatic diabetic children. There was a significant association in the diabetic subjects between positivity for anti-cow's milk protein and anti-Helicobacter antibodies, compared to the control group. Seven of the 17 diabetics studied within 3 months of the onset of diabetes had positive antibody titres for Helicobacter. Of these seven patients, five were positive for anti-cow's milk protein antibodies. In our study the prevalence of Helicobacter pylori infection was significantly higher in diabetic subjects than in controls, but the infection was asymptomatic and there was no correlation with diabetes control. In diabetic subjects Helicobacter pylori infection was associated with a humoral response to cow's milk proteins and was often present from the onset of diabetes.

Prevalence of Helicobacter pylori infection in Nicaraguan children with persistent diarrhea, diagnosed by the 13C-urea breath test

BACKGROUND

The impairment of gastric acid barrier caused by Helicobacter pylori (H. pylori) at the onset of infection may predispose to small bowel bacterial overgrowth, which could contribute to persistent diarrhea.

METHODS

Using the 13C-urea breath test, we determined the prevalence of H. pylori infection in 123 Nicaraguan children from Tipitapa, aged 1 to 65 months, from a low socioeconomic background.

RESULTS

The overall prevalence of H. pylori infection was 77.2% (95/123). The prevalence varied with age and was significantly (p < 0.001) higher in infants < or = 12 months than in children aged 13-65 months, 91% (57/63) as against 63% (38/60). H. pylori infection was present in 44 of 59 (75%) children suffering from persistent diarrhea compared with 51 of 64 (80%) age-matched asymptomatic controls. In the diarrheal group, 20 of 59 (34%) children presented with malnutrition, and 16 (80%) of them showed H. pylori infection. In the control group, 20 of 64 (31%) were malnourished, and 14 (70%) of them showed H. pylori infection.

CONCLUSIONS

In Nicaragua, H. pylori is acquired in early infancy. The high prevalence among children in the first 12 months of life and the lower infection rate between 1 and 5 years of age suggest a loss or clearance of infection, also an occasional finding in adults. H. pylori infection appears to be not a risk factor for persistent diarrhea or malnutrition in Nicaraguan children.

Normal gastric histology in Helicobacter pylori-infected children

BACKGROUND

In adults, Helicobacter pylori infection is always associated with gastritis or ulcer. However, very active gastritis and ulcers are rarely seen in children. The aim of the present work was to study the relationships between H. pylori and gastric mucosa in children.

METHODS

Eighty infected children and adolescents including 48 (60%) neurologically impaired institutionalized patients, aged 2 months-22 years (mean 11.7 +/- 5.2 years) were studied retrospectively. All the patients underwent gastroscopy, and three antral and two fundic biopsy specimens were taken for histology and bacteriology.

RESULTS

A normal gastric mucosa was found in 22 of 80 patients (27.5%), whereas the others had gastritis (n = 58, 72.5%). There were no statistical differences between patients with normal histology and those presenting with gastritis for age, sex, ethnic background, symptoms, and the degree of bacterial colonization. The macroscopic aspect of gastritis was less frequently found in children with a normal histology compared with those with histological gastritis (p < 0.001).

CONCLUSIONS

These data show that H. pylori infection can be associated with a normal gastric histology in children.

Helicobacter pylori is not associated with nonspecific abdominal pain in children

Nonspecific abdominal pain is a significant problem in the pediatric population, and there has been much recent interest in the role that Helicobacter pylori (HP) might play in this disorder. A retrospective review was conducted at our center to determine its prevalence among children with otherwise undiagnosed abdominal pain. The study was conducted over a 45-month period during which 47 patients underwent gastroscopy and antral biopsies in the workup of this problem. Of the 37 patients who did not have a history of acid-pepsin disease (APD), only one (2.7%) tested positive for HP. In contrast, of the 10 who had a history of APD, three (30%) tested positive (P < .03). There were no distinguishing features among the HP-positive patients except for the presence of associated antral gastritis. Based on the current endoscopic results, of the nine patients with current evidence of APD, four (44%) were positive for HP; of the other 38 patients, none was positive for HP. Therefore, HP appears to be associated with antral gastritis, and HP does not play a role in nonspecific abdominal pain in this population.

Helicobacter pylori and recurrent abdominal pain in children

Recurrent abdominal pain is one of the most common presentations to pediatricians; yet an organic etiology can be found in only 10% of cases. Because infection with Helicobacter pylori in adults and children results in gastritis, a causative role for the organism has been postulated. To investigate this theory, we conducted a prospective case-control study in children with recurrent abdominal pain using serum H. pylori IgG antibodies measured by an enzyme immunoabsorbent assay. Age, sex, ethnicity, and socioeconomic status were adjusted in the statistical model. Five subjects (5.1%) and 14 controls (14.3%) had raised serum IgG antibodies to H. pylori (adjusted OR, 0.21; 95% confidence interval, 0.05, 0.85). The negative association between H. pylori and recurrent abdominal pain indicates that this organism is unlikely to have an important etiologic role in this disorder.

Somatisation in children

This review summarises recent work on somatisation in childhood. Minor physiological dysfunction may play a part in a number of cases and associated psychiatric disorders are commonly though not universally found. Contributory family factors include high rates of health problems and of parental psychological distress and there is some evidence for the role of family modelling and reinforcement of illness behaviour. There is suggestive evidence linking somatisation to emotional closeness in families, to family togetherness around health matters and to anomalies in children's social relationships. Somatisation in children can respond to treatments involving cognitive-behavioural and family techniques as well as to sensitive, psychologically sound advice from paediatricians.

[Helicobacter pylori infection in children]

Helicobacter pylori (Hp) is a pathogen of human gastric mucosa and is considered as the major cause of chronic gastritis and duodenal ulcer disease recurrence. The prevalence rate of Hp infection increases with age and is related to low socioeconomic status in childhood. Childhood appears to be a high-risk period for Hp infection. Clinical and histological features of Hp infection are variable and often moderate in children. This is probably due to both genetic and environmental factors. Abdominal pain is the most frequent symptom and is usually associated with a mild chronic gastritis. Serology, 13C-urea breath test, bacterial culture and histological examination of biopsy specimen can be used for the diagnosis of Hp infection. Eradication of Hp infection is difficult and indications and modalities of treatment need to be specified in children. A better knowledge of epidemiology and natural history of Hp infection in childhood should permit to answer these questions.

Association of symptoms with Helicobacter pylori infection in children

The aim of this study was to determine prospectively whether Helicobacter pylori-associated gastritis is associated with specific symptoms by evaluating whether these symptoms are relieved by treatment of the infection. Symptoms resolved after the eradication of H. pylori in only three of eight children with H. pylori-associated gastritis alone, in comparison with all six children with duodenal ulcer disease.

Abdominal pain in cystic fibrosis

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