Helicobacter pylori

Dr.T.V.Rao MD
A Tribute to Warren and
Marshall
for Discovery of H.pylori
 Helicobacter pylori

• Helicobacter pylori (H. pylori) is a type of

bacteria. Researchers believe that H.
pylori is responsible for the majority of
peptic ulcers.
• H. pylori infection is common in the United
States. About 20 percent of people under
40 years old and half of those over 60
years have it. Most infected people,
however, do not develop ulcers. Why H.
pylori does not cause ulcers in every
infected person is not known. Most likely,
infection depends on characteristics of the
infected person, the type of H. pylori, and
 Beginning of Scientific
understanding
• Peptic ulcers have plagued men
throughout the centuries, but the
exact cause of the condition was
uncertain. In 1940, Dr. A. Stone
Freedberg of Harvard Medical School
identified unusual curved bacteria in
the stomachs of ulcer victims; he
suspected that they might be
responsible for ulcers but abandoned
the research when his team was
 History of H.pylori
• Helicobacter pylori (H.pylori for short)
was first discovered in the stomachs
of patients with gastritis & stomach
ulcers nearly 25 years ago by Dr
Barry J. Marshall and Dr J. Robin
Warren of Perth, Western Australia.
At the time (1982/83) the
conventional thinking was that no
bacterium can live in the human
stomach as the stomach produced
extensive amounts of acid which was
similar in strength to the acid found
in a car-battery. Marshall & Warren
 Land Mark Changes in
H.pylori
• The name of the bacterium was grammatically
corrected in 1987 to Campylobacter pylori
and, in 1989 the bacterium was renamed
Helicobacter pylori and assigned as the
type species of a novel genus due to its
16s rRNA sequence. Interest in this
bacterium is reflected in the increase in
the number of papers on the subject from
20 in 1984 to over 300 in 1990 and over
1000 in 1999 making it one of the most
active areas of research in the medical
field
 Helicobacter pylori
• Helicobacter pylori
is a spiral gram
negative bacteria.
• It has a multiple
polar flagella
above the pole and
motile
 Culturing H.pylori
• H.pylori grows on
Skirrow”s medium
with 1Vancomycin,
2 Polymyxin
3 Trimethoprim
Grows in 3 -6 days at
370c
Colonies appear
Translucent 1-2 mm in
diameter
Optimal growth occurs in
Microaerophic
environment
 Biochemical Characters
• Motile
• Catalase +
• Oxidase +

Strong producer of
Urease
 Pathology and
Pathogenesis
• H.pylori is found in the deep mucus
layer
• Grows optimally at pH 6.0 to 7.0
• But gastric mucosa has a strong
buffering in spite of lower pH on the
lumen side of stomach
• H.pylori also produces a protease
that modifies the gastric mucus and
further reduces the ability of acid
through the mucus
Mechanisms in
Pathogenicty
 Pathogenesis
• The potential character of H.pylori lie
with production of potent Urease
activity which yields production of
Ammonia and further buffering acid.
• H.pylori is quite motile even in
mucus finds its way to epithelial
surface
• H.pylori overlies the gastric type but
not intestinal epithelial cells.
 Factors contributing to
Peptic ulceration
• There is a strong association
between presence of H.pylori
infection and peptic ulceration
• Mucosal inflammation and damage
involves both bacterial and host
factors
H.Pylori causes Peptic ulcer
in the Stomach
 Factors influencing
Pathogenicty
• Lipopolysaccharides - damage mucosal
cells and Ammonia produced by Urease
acitivity may directly damage cells.
• Gastritis – Chronic and active inflammation
establishes Polymorphonuclear and
Mononuclear cell infiltration within the
Epithelial and Lamina propria
• Events lead to Destruction of epithelium is
common.
• Glandular atrophy is common.
 Clinical Manifestations
• Acute infection
Upper Gastrointestinal illness
Nausea
Pain
Fever – very occasionally
Acute symptoms lasts for < 1 week,
May extend upto 2 weeks
Infection last for years, decades or even lifetime
Consequences of H.pylori
Infection
 Association of Duodenal
and Gastric ulcers in
H.pylori
• About 90 % of patients with
Duodenal ulcer, and 50- 80 % of
gastric ulcers are associated with
H.pylori infection.
• H.pylori may have greater role in
Gastric carcinoma and Lymphomas
Mechanism of Cancer in
H.pylori
 Laboratory Diagnosis
• Specimens for histopathology –
Gastric biopsy specimens can be
used for Histological examination
• Specimens obtained after
Gastroscopy, Biopsy, routine stains
will demonstrate Gastritis and special
stains show curved spiral organisms
• Specimens collected in sterile saline
mixed are used for culturing
Endoscopy – Gastric
Biopsy
 Culturing for H.pylori
• Culturing of H.pylori
needs specific
conditions
• Media
Skirrow”s Medium
with
Vancomycin
Polymyxin B
Trimethoprim
Chocolate Medium
with
Vancomycin,
Nalidixic acid
Amphotericin
 Serology
• The detection of
Antibodies in active
infection is useful
• But the tests are
limited utility as
antibodies persist
even after H.pylori
infection is eradicated.
• Several commercial
kits are available, but
lacks the role in
identifying acute
infections.
Special Tests for H.pylori
• Rapid tests for
detection of Urease
activity are widely
used in presumptive
identification of
Gastric Biopsy
specimens.
• Gastric Biopsy can be
placed into urea
containing medium
with color indicator.
• If H.pylori is
present the Urease
rapidly splits urea
and resulting shift
 Urea Breath Test

– H. pylori infection
can be detected in
the exhaled breath
using this special
test. This test is
positive only if the
person has a
current infection.
Sensitivity and
specificity of this
test ranges from
94-98%.
 Urea Breath Test
• In this test 13C or
14
C labelled urea is
ingested by
patients
• If H.pylori is
present the
urease activity
generates
labelled Co2 that
can be detected
in the patients
exhaled breath
 Antigen Detection Test
in Stool
• Detection of
H.pylori antigen in
stool is appropriate
test in patients
with H.pylori
infection
• Absence of
antigen indicates
cure of Infection
after
Chemotherapy.
 Treatment
• Triple therapy has prompt response,
contain a combination of following drugs
1 Metronidazole
2 Bismuth subsalicylate or Bismuth sub
citrate
3 Amoxicillin or Tetracycles
administered upto 14 days
Eradicates H.pylori
In 70 – 95 % of patients
Acid suppressing agent is supporting
Other Drug Combination
• Other alternatives
Proton pump inhibitor directly
inhibit
H.pylori
Combined with
Amoxicillin
Clarithromycin or
Amoxicillin
And Metronidazole
 Epidemiology
• In Developed countries H.pylori are
present in <20 % of the persons below 30
years.
• By 60 years prevalence increases to 40 –
60 %
• In Developing countries prevalence of
infection is higher to 80 % even in
younger individuals
• Person to person transmission of H.pylori
is likely because of interfamilial clustering
of infection
 Discovery of H.pylori
changes the Peptic Ulcer
Disease
 Barry J. Marshall and J.
Robin Warren have been
awarded the 2005 Nobel
Prize in medicine
Created for Graduate
Medical Students in
Devloping World
Dr.T.V.Rao MD
Email
doctortvrao@gmail.com