CHAPTER ONE

1.0 INTRODUCTION Helicobacter pylori, previously named Campylobacter pyloridis, is a Gram-negative, microaerophilic bacterium found in the stomach. It is a spiral-shaped pathogenic bacterium found on the human gastric mucosa, was first isolated by Warren and Marshall. In 1982 and soon after was linked with chronic antral gastritis and peptic ulceration, (Marshall, et al., 1984). Initially, this bacterium was classified as Campylobacter pylori but in 1989 was included in a new genus, Helicobacter, and renamed Helicobacter pylori, (Goodwin, et al., 1989). It is also linked to the development of duodenal ulcers and stomach cancer. However, over 80 percent of individuals infected with the bacterium are asymptomatic and it has been postulated that it may play an important role in the natural stomach ecology, (Blaser, 2006). 1.1 HISTORY OF HELICOBACTER PYLORI Helicobacter pylori was first discovered in the stomachs of patients with gastritis and stomach ulcers in 1982 by Dr. Barry Marshall and Dr. Robin Warren of Perth, Western Australia. At the time, the conventional thinking was that no bacterium can live in the human stomach, as the stomach produced extensive amounts of acid of a strength similar to the acid found in a car battery. Marshall and Warren rewrote the textbooks with reference to what causes gastritis and gastric ulcers. German scientists found spiral-shaped bacteria in the lining of the human stomach in 1875, but they were unable to culture it, and the results were eventually forgotten, (Blaser, 2005). The Italian researcher Giulio Bizzozero described similarly-shaped bacteria living in the acidic environment of the stomach of dogs in 1893, Professor Walery Jaworski of the Jagiellonian University in Krakw investigated sediments of gastric washings obtained from humans in 1899. Among some rod-like bacteria, he also found bacteria with a characteristic spiral shape, which he called Vibrio rugula. He was the first to suggest a possible role of this organism in the pathogenesis of gastric diseases, (Konturek, 2003). Several small studies conducted in the early 20th century demonstrated the presence of curved rods in the stomach of many patients with peptic ulcers and stomach cancer, (Egan, et al., 1

2007). Interest in the bacteria waned, however, when an American study published in 1954 failed to observe the bacteria in 1180 stomach biopsies, (Palmer, 1954). Interest in understanding the role of bacteria in stomach diseases was rekindled in the 1970s, with the visualization of bacteria in the stomach of gastric ulcer patients. The bacterium had also been observed in 1979 by Australian pathologist Robin Warren, who did further research on it with Australian physician Barry Marshall beginning in 1981. After numerous unsuccessful attempts at culturing the bacteria from the stomach, they finally succeeded in visualizing colonies in 1982, when they unintentionally left their Petri dishes incubating for 5 days over the Easter weekend. In their original paper, Warren and Marshall contended that most stomach ulcers and gastritis were caused by infection by this bacterium and not by stress or spicy food, as had been assumed before, (Marshall, et al., 1984). Although there was some skepticism initially, within several years numerous research groups verified the association of Helicobacter pylori with gastritis and, to a lesser extent, ulcers, (Atwood, 2004). To demonstrate Helicobacter pylori caused gastritis and was not merely a bystander, Marshall drank a beaker of Helicobacter pylori culture. He became ill with nausea and vomiting several days later. An endoscopy ten days after inoculation revealed signs of gastritis and the presence of Helicobacter pylori. These results suggested Helicobacter pylori was the causative agent of gastritis. Marshall and Warren went on to demonstrate that antibiotics are effective in the treatment of many cases of gastritis. In 1987, the Sydney gastroenterologist Thomas Borody invented the first triple therapy for the treatment of duodenal ulcers. In 1994, the National Institutes of Health (USA) published an opinion stating most recurrent duodenal and gastric ulcers were caused by Helicobacter pylori, and recommended antibiotics be included in the treatment regimen, (Borody, et al., 1989). When 16S ribosomal RNA gene sequencing and other research showed in 1989 that the bacterium did not belong in the genus Campylobacter, it was placed in its own genus, Helicobacter. The genus derived from the ancient Greek hlix/ "spiral" or "coil". The specific epithet pylri means "of the pylorus" or pyloric valve (the circular opening leading from the stomach into the duodenum), from the Ancient Greek word , which means gatekeeper, (Liddell, et al., 1966). 1.2 CLASSIFICATION OF HELICOBACTER PYLORI Scientifically, Helicobacter pylori is classified as follows; 2

Kingdom: Bacteria Phylum: Proteobacteria Class: Epsilonproteobacteria Order: Campylobacterales Family: Helicobacteraceae Genus: Helicobacter Species: pylori, (Marshall, et al., 1984). The generic name, Helicobacter is derived from the helical shape of the bacterium. There are at least 23 species of Helicobacter, all isolated from the stomachs and upper intestines of humans, dogs, cats and other mammals, (Willey, et al., 2009). 1.3 MICROBIOLOGICAL CHARACTERISTICS Helicobacter pylori is an S-shaped or curved gram-negative rod. It has from two to six flagella that give it the mobility to withstand rhythmic gastric contractions and penetrate the gastric mucosa. It is 2.4 - 4.0m long and 0.5-1.0m wide. The principal reservoir for Helicobacter pylori infection appears to be the human stomach, especially the antrum. However, it does not colonize areas of the stomach in which intestinal metaplasia or dysplasia is present (Lambert, et al., 1995). Helicobacter pylori is also microaerophilic; that is, it requires oxygen, but at lower concentration than is found in the atmosphere. It contains a hydrogenase which can be used to obtain energy by oxidizing molecular hydrogen (H2) produced by intestinal bacteria, (Olson, et al., 2002). It produces oxidase, catalase, and urease, which enables the organism to survive in the acidic stomach by creating an alkaline environment. Helicobacter pylori produce a number of virulence factors, including vacuolating cytotoxin (vacA), which may have different disease associations, (Atherton, 1997). It is capable of forming biofilms and can convert from spiral to a possibly viable but nonculturable coccoid form both likely to favor its survival and be factors in the epidemiology of the bacterium, (Chan, et al., 1994). Helicobacter pylori possesses five major outer membrane protein (OMP) families. The largest family includes known and putative adhesins. The other four families include porins, iron transporters, flagellum-associated proteins and proteins of unknown function. Like other typical 3

Gram-negative bacteria, the outer membrane of Helicobacter pylori consists of phospholipids and lipopolysaccharide (LPS). The O antigen of LPS may be fucosylated and mimic Lewis blood group antigens found on the gastric epithelium. The outer membrane also contains cholesterol glucosides, which are found in few other bacteria, (Kusters, et al., 2006). Helicobacter pylori has four to six lophotrichous flagella; all gastric and enterohepatic Helicobacter species are highly motile due to flagella. The characteristic sheathed flagellar filaments of Helicobacter are composed of two copolymerized flagellins, FlaA and FlaB, (Rust, et al., 2008). 1.4 HELICOBACTER PYLORI GENOME Helicobacter pylori consists of a large diversity of strains, and the genomes of three have been completely sequenced. The genome of the strain "26695" consists of about 1.7 million base pairs, with some 1,550 genes. The two sequenced strains show large genetic differences, with up to 6% of the nucleotides differing, (Tomb, et al., 1997). Study of the Helicobacter pylori genome is centered on attempts to understand pathogenesis, the ability of this organism to cause disease. Approximately 29% of the loci are in the "pathogenesis" category of the genome database. Two of sequenced strains have an approximately 40 kb-long Cag pathogenicity island (a common gene sequence believed responsible for pathogenesis) that contains over 40 genes. This pathogenicity island is usually absent from Helicobacter pylori strains isolated from humans who are carriers of Helicobacter pylori, but remain asymptomatic, (Baldwin, et al., 2007). The cagA gene codes for one of the major Helicobacter pylori virulence proteins. Bacterial strains that have the cagA gene are associated with an ability to cause ulcers. The cagA gene codes for a relatively long (1186 amino acid) protein. The cag pathogenicity island (PAI) has about 30 genes, part of which code for a complex type IV secretion system. The low GC-content of the cag PAI relative to the rest of the Helicobacter genome suggests the island was acquired by horizontal transfer from another bacterial species, (Tomb, et al., 1997).

CHAPTER TWO
2.0 EPIDEMIOLOGY 2.1 DESCRIPTION STUDIES AND PREVALENCE The prevalence of Helicobacter pylori infection varies widely by geographic area, age, race, and socioeconomic status. Because it is not possible to ascertain when infection occurs clinically, most of the information on the rates of Helicobacter pylori in geographically and demographically diverse populations comes from seroprevalence studies. This has major disadvantages for epidemiologists, since it is generally not possible to distinguish between factors associated with acquiring versus maintaining Helicobacter pylori infection, (Parsonnet, 1995). The acquisition rate of Helicobacter pylori appears to be more rapid in developing than developed countries, (Pounder, et al., 1995). In a rural village of Linqu County, Shandong Province, China, a study of 98 children found that nearly 70 percent of those aged 5-6 years were infected with Helicobacter pylori, a rate similar to that reported for adults in that area, suggesting that most infection takes place early in childhood, (Ma, et al., 1998). The annual rate of seroconversion in adult populations in developed countries appears to be small, about 0.2-1.0 percent. However, two recent studies of young adults, one of Israeli backpackers to southeast Asia, South America, and Africa and the other of military personnel deployed to the Persian Gulf during Desert Storm, found much higher annual rates of seroconversion, 6.4 and 7.3 percent, respectively, suggesting that adults can seroconvert at higher rates than normal under unusual circumstances, (Xia, et al., 1997). In the United States, differences by race are evident, with Whites having a substantially lower seroprevalence of Helicobacter pylori than either Blacks or Hispanics. In the study by Replogle et al. in California, the odds ratios for being Helicobacter pylori seropositive given African-American and Hispanic ethnicity were 4.1 (95 percent confidence interval (CI): 2.2, 7.4) and 3.1 (95 percent CI: 1.6, 6.2), respectively. Similar risk estimates for Blacks (odds ratio (OR) = 4.4, 95 percent CI: 3.0, 6.3) and Hispanics (OR = 4.2, 95 percent CI: 2.1, 8.6) were found in a study of US Army recruits and a study of US Navy and Marine Corps personnel (OR = 4.2, 95 percent CI: 2.9, 6.0 for Blacks; OR = 3.9, 95 percent CI: 2.4, 6.3 for Hispanics), (Smoak, et al., 1994). Ethnic differences were also evident in New Zealand, where Helicobacter pylori infection was most prevalent in Pacific Islanders, intermediate in Maori, and least prevalent in Europeans. After adjusting for age and SES, the relative risks for Maori and Pacific Island subjects compared with European subjects were 1.4 (95 percent CI: 1.1,1.8) and 1.8 (95 percent CI: 1.4, 2.2), respectively. These differences in Helicobacter pylori prevalence by race/ethnicity and nationality 5

may reflect differences in social and/or hygiene factors or the widespread use of antimicrobials for treatment of other common infections, especially during childhood. This variability may also be explained by differences in ethnic or genetic predisposition to infections. Although some studies have reported an excess of Helicobacter pylori in one gender versus the other, no noteworthy gender differences exist in Helicobacter pylori prevalence overall, (Replogle, et al., 1995). 2.2 PREVALENCE OF HELICOBACTER PYLORI AMONG NIGERIA PATIENTS WITH DYSPEPSIA IN IBADAN, A PRACTICAL REPORT Determination of the true prevalence of Helicobacter pylori is difficult in a hyper-endemic area like Nigeria with use of serological tests because of their low discriminatory power between previous and current infections. The use of biopsy based methods will go a long way to mitigate this problem, (Abiodun, et al., 2002). Abiodun, et al., investigated the prevalence of Helicobacter pylori in dyspeptic patients and its relationship with gastroduodenal pathologies using gastric biopsy histology and rapid urease test. Eighty-six consecutive adult patients with dyspepsia underwent upper gastrointestinal endoscopy using forward-viewing endoscopes. Antral biopsy specimens were collected for histology and rapid urease test. Diagnosis of Helicobacter pylori infection was made if both or either of the tests was positive. Of the 86 subjects, there were 39 (45.3%) males and 47(54.7%) females. The age range was 23 to 85 years with a mean of 49.1913.75 years. Diagnosis of Helicobacter pylori was made in 55(64%) patients. Gastritis was the commonest endoscopic finding (60.5%), serious gastroduodenal pathology (gastric ulcer, duodenal ulcer and gastric cancer) were documented in only 12 (14%) patients. Thirty three (63.5%) of the 55 patients with gastritis had Helicobacter pylori infection while 7(58.3%) of the 12 patients with serious gastroduodenal lesions had the infection. Thirteen (72.2%) of the 18 patients that had normal endoscopic findings were Helicobacter pylori positive. It was concluded that the prevalence of Helicobacter pylori among dyspeptics using biopsy based methods is high in the South-Western part of Nigeria. It is therefore important to test and treat Helicobacter pylori among Nigerians with dyspepsia, (Abiodun, et al., 2002). 2.3 RISK FACTOR In addition to determining the prevalence of Helicobacter pylori in various geographic areas, a number of studies included a questionnaire component designed to investigate risk factors for 6

Helicobacter pylori positivity. The quality of these studies was variable, and, in many cases, the statistical procedures used were not well described. Also, it was not always clear whether prevalence rates for the various groups compared were standardized either directly or indirectly to adjust for differences in their age structures. The most common tests used to determine statistical significance were the chi-square test (for independence and homogeneity), Fisher's exact test, and Student's t test. Crude and adjusted relative risks and odds ratios were calculated by using the Mantel- Haenszel procedure and unconditional logistic regression, respectively. Odds ratios were the most common measure of association presented. While the odds ratio is a legitimate measure of association in its own right, it can be used as an estimate of the relative risk only when the incidence of disease in the population studied is rare. In addition, the cases and non cases included in the study should be representative of the cases and non cases in the population from which the study subjects were recruited. Because this "rare disease assumption" does not hold for Helicobacter pylori infection in any of the populations studied, the odds ratio should not be considered an approximation of the relative risk in studies of Helicobacter pylori. In addition, since these are cross-sectional studies, the outcome measure is prevalence of Helicobacter pylori infection at the time blood was drawn for serology, biopsy and culture were performed, or the breath test samples were obtained. Thus, the measure of association in a logistic regression analysis is the prevalence odds ratio, which compares the odds of being infected with Helicobacter pylori in the exposed group with the odds of being infected with Helicobacter pylori in the unexposed/referent group. The major factors investigated for their possible association with Helicobacter pylori positivity is discussed based on the following: smoking, alcohol consumption, diet, occupational exposures, waterborne exposures, hygiene practices, density/crowding, social factors, and family history of gastric disease, (Smoak, et al., 1994). 2.3.1 SMOKING Studies have assessed the possible association between Helicobacter pylori infection and smoking. Whereas some found that Helicobacter pylori-seropositive subjects were overall more likely than -seronegative subjects to be current smokers, (Fontham, et al., 1995). Results were often not consistent by race or gender. For example, Hamajima et al. found an odds ratio of 7.8 for Helicobacter pylori infection for current male smokers but an odds ratio of only 1.2 for current female smokers. Conversely, Lin et al. found a significant association with current smoking for females (OR = 2.8) but not for males. The positive finding (OR = 1.7) reported 7

by Fontham et al. held for Blacks (OR = 3.1) but not for Whites (OR = 0.6), and Lin et al. found no association with intensity or age at which smoking began. Most of the recent studies found no significant association with current smoking or any other measure of tobacco use. One recent study from Japan reported a significant negative association with current smoking. Some authors have suggested that these contradictory results may be due to uncontrolled confounding by social class or to differential antibiotic use, since smoking appears to affect treatment success, (Hamajima, et al., 1997). 2.3.2 ALCOHOL CONSUMPTION None of several recent epidemiologic studies of the relation between alcohol consumption and Helicobacter pylori infection found a positive association, but many noted a non-statistically significant reduction in risk, (Fontham, et al., 1995). Brenner et al., who incorporated a quantitative measure of alcohol consumption while controlling for potential confounding factors, found a significant negative association with alcohol consumption, especially at moderate to high levels. In two of these studies, the association was stronger for wine than for beer. Several studies did not adequately control for potential confounding variables or did not present the actual risk estimate or prevalence; thus, it is difficult to evaluate whether alcohol consumption has a "protective" effect on the prevalence of Helicobacter pylori. Helicobacter pylori is better able to survive in the acid environment of the stomach than other bacteria are because of its production of urease. Therefore, it is not surprising that the reduction in pH that may accompany alcohol consumption would have little effect on the prevalence of Helicobacter pylori, (Jenkins, et al., 1997). However, alcohol is known to have direct antimicrobial effects that appear to be more pronounced for wine than for other types of alcoholic beverages. The differing results may be due to the different methodologies used or to real differences in either the type or amount of alcohol consumed and its effect on Helicobacter pylori in different populations. 2.3.3 DIET Studies have also looked at dietary associations with Helicobacter pylori. Although the studies cover many different types of populations and include both adults and children, some consistent associations suggest that nutritional status may be related to Helicobacter pylori infection. Goodman et al. and Fontham et al., found significantly reduced odds ratios and negative gradients in risk of Helicobacter pylori infection with increased consumption of fruits and/or vegetables, (Fontham, et al., 1985).

An intervention study by Jarosz et al. found that Helicobacter pylori infection was apparently eradicated in 30 percent of patients with chronic gastritis who were treated with vitamin C for 4 weeks compared with 0 percent in the control group. Trends of decreasing risk with increasing consumption of vitamin C were observed in studies by Goodman et al. and Fontham et al.; however, Malaty et al. found high levels of vitamin C to be associated with Helicobacter pylori infection in twins reared apart. Goodman et al. also reported high levels of beta-carotene to be protective. In contrast, in studies by Goodman et al. and Hopkins et al. consumption of raw or uncooked vegetables was related to the risk of Helicobacter pylori infection (OR = 2.0 for three or more servings per day and OR = 3.2, respectively). The cause of this increased risk has not been determined but may have been due to contaminated water or soil or contamination by a vector such as the fly. The role of food prepared under less than ideal sanitary conditions as a possible mechanism of Helicobacter pylori transmission was suggested by Begue et al. who found elevated risks for consumption of food obtained from street vendors in Peru. 2.3.4 OCCUPATIONAL EXPOSURES Occupational exposures have been studied by several researchers to determine whether people working in certain occupations with potentially greater exposure to Helicobacter pylori had an increased prevalence of infection. Bohmer et al., in a study of inhabitants of institutes for the intellectually disabled in the Netherlands, found most of the intellectually disabled to be seropositive (83 percent). They also reported a higher rate of seropositivity (32 percent) among employees such as the nursing staff, who had intensive contact with institutionalized inhabitants, than among employees such as medical staff, speech trainers, secretarial staff, and drivers, who had little or no direct contact (14.1 percent), (Bohmer, et al., 1997). 2.3.5 WATERBORNE EXPOSURES Water has been suggested as a possible source of Helicobacter pylori infection. Studies in Colombia, rural China, and Lima, Peru found that water source may be related to risk of Helicobacter pylori infection, (Klein, et al., 1991). Three waterborne factors were linked to higher risks of Helicobacter pylori infection in Colombian children: drinking water from a stream, swimming in a stream, and swimming in a swimming pool, (Goodman, et al., 1996).

Klein et al. found that the water supply in Lima, Peru, may be vulnerable to bacterial contamination, especially if it is stored in a cistern or obtained through central community water taps, (Klein, et al., 1991). 2.3.6 HYGIENE PRACTICES Studies also have assessed the relation between Helicobacter pylori infection and various hygiene practice indicators in a number of countries. Overall, poor hygiene practices, especially during childhood, appear to be related to a higher seroprevalence of Helicobacter pylori. Some of these practices include having no water closet or bathroom or no hot water supply in the house when the subject was a child, sharing cups as children, having mothers who did not use soap when they washed their hands, having mothers pre-chew the food for their young children, using chopsticks, not usually washing one's hands after going to the toilet, and living in a relatively small area with extremely limited sanitary facilities (e.g., submarine crews), (Goodman, et al., 1996). Other hygiene practices during adulthood, such as sharing a toothbrush or cup and the type of toilet/bathroom facility, were not strongly related to Helicobacter pylori infection, (Beuer, et al., 1996). 2.3.7 DENSITY/CROWDING

In all recent studies that have evaluated various density measures during both childhood and adulthood, some measure of overcrowding, such as living in a crowded environment, sib-ship size, number of persons or children in the home, number of persons per room, crowding index, having to share a room or bed with a parent, or living in an overcrowded space in a submarine, was consistently related to Helicobacter pylori positivity. The positive association of Helicobacter pylori with high-density environments, especially during childhood, suggests that crowded household quarters may facilitate transmission of infection among siblings and other family members, (Beuer, et al., 1996). 2.3.8 SOCIAL FACTORS In a variety of studies throughout the world, social factors have been independently associated with Helicobacter pylori status. The most commonly used measures were socioeconomic status-based occupation, education, and income, (Replogle, et al., 1995).

10

2.3.9

FAMILY HISTORY OF GASTRIC DISEASE Studies have also evaluated the relation between Helicobacter pylori infection and family

history of gastric disease. In a recent study by Brenner et al. the risk of being infected with Helicobacter pylori was significantly greater for adults with a parental history of stomach cancer than for those without such a history. The results for ulcer are somewhat inconsistent. Whereas the study in Germany by Brenner et al. found a significantly elevated risk for children whose mothers, but not fathers, had ulcer disease, (Brenner et al., 2000).

11

CHAPTER THREE
3.0 DISEASE ASSOCIATIONS Helicobacter pylori is thought to be indigenous to the human population and is well adapted to existing in the human stomach for the lifetime of its host, (Blaser, 1997). Spontaneous eradication of Helicobacter pylori from the gastric mucosa, as measured by seroreversion, is a relatively rare event 0.1-1.1 percent annually (Xia, et al., 1997). Infection with Helicobacter pylori can result in chronic gastritis, a cellular infiltrate of immunocompetent lymphocytes and of IgA-, IgG-, and IgM-secreting plasma cells in the gastric mucosa, (Sipponen, 1997). Infection is generally asymptomatic, with the majority of those persons infected not developing clinical disease. However, because Helicobacter pylori has been recognized as a major cause of gastritis and is associated with duodenal ulcer disease, gastric ulcer disease, gastric lymphoma, and gastric cancer in humans. It is a public health problem in both developed and developing countries, (Graham, 1994). Environmental and genetic factors appear to be important in the progression of Helicobacter pylori-initiated gastritis to more serious outcomes. Additionally, variation in age at acquisition of Helicobacter pylori has been proposed as a possible factor to explain the observation that the same organism, Helicobacter pylori, apparently produces different effects on the gastric mucosa that result in different clinical outcomes, (McColl, 1997). Early age at acquisition of Helicobacter pylori infection may result in more intense inflammation and the early development of atrophic gastritis and subsequent risk of gastric ulcer, gastric cancer, or both. Later acquisition of infection would induce a different series of gastric changes that would favor the development of duodenal ulcer. High rates of gastric cancer in areas in which infection is common in early childhood support this hypothesis. Other host and environmental factors such as hygiene practices and diet may also play a role in the acquisition of infection and the expression of clinical disease, (Fallone, 1999). In 1994, an International Agency for Research on Cancer Working Group found sufficient evidence to classify Helicobacter pylori as a human carcinogen for gastric cancer. However, some researchers now believe that the epidemiologic evidence is contradictory and that this agency was premature in its group 1 designation, because Helicobacter pylori seems to play a role in only the initial steps that result in chronic inflammation (a common occurrence in much of the world) but not in the later steps that lead to carcinogenesis, (Nyren, 1998). 12

Intervention studies that include treatment for Helicobacter pylori for subjects at different stages in the progression toward cancer will be informative in clarifying the " Helicobacter pylori = gastric cancer" controversy, (Gail, et al., 1998). On the other hand, some Helicobacter pylori strains, particularly cagA+, appear to protect against adenocarcinomas of the esophagus and gastric cardia, (Hansen, et al., 1999). Also, the prevalence of Helicobacter pylori infection appears to be lower in persons with gastroesophageal reflux disease (the major risk factor for Barrett's esophagus, which is strongly associated with adenocarcinoma of the esophagus) than in controls, (Wu, et al., 1999). The relation between Helicobacter pylori infection and non-ulcer dyspepsia is controversial. For example, while a recent meta-analysis reported an improvement in dyspeptic symptoms among subjects receiving antibiotics treatment, two recent randomized controlled trials did not. There is now some concern that Helicobacter pylori infection may be associated with an increased risk of coronary heart disease possibly because of a low-grade systemic inflammatory response or an increase in concentrations of circulating coagulation factors. However, the results from several prospective studies and a meta-analysis of more than 20 epidemiologic studies suggest that Helicobacter pylori is probably not an important contributor to coronary heart disease, (Strachan, et al., 1998). Figure 1 on the back page present a diagram of Helicobacter pylori causing peptic ulcer disease. 3.1 PATHOPHYSIOLOGY OF HELICOBACTER PYLORI To colonize the stomach, Helicobacter pylori must survive the acidic pH of the lumen and use its flagella to burrow into the mucus to reach its niche, close to the stomach's epithelial cell layer, (Amieva, et al., 2008). Many bacteria can be found deep in the mucus, which is continuously secreted by mucussecreting cells and removed on the luminal side. To avoid being carried into the lumen, Helicobacter pylori senses the pH gradient within the mucus layer by chemotaxis and swims away from the acidic contents of the lumen towards the more neutral pH environment of the epithelial cell surface, (Schreiber, et al., 2004). Helicobacter pylori is also found on the inner surface of the stomach epithelial cells and occasionally inside epithelial cells. It produces adhesins which bind to membrane-associated lipids 13

and carbohydrates and help it adhere to epithelial cells. For example, the adhesin BabA binds to the Lewis b antigen displayed on the surface of stomach epithelial cells, (Ilver, et al., 1998). Helicobacter pylori produces large amounts of the enzyme urease, molecules of which are localized inside and outside of the bacterium. Urease breaks down urea (which is normally secreted into the stomach) to carbon dioxide and ammonia. The ammonia is converted to ammonium by accepting a proton (H+), which neutralizes gastric acid. The survival of Helicobacter pylori in the acidic stomach is dependent on urease. The ammonia produced is toxic to the epithelial cells, and, along with the other products of Helicobacter pyloriincluding proteases, vacuolating cytotoxin A (VacA), and certain phospholipasesdamages those cells, (Smoot, 1997). Inflammatory processes of Helicobacter pylori infections are also mediated by highly disulfide-bridged proteins. Helicobacter cysteine-rich proteins (Hcp), particularly HcpA (hp0211), triggers an immune response through the differentiation of human myeloid Thp1 monocytes into macrophages. In analogy to eucaryotic cytokines, they interfer with host cell functions and change the morphology of monocytes, inducing the expression of the surface marker protein CD11b, phagocytic activity, as well as cell adherence, which are indicative of monocyte differentiation into macrophages, (Mittl, et al., 2009). Colonization of the stomach by Helicobacter pylori results in chronic gastritis, an inflammation of the stomach lining. The severity of the inflammation is likely to underlie Helicobacter pylori-related diseases. Duodenal and stomach ulcers result when the consequences of inflammation allow the acid and pepsin in the stomach lumen to overwhelm the mechanisms that protect the stomach and duodenal mucosa from these caustic substances. The type of ulcer that develops depends on the location of chronic gastritis, which occurs at the site of Helicobacter pylori colonization. The acidity within the stomach lumen affects the colonization pattern of Helicobacter pylori, and therefore ultimately determines whether a duodenal or gastric ulcer will form. In people producing large amounts of acid, Helicobacter pylori colonizes the antrum of the stomach to avoid the acid-secreting parietal cells located in the corpus (main body) of the stomach, (Kusters, et al., 2006). The inflammatory response to the bacteria induces G cells in the antrum to secrete the hormone gastrin, which travels through the bloodstream to the corpus. Gastrin stimulates the parietal cells in the corpus to secrete even more acid into the stomach lumen. Chronically increased gastrin levels eventually cause the number of parietal cells to also increase, further escalating the 14

amount of acid secreted. The increased acid load damages the duodenum, and ulceration may eventually result. In contrast, gastric ulcers are often associated with normal or reduced gastric acid production, suggesting the mechanisms that protect the gastric mucosa are defective, (Schubert, et al., 2008). In these patients, Helicobacter pylori can also colonize the corpus of the stomach, where the acid-secreting parietal cells are located. However chronic inflammation induced by the bacteria causes further reduction of acid production and, eventually, atrophy of the stomach lining, which may lead to gastric ulcer and increases the risk for stomach cancer, (Suerbaum, et al., 2002). About 50-70% of Helicobacter pylori strains in Western countries carry the cag pathogenicity island (cag PAI). Western patients infected with strains carrying the cag PAI have a stronger inflammatory response in the stomach and are at a greater risk of developing peptic ulcers or stomach cancer than those infected with strains lacking the island, (Kusters, et al., 2006). Two related mechanisms by which Helicobacter pylori could promote cancer are under investigation. One mechanism involves the enhanced production of free radicals near Helicobacter pylori and an increased rate of host cell mutation. The other proposed mechanism has been called a "perigenetic pathway", and involves enhancement of the transformed host cell phenotype by means of alterations in cell proteins, such as adhesion proteins. Helicobacter pylori has been proposed to induce inflammation and locally high levels of TNF- and/or interleukin 6 (IL-6). According to the proposed perigenetic mechanism, inflammation-associated signaling molecules, such as TNF-, can alter gastric epithelial cell adhesion and lead to the dispersion and migration of mutated epithelial cells without the need for additional mutations in tumor suppressor genes, such as genes that code for cell adhesion proteins, (Suganuma, et al., 2008). 3.2 SIGNS AND SYMPTOMS Most people (over 80%) infected with Helicobacter pylori show no symptoms, (Boyanova, 2011). Acute infection may appear as an acute gastritis with abdominal pain (stomach ache) or nausea, (Butcher, et al., 2003). Abdominal pain or discomfort is the most common symptom of both duodenal and gastric ulcers. Felt anywhere between the navel and the breastbone, this discomfort usually is a dull or 15

burning pain, occurs when the stomach is empty (between meals or during the night), may be briefly relieved by eating food, in the case of duodenal ulcers, or by taking antacids, in both types of peptic ulcers. This lasts for minutes to hours and comes and goes for severl days or weeks. Where this develops into chronic gastritis, the symptoms, if present, are often those of nonulcer dyspepsia: stomach pains, nausea, bloating, belching and sometimes vomiting, (Ryan, et al., 2010). Individuals infected with Helicobacter pylori have a 10 to 20% lifetime risk of developing peptic ulcers and a 1 to 2% risk of acquiring stomach cancer, (Kusters, et al., 2006). Inflammation of the pyloric antrum is more likely to lead to duodenal ulcers, while inflammation of the corpus (body of the stomach) is more likely to lead to gastric ulcers and gastric carcinoma, (Suerbaum, et al., 2002). 3.3 MODE OF TRANSMISSION Understanding the route of Helicobacter pylori transmission is important if public health measures to prevent its spread are to be implemented. Iatrogenic transmission of Helicobacter pylori following endoscopy is the only proven mode. For the general population, the most likely mode of transmission is from person to person, by either the oral-oral route (through vomitus or possibly saliva) or perhaps the fecal-oral route. The person-to-person mode of transmission is supported by the higher incidence of infection among institutionalized children and adults and the clustering of Helicobacter pylori infection within families. Also lending support to this concept is the detection of Helicobacter pylori DNA in vomitus, saliva, dental plaque, gastric juice, and feces. Waterborne transmission, probably due to fecal contamination, may be an important source of infection, especially in parts of the world in which untreated water is common. Zoonotic or Vector borne transmission is a likely mode of transmission of Helicobacter pylori. Several studies have suggested sheep as a possible source of Helicobacter pylori transmission, a hypothesis that deserves additional investigation. Helicobacter pylori has been isolated in domestic cats. The most recent reservoir suggested for Helicobacter pylori transmission is the housefly. However, evidence is lacking that Helicobacter pylori can be transmitted to humans from flies that have been in contact with Helicobacter pylori-infected feces, (http://epirev.oxfordjournals.org). 16

CHAPTER FOUR
4.0 DIAGNOSTIC TESTS Because acute infection with Helicobacter pylori is generally asymptomatic, it is not possible to ascertain when infection occurs on the basis of symptoms or clinical findings, (Parsonnet, 1995). Diagnosis of infection is usually made by checking for dyspeptic symptoms and by tests which can indicate Helicobacter pylori infection. One can test noninvasively for Helicobacter pylori infection with a blood antibody test, stool antigen test, or with the carbon urea breath test (in which the patient drinks
14

C- or

13

C-labelled urea, which the bacterium metabolizes, producing

labelled carbon dioxide that can be detected in the breath), (Stenstrom, et al., 2008). However, the most reliable method for detecting Helicobacter pylori infection is a biopsy check during endoscopy with a rapid urease test, histological examination, and microbial culture. There is also a urine ELISA test with a 96% sensitivity and 79% specificity. None of the test methods are completely failsafe. Even biopsy is dependent on the location of the biopsy. Blood antibody tests, for example, range from 76% to 84% sensitivity. Some drugs can affect Helicobacter pylori urease activity and give false negatives with the urea-based tests, (Logan, et al., 2001). 4.1 PREVENTION AND CONTROL OF HELICOBACTER PYLORI Helicobacter pylori is a major cause of diseases of the upper gastrointestinal tract. Eradication of the infection improves symptoms including dyspepsia, gastritis and peptic ulcers, and may prevent gastric cancer. No one knows for sure how Helicobacter pylorispreads, so prevention is difficult. Researchers are trying to develop a vaccine to prevent and even cure Helicobacter pylori infection. To help prevent infection, doctors advise people to; Wash their hands with soap and water after using the bathroom and toilet and before eating. Eat foods that has been washed well and cooked properly. Drink water from a clean, safe source. Extensive vaccine studies in mouse models have shown promising results. Researchers are studying different adjuvants, antigens, and routes of immunization to ascertain the most appropriate system of immune protection, with most of the research only recently moving from animal to human trials, (Kabir, 2007). 17

A number of foods may be useful to prevent colonization with Helicobacter pylori including: green tea, red wine, broccoli sprouts, garlic, probiotics and flavonoids, (Lee, et al., 2008). 4.2 TREATMENT Once Helicobacter pylori is detected in patients with a peptic ulcer, the normal procedure is to eradicate it and allow the ulcer to heal. The standard first-line therapy is a one week "triple therapy" consisting of proton pump inhibitors such as omeprazole, lansoprazole and the antibiotics clarithromycin and amoxicillin, (Mirbagher, et al., 2006). Variations of the triple therapy have been developed over the years, such as using a different proton pump inhibitor, as with pantoprazole or rabeprazole, or replacing amoxicillin with metronidazole for people who are allergic to penicillin. Such a therapy has revolutionized the treatment of peptic ulcers, and has made a cure to the disease possible; previously, the only option was symptom control using antacids, H2-antagonists or proton pump inhibitors alone, (Graham, et al., 1991). An increasing number of infected individuals are found to harbour antibiotic-resistant bacteria. This results in initial treatment failure and requires additional rounds of antibiotic therapy or alternative strategies, such as a quadruple therapy, which adds a bismuth colloid, such as bismuth subsalicylate. For the treatment of clarithromycin-resistant strains of Helicobacter pylori, the use of levofloxacin as part of the therapy has been suggested, (Graham, et al., 2008). Ingesting lactic acid bacteria exerts a suppressive effect on Helicobacter pylori infection in both animals and humans. Supplementing with Lactobacillus- and Bifidobacterium-containing yogurt (AB-yogurt) was shown to improve the rates of eradication of Helicobacter pylori in humans, (American Journal of Clinical Nutrition). CONCLUSION Helicobacter pylori is a common bacterium, and approximately 50 percent of the world's population has been estimated to be infected. Humans are the principal reservoir. The prevalence of Helicobacter pylori infection varies widely by geographic area, age, race, ethnicity, and socioeconomic status. Rates appear to be higher in developing than in developed countries, with most of the infections occurring during childhood, and they seem to be decreasing with improvements in hygiene practices. Helicobacter pylori causes chronic gastritis and has been associated with several serious diseases of the gastrointestinal tract, including duodenal ulcer and gastric cancer. Since its "discovery" in 1982 by Warren and Marshall, Helicobacter pylori has been the topic of extensive research. 18

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