Serum pepsinogen values and Helicobacter pylori status among control subjects of a nested case-control study in the JACC study

Changing trends in the prevalence of H. pylori infection in Japan (1908-2003): a systematic review and meta-regression analysis of 170,752 individuals

Changing trends in the prevalence of H. pylori infection in the general population over time are thought to be the main driving force behind the declining gastric cancer mortality in Japan. However, whether the prevalence of H. pylori infection itself shows a birth-cohort pattern needs to be corroborated. We performed a systematic review of studies that reported the prevalence of H. pylori infection among Japanese individuals. Meta-regression was conducted in the framework of a generalized additive mixed model (GAMM) to account for heterogeneity in the prevalence of H. pylori infection as a function of birth year. The prevalence of H. pylori infection confirmed a clear birth cohort pattern: the predicted prevalence (%, 95% CI) was 60.9 (56.3–65.4), 65.9 (63.9–67.9), 67.4 (66.0–68.7), 64.1 (63.1–65.1), 59.1 (58.2–60.0), 49.1 (49.0–49.2), 34.9 (34.0–35.8), 24.6 (23.5–25.8), 15.6 (14.0–17.3), and 6.6 (4.8–8.9) among those who were born in the year 1910, 1920, 1930, 1940, 1950, 1960, 1970, 1980, 1990, and 2000, respectively. The present study demonstrated a clear birth-cohort pattern of H. pylori infection in the Japanese population. The decreased prevalence of H. pylori infection in successive generations should be weighed in future gastric cancer control programs.

Contemporary migration patterns in the prevalence of Helicobacter pylori infection: A systematic review

BACKGROUND

A rapid growth in the number of international migrants over the past years has occurred with most traveling to more affluent settings. As Helicobacter pylori infects over half of the adult population and its prevalence is higher in developing countries, understanding the prevalence of infection in migrants can provide insight into future trends in the burden and management of infection. We aimed to describe the prevalence of H. pylori among migrants through a systematic literature review.

METHODS

We searched PubMed^® from inception to September 2015 to identify studies reporting the prevalence of H. pylori in international migrants according to country of birth for first-generation, and country of birth and parents' nationality for successive generations. Comparable data from origin and destination populations were obtained from the same studies or, when not present, from a previous systematic review on H. pylori worldwide.

RESULTS

A total of 28 eligible studies were identified with data for 29 origin and 12 destination countries. Two studies that evaluated refugees presented prevalences of infection higher than both the origin and destination countries. Otherwise, the prevalences among migrants were generally similar or below that of the origin and higher than the destination. Second- or more generation had lower prevalences compared to first-generation migrants.

CONCLUSIONS

Our study findings are consistent with what would be expected based on the prevalence of H. pylori worldwide. The results of this review show that migrants are particularly at risk of infection and help to identify gaps in the knowledge of migrants' prevalence of infection globally.

Prevalence of Helicobacter pylori infection worldwide: a systematic review of studies with national coverage

The systematic assessment of large population-based surveys addressing the prevalence of Helicobacter pylori infection may provide robust evidence for understanding the trends in the exposure to this major risk factor across settings with distinct patterns of gastric cancer variation. Our aim was to describe the prevalence of H. pylori infection in different countries and periods, through systematic review of the literature. We searched PubMed from inception up to September 2013 to identify original studies reporting on the prevalence of H. pylori, and only those evaluating samples with national coverage were included. We identified 37 eligible studies including data for 22 countries. The prevalences were higher in Central/South America and Asia, and at least two-fold higher in countries with high gastric cancer incidence. In most countries presenting data for different time periods, the prevalences were usually lower in the most recent surveys. However, there was little variation in settings where prevalences were already low. Among countries with high prevalence of H. pylori infection there is an ample scope for reducing its burden in the next decades, whereas further declines in settings with already low prevalences will require more intensive efforts.

Prevalence of Helicobacter pylori infection by birth year and geographic area in Japan

BACKGROUND

Helicobacter pylori (H. pylori)-related diseases are responsible for a tremendous amount of morbidity and mortality in Japan. We estimated the prevalence of H. pylori infection by sex, birth year, and geographic area among Japanese adults.

MATERIALS AND METHODS

This cross-sectional study included 14,716 subjects aged 20 years or more who underwent a health checkup between May 1997 and March 2013 in seven geographic areas throughout Japan. Relevant information on the demographics and status of H. pylori infection was retrieved from the electronic database. The univariate log-binominal regression model was used to estimate the prevalence of H. pylori infection, taking birth year into consideration. The multivariate log-binominal regression model was used to compare the prevalence of H. pylori infection between seven geographic areas.

RESULTS

The overall prevalence of H. pylori infection was 37.6% in women and 43.2% in men. Among seven geographic areas, Hokkaido showed the lowest prevalence (29.4%), while Yamagata Prefecture represented the highest (54.5%). The prevalence of H. pylori infection was highest in the 1940-1949 birth cohort and then decreased in the ensuing birth cohorts; the risk ratio (RR) was 0.85 (95% confidence interval (CI) 0.84-0.87) for changes in the 10-year birth cohort. Individuals in Yamagata Prefecture had the highest RR of acquiring H. pylori infection in all three birth cohorts (RR = 1.53 for 1940, RR = 1.69 for 1950, and RR = 1.85 for 1960) when compared with those in Hokkaido.

CONCLUSIONS

The prevalence of H. pylori infection increases with age and exhibits geographic variation in Japan. There has been a striking decrease in the prevalence of H. pylori infection, especially in younger Japanese populations.

Serum pepsinogen II: a neglected but useful biomarker to differentiate between diseased and normal stomachs

BACKGROUND AND AIM

Serum pepsinogen II (sPGII) is underutilized and considered an inconspicuous biomarker in clinical practice. We refocused on this neglected but novel biomarker and conducted the present study, aiming to elucidate the normal level of sPGII in healthy Chinese patients and to investigate the clinical utility of sPGII for gastric disease screening.

METHODS

In 2008-2009, a total of 2022 participants from northern China were selected and enrolled in the study. sPGII and Helicobacter pylori (H. pylori)-immunoglobulin G were measured with ELISA.

RESULTS

sPGII showed a normal value of 6.6 microg/L in a total of 466 patients with endoscopically- and histologically-normal stomachs. A small sex difference was observed: the average value of sPGII was 7 microg/L and 6 microg/L in males and females, respectively (P < 0.001). In the differentiation between healthy and diseased (endoscopically-diseased stomach or gastritis/atrophic gastritis in endoscopic biopsies) stomach mucosae, the best sPGII cut-off value was 8.25 microg/L (sensitivity 70.6%, specificity 70.8%). In screening the H. pylori seropositivity, the optimum cut-off sPGII value was 10.25 microg/L (sensitivity 71.6%, specificity 70.1%).

CONCLUSIONS

We demonstrated that the mean values of sPGII in a healthy Chinese population are 7 microg/L and 6 microg/L for males and females, respectively. sPGII significantly increases in diseased and H. pylori-infected stomach, and the best sPGII cut-off value is 8.25 microg/L in the differentiation between patients with healthy and diseased stomach mucosae. Furthermore, Chinese patients with sPGII greater than 10.25 microg/L are at greater risk of various H. pylori-related gastropathies, and are therefore prior candidates for gastro-protection therapy.

Helicobacter pylori infection and gastritis: the Systematic Investigation of gastrointestinaL diseases in China (SILC)

BACKGROUND AND AIM

Helicobacter pylori infection remains common in East Asia, though its prevalence is decreasing in Western countries. H. pylori-related atrophic gastritis (AG) may reduce the likelihood of gastroesophageal reflux disease (GERD). We investigated the prevalence of H. pylori infection and AG and their association with endoscopic findings and symptom-defined GERD in Shanghai.

METHODS

A representative random sample of 3600 Shanghai residents aged 18-80 years was invited to complete a general information questionnaire and a Chinese version of the Reflux Disease Questionnaire, to provide blood samples for H. pylori serology and pepsinogen (PG) I/II assay (to detect AG, defined as PGI < 70 µg/L and/or PGI/PGII < 7), and to undergo endoscopy. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated by multivariate logistic regression.

RESULTS

A total of 1022 Shanghai residents underwent endoscopy and were valid for inclusion in the study. Of these, 71.7% tested positive for H. pylori, 63.8% had AG and 30.5% had moderate/severe AG (PGI < 50 µg/L and/or PGI/PGII < 5). Helicobacter pylori infection was equally common in all age groups. Severity of AG increased with age in women. Reflux esophagitis was inversely associated with AG (OR, 0.23 [CI, 0.09-0.55] for moderate/severe AG compared with no H. pylori or gastritis). However, symptom-defined GERD showed no clear association with AG.

CONCLUSIONS

Helicobacter pylori infection and AG are very common in Shanghai, and the infection is acquired early in life. Atrophic gastritis is inversely associated with reflux esophagitis but is not significantly associated with symptom-defined GERD.

Association of Helicobacter pylori infection with chronic atrophic gastritis: Meta-analyses according to type of disease definition

Helicobacter pylori is a major risk factor for chronic atrophic gastritis (CAG). A large variety of definitions of CAG have been used in epidemiologic studies in the past. The aim of this work was to systematically review and summarize estimates of the association between H. pylori infection and CAG according to the various definitions of CAG. Articles on the association between H. pylori infection and CAG published until July 2007 were identified. Separate meta-analyses were carried out for studies defining CAG based on gastroscopy with biopsy, serum pepsinogen I (PG I) only, the pepsinogen I/pepsinogen II ratio (PG I/PG II ratio) only, or a combination of PG I and the PG I/PG II ratio. Numbers of identified studies and summary odds ratios (OR) (95% confidence intervals) were as follows: gastroscopy with biopsy: n = 34, OR = 6.4 (4.0-10.1); PG I only: n = 13, OR = 0.9 (0.7-1.2); PG I/PG II ratio: n = 8, OR = 7.2 (3.1-16.8); combination of PG I and the PG I/PG II ratio: n = 20, OR = 5.7 (4.4-7.5). Studies with CAG definitions based on gastroscopy with biopsy or the PG I/PG II ratio (alone or in combination with PG I) yield similarly strong associations of H. pylori with CAG. The association is missed entirely in studies where CAG is defined by PG I only.

Follow-up study on a high risk population of gastric cancer in north China by serum pepsinogen assay

OBJECTIVE

To explore the features and clinical significance of serum pepsinogen (PG) assay in a follow-up study on a high-risk gastric cancer (GC) population.

METHODS

A total of 444 participants from a high-risk area of GC in north China were enrolled in this follow-up study from April 1997 to December 1999. Serum PG was measured by enzyme-linked immunosorbent assay (ELISA), and the percentage changes in PG were calculated with 'PG( follow-up)/PG (first test)' thrice from the beginning to the end of these 30 months. Stomach diseases were diagnosed by a gastroscopy with biopsy examination. Helicobacter pylori (H. pylori) status was assessed by histopathological examination and serum H. pylori-immunoglobulin (Ig)G antibody assay with ELISA.

RESULTS

In all groups except for the 51-60-year olds no significant differences of percentage changes in PGII and the PGI/II ratio were observed during 30-month follow-up period. In the superficial gastritis (SG) group the percentage change in PGI of group A (after 6 months' follow up) was significantly lower than that of group B (after 12 months' follow up) (0.69 vs 0.97, P = 0.002) in SG-->SG; while in SG-->normal (NOR), it was significantly higher than that in SG-->atrophic gastritis (AG) (0.94 vs 0.79, P = 0.022). In the AG group the percentage change in the PGI/II ratio of group A was significantly higher than that of group C (after 30 months' follow up) (1.13 vs 0.75, P = 0.042) in AG-->AG; and the percentage changes in PGI and PGII in AG-->NOR were significantly lower than those in AG-->SG (0.43 vs 0.87, P = 0.000; 0.60 vs 1.11, P = 0.010, respectively). In the H. pylori(-) (Hp(-)) group, the percentage change in PG of Hp(-)-->Hp(+) was significantly higher than that of Hp(-)-->Hp(-) (0.94 vs 0.81, P = 0.026). Percentage changes in PGI and PGII of Hp(+)-->Hp(-) were significantly lower than those of Hp(+)-->Hp(+) (0.74 vs 0.93, P = 0.000; 0.86 vs 1.15, P = 0.000, respectively), while the percentage change in the PGI/II ratio was higher than that the group of Hp(+)-->Hp(-) (0.90 vs 0.70, P = 0.022).

CONCLUSION

The serum PG levels were influenced by the physiopathologic status of gastric mucosa and H. pylori infection, but they altered during the period of follow up. Serum PG assay might be a feasible and appropriate procedure to use in following up on a high-risk GC population.

Epidemiologic findings on serologically defined chronic atrophic gastritis strongly depend on the choice of the cutoff-value

Chronic atrophic gastritis (CAG), a precursor of intestinal gastric cancer, is mostly ascertained noninvasively by serum pepsinogens in epidemiologic studies. However, serological definitions vary widely. We aimed to investigate the impact of this variation on estimated prevalence of CAG and its association with its main risk factors, age and Helicobacter pylori infection. Serum pepsinogen I and II and antibodies against H. pylori were measured by ELISA among 9,444 women and men aged 50-74 years in a population-based cohort study in Saarland/Germany. Application of the various definitions resulted in a wide range of prevalence estimates of CAG prevalence (2.1%-8.2%, with an outlier of 18.8% for one particular definition) and its associations with age and H. pylori infection (age adjusted odds ratios, OR, for CagA positive H. pylori infection: 0.98-4.48). Definitions of CAG based on both pepsinogen I and the pepsinogen I/II ratio or on the pepsinogen I/II ratio only revealed much clearer associations with both age and H. pylori infection than definitions of CAG based on pepsinogen I only (ORs for H. pylori infection: 1.45-4.48 and 0.86-1.30, respectively). Epidemiologic findings on CAG lack comparability due to the heterogeneity in serologic definitions of CAG. The association of age and H. pylori infection with CAG may be strongly underestimated in studies in which CAG is defined by pepsinogen I only.

Epidemiology of chronic atrophic gastritis: population-based study among 9444 older adults from Germany

BACKGROUND

Epidemiological data on chronic atrophic gastritis from general population samples are sparse in Germany.

AIM

To assess prevalence of chronic atrophic gastritis according to potential risk factors and clinical outcomes in a large-scale population-based study.

METHODS

In the baseline examination of ESTHER, a population-based cohort study conducted in Germany, serological measurements of pepsinogen (PG) I and II and Helicobacter pylori antibodies were taken in 9444 women and men aged 50-74 years. Information on potential risk factors and medical history were obtained by questionnaire.

RESULTS

With the definition used in the EUROGAST study (PG I < 25 ng/mL), prevalence of chronic atrophic gastritis increased from 4.8% in age group 50-54 to 8.7% in age group 70-74. An alternative definition of chronic atrophic gastritis (PG I < 70 ng/mL and PG I/PG II < 3), used in multiple studies from Japan, revealed a greater increase with age (from 2.7% to 9.1%) and a strong association with H. pylori infection (adjusted odds ratio: 2.9, 95% confidence interval: 2.4-3.7). With both definitions, a strong inverse association with heartburn was observed.

CONCLUSIONS

Overall chronic atrophic gastritis prevalence is low among older adults in Germany, but it strongly increases with age and H. pylori infection.

Using serum pepsinogens wisely in a clinical practice

Serum pepsinogen (PG) has been used as biomarkers of gastric inflammation and mucosal status, including atrophic change, before the discovery of Helicobacter pylori (H. pylori). Serum pepsinogen I (PG I) and pepsinogen II (PG II) levels are known to increase in the presence of H. pylori-related nonatrophic chronic gastritis. The measurement of serum PG provides much information on the presence of intestinal metaplasia as well as atrophic gastritis. The eradication of H. pylori provokes a significant change in serum PG values: it reduces both PG I and PG II and elevates the PG I to PG II ratio. Recently, the serum PG test method has been the first screening step in Japan, as well as photofluorography. Serum PG tests are used to screen for high risk subjects with atrophic gastritis, rather than as a test for cancer itself. Unlike photofluorography or endoscopy, serum PG screening can identify non-ulcerated differentiated asymptomatic cancer, irrespective of the size and location of the lesion. Most cases detected by the PG method are asymptomatic early gastric cancers and are limited to the mucosa, which are particularly well suited for endoscopic treatment. The PG method can contribute greatly to the patients' quality of life.

Non-invasive diagnosis of gastric mucosal atrophy in an asymptomatic population with high prevalence of gastric cancer

AIM: To validate a non-invasive method to detect gastric mucosal atrophy in a Chilean population with high prevalence of gastric cancer and a poor survival rate.

METHODS: We first determined the optimal cut-off level of serum pepsinogen (PG)-1, PG-1/PG-2 ratio and 17-gastrin in 31 voluntary symptomatic patients (mean age: 66.1 years), of them 61% had histologically confirmed gastric atrophy. Then, in a population-based sample of 536 healthy individuals (209 residents in counties with higher relative risk and 327 residents in counties with lower relative risk for gastric cancer), we measured serum anti-H pylori antibodies, PG and 17-gastrin and estimated their risk of gastric cancer.

RESULTS: We found that serum PG-1 < 61.5 μg/L, PG-1/PG-2 ratio < 2.2 and 17-gastrin > 13.3 pmol/L had a high specificity (91%-100%) and a fair sensitivity (56%-78%) to detect corpus-predominant atrophy. Based on low serum PG-1 and PG-1/PG-2 ratio together as diagnostic criteria, 12.5% of the asymptomatic subjects had corpus-predominant atrophy (0% of those under 25 years and 20.2% over 65 years old). The frequency of gastric atrophy was similar (12% vs 13%) but H pylori infection rate was slightly higher (77% vs 71%) in the high-risk compared to the low-risk counties. Based on their estimated gastric cancer risk, individuals were classified as: low-risk group (no H pylori infection and no atrophy; n = 115; 21.4%); moderate-risk group (H pylori infection but no atrophy; n = 354, 66.0%); and high-risk group (gastric atrophy, with or without H pylori infection; n = 67, 12.5%). The high-risk group was significantly older (mean age: 61.9 ± 13.3 years), more frequently men and less educated as compared with the low-risk group.

CONCLUSION: We propose to concentrate on an upper gastrointestinal endoscopy for detection of early gastric cancer in the high-risk group. This intervention model could improve the poor prognosis of gastric cancer in Chile.

Prevalence of chronic atrophic gastritis in different parts of the world

Chronic atrophic gastritis (CAG) is a well-established precursor of intestinal gastric cancer, but epidemiologic data about its occurrence are sparse. We provide an overview on studies that examined the prevalence of CAG in different parts of the world. Articles containing data about the prevalence of chronic atrophic gastritis in unselected population samples and published until November 2005 were identified by searching the MEDLINE database. Furthermore, the references in the identified publications were screened for additional suitable studies. Studies comprising at least 50 subjects were included. Forty-one studies providing data on the prevalence of CAG in unselected population samples could be identified. CAG was determined by gastroscopy in 15 studies and by pepsinogen serum levels in 26 studies. Although results are difficult to compare due to the various definitions of CAG used, a strong increase with age, the lack of major gender differences, and strong variations between populations and population groups (in particular, relatively high rates in certain Asian populations) could be observed quite consistently. We conclude that CAG is relatively common among older adults in different parts of the world, but large variations exist. Large-scale international comparative studies with standardized methodology to determine CAG are needed to provide a coherent picture of the epidemiology of CAG in various populations. Noninvasive measurements of CAG by pepsinogen levels may be particularly suited for that purpose.

Highly salted food and mountain herbs elevate the risk for stomach cancer death in a rural area of Japan

BACKGROUND

Although many case-control and experimental studies have shown that highly salted foods are risk factors for stomach cancer, only a few cohort studies have supported the relationship.

METHODS

In a cohort study conducted in a rural area of Japan, 8035 residents aged over 30 years (approx. 55% were female) filled out a questionnaire. Seventy-six of them died from stomach cancer during an 11-year follow-up period. In the questionnaire, intake frequencies of 29 food items, smoking and drinking habits were investigated. Tsukemono (pickled vegetables) and tsukudani (foods deep boiled in soy sauce) are highly salted foods in the area. Frequency of each food item intake was classified into three levels, and age- and sex-adjusted risks were calculated using proportional hazard models.

RESULTS

In the final model obtained by backward elimination, frequent intake of tsukemono and tsukudani and that of mountain herbs remained as significant risk factors. Compared with the least frequent intake, risk (95% confidence interval) of the most frequent intake was 5.4 (1.8-16.3) for highly salted foods (P for trend < 0.01) and 3.7 (1.4-9.6) for mountain herbs (P for trend = 0.04).

CONCLUSION

Highly salted foods and mountain herbs were important risk factors for death from stomach cancer.

Updates on esophageal and gastric cancers

Esophageal and gastric cancers are both common and deadly. Patients present most often after disease progression and survival is therefore poor. Due to demographic variability and recent changes in disease incidence, much emphasis has been placed on studying risk factors for both esophageal and gastric cancers. However, with increasing understanding of these diseases, low survival rates persist and continued intensive studies are necessary to optimize treatment plans. This review article discusses updates in the evolving epidemiology, clinical presentation, risk factors, and diagnostic and treatment modalities of esophageal and gastric cancers.