HELICOBACTER PYLORI

Dr. Chairul Sandro

1
 HISTORY OF H. PYLORI
• 1890’s: Spirochetes in animal stomachs
• 1900’s: Spirochetes in human stomachs
• 1954: No bacteria in gastric biopsies of 1000 patients
• 1975: Gram negative bacteria in 80% of GU’s
(Pseudomonas)
• 1983: Warren and Marshall characterize H. pylori
• 2005 Nobel prize in 2005
 HELICOBACTER PYLORI
Background

Human stomach long considered inhospitable for

bacteria

Spiral shaped organisms occasionally visualized in

gastric mucous layer, but no evidence of disease
association

Organism classified first as Campylobacter pylori

Now Helicobacter pylori

Other species of Helicobacter isolated from

stomach, intestine of other animals

Marshall and Warren culture organism from human

gastric mucosa and show association with gastric
inflammation
DR.T.V.RAO MD 3
 HELICOBACTER
( WARREN AND MARSHAL )
• Campylobacter like organisms
• Spiral shaped colonizes Gastric mucosa
• Etiological agent in Gastritis and peptic ulcer
• Most important bacteria.
Helicobacter pylori
Colonizes 50 % of the Individuals

DR.T.V.RAO MD 4
 WARREN AND MARSHAL WINS
NOBEL PRIZE

DR.T.V.RAO MD 5
 GENERAL CHARACTERISTICS OF
HELICOBACTER
• Helicobacter pylori is major human pathogen associated with
gastric antral epithelium in patients with active chronic gastritis
• Stomach of many animal species also colonized
• Urease (gastric strains only), mucinase, and catalase positive
highly motile microorganisms
• Other Helicobacters: H. cinnaedi and H. fenneliae
• Colonize human intestinal tract
• Isolated from homosexual men with proctitis, proctocolitis,
enteritis, and bacteremia and are often transmitted through
sexual practices
DR.T.V.RAO MD 6
 A silver stain of H. pylori on gastric mucus-
secreting epithelial cells (x1000).
From Dr. Marshall's stomach biopsy taken 8 days
after he drank a culture of H. pylori (1985).

DR.T.V.RAO MD 7
 HELICOBACTER PYLORI

• Gram –ve spiral

shaped , motile
with unipolar tuft
of lopotrichus
flagella
DR.T.V.RAO MD 8
 H. PYLORI BACTERIA
• Gram negative
• Spiral rod
• Unipolar flagella
• Microaerophilic
• Urease positive*
*Most important
character

*Scanning microscopic view of H. pylori

 MORPHOLOGY & PHYSIOLOGY OF
HELICOBACTER

• Gram-negative; Helical (spiral or curved) (0.5-1.0 um X

2.5-5.0 um); Blunted/rounded ends in gastric biopsy
specimens; Cells become rod-like and coccoid on
prolonged culture
• Produce urease, mucinase, and catalase
• H. pylori tuft (lophotrichous) of 4-6 sheathed flagella
(30um X 2.5nm) attached at one pole
• Single polar flagellum on H. fennellae & H. cinaedi
• Smooth cell wall with unusual fatty acids
DR.T.V.RAO MD 10
 H. PYLORI INFECTION
TRANSMISSION
• Transmissible
• Oral-oral and oral-
fecal
• Infects the human
stomach
• Produces inflammatory
response

• This brings up the point

of the importance of
“hand washing”
 DYNAMICS OF H.PYLORI INFECTION

DR.T.V.RAO MD 12
 CULTURING AND BIOCHEMICAL
CHARACTERS
• Grows on chocolate agar, Campylobacter media
• Grows under Microaerophilic conditions
• With presence of 5 – 20% co2
• Oxidase +
• Catalase –
• Urease strongly +++
• H2S

DR.T.V.RAO MD 13
 H. PYLORI PATHOGENESIS
BACTERIAL VIRULENCE FACTORS
(CAG- PAI)( 37000 B-P – 29 GENES)

• Type IV secretions apparatus (1) (translocate cag A)

• Possible insertion by needle like organelle coated with a sheath (Cag 7

protein) [Rohde et al]

• Phosphorylated + binds to SHP-2 tyrosine Phosphates

Cytokine Production Growth Factor

IL- 8+ chemokines Like cellular response

(1) Odenbreit S, et al. Science 2000;287:1497-1500

 H. PYLORI PATHOGENESIS
BACTERIAL VIRULENCE FACTORS

Ingestion Evasion + Entrance of Mucus

1 Layer (Motility + Urea I)

2 Binding

3 Insertion

4 Intra cellular pathway

HELICOBACTER PYLORI AND PEPTIC ULCER DISEASE
HISTOPATHOLOGY WITH SPECIAL STAINS .
DR.T.V.RAO MD 17
 PATHOLOGY AND PATHOGENESIS
• H.pylori colonizes gastric mucosa
• Spread by oral – oral contact
• Feco oral spread prominent
• Poverty and overcrowding predisposes
• Poor Hygiene
• Causes mild to acute gastritis
• Gastric antrum - causes gastric metaplasia
• Any part of the stomach can be involved
• Colonizes overlying mucosa but donot invade mucosa
DR.T.V.RAO MD 18
 MAJOR LOCATION OFH.PYLORI
INFECTIONS

DR.T.V.RAO MD 19
 Pathogenesis of Helicobacter Infections
 Colonize mucosal lining of stomach & duodenum in
man & animals
• Adherent to gastric surface epithelium or pit epithelial
cells deep within the mucosal crypts adjacent to gastric
mucosal cells
• Mucosa protects the stomach wall from its own gastric
milleu of digestive enzymes and hydrochloric acid
• Mucosa also protects Helicobacter from immune
response
 Most gastric adenocarcinomas and lymphomas are
concurrent with or preceded by an infection with H.
pylori
 H.PYLORI INFECTING MUCOSAL
LAYER

DR.T.V.RAO MD 21
 PATHOGENESIS OF H.PYLORI.

DR.T.V.RAO MD 22
 Virulence Factors of Helicobacter
 Multiple polar, sheathed flagella
• Corkscrew motility enables penetration into viscous
environment (mucus)
 Adhesins: Hemagglutinins; Sialic acid binding
adhesin; Lewis blood group adhesin
 Mucinase: Degrades gastric mucus; Localized
tissue damage
 Urease converts urea (abundant in saliva and
gastric juices) into bicarbonate (to CO2) and
ammonia
• Neutralize the local acid environment
• Localized tissue damage
 Acid-inhibitory protein
H. Pylori Specific T Cell and B Cell Responses
 MECHANISM OF H.PYLORI INFECTION

DR.T.V.RAO MD 25
 Urea Hydrolysis
Urease
C=O(NH2)2 + H+ + 2H2O  HCO3- + 2 (NH4+)
Urea Bicarbonate Ammonium
ions
And then… HCO3- 
CO2 + OH-
 Virulence Factors of Helicobacter )
Tissue damage:
 Vacuolating cytotoxin: Epithelial cell damage
 Invasin(s)(??): Poorly defined (e.g., hemolysins;
phospholipases; alcohol dehydrogenase)
Protection from phagocytosis & intracellular killing:
 Superoxide dismutase
 Catalase
 H. Pylori Pathogenesis and Application of
Cutting Edge Technologies

Molecular Genetics Imaging Cell culture

biology models
 INDICATIONS FOR NONINVASIVE
TESTING FOR H. PYLORI *
• Strongly Recommended
• Dyspepsia
• History of/active peptic ulcer disease
• Gastric MALT lymphoma
• Following gastric cancer resection
• Following peptic ulcer surgery
• First-degree relative with gastric cancer
• Long-term Non-steroidal anti-inflamatory drugs (NSAID)
therapy
* In the absence of alarm signs for gastric cancer or ulcer disease
1. Malfertheiner P, et al. Aliment Pharmacol Ther. 2002;16:167. 2. Talley NJ et al. Aliment Pharmacol Ther.
1999;12:1135.
TYPES OF H. PYLORI TESTS
• Endoscopy • Stool antigen tests
• Rapid urease 13
• C Urea blood
tests test
• Histology • Urea breath tests
• Culture 14
• C-urea
• Serologic (antibody) 13
• C-urea
Malfertheiner P, et al. Aliment Pharmacol Ther. 2002;16:167.
 13C UREA BREATH TEST
• Detects active infection
• Sensitive and specific
• Non-radioactive
• No special handling
requirements
• Easy to collect and handle
sample
• Not indicated in pediatric
population

1. Graham DY et al. Am J Gastroenterol. 2001;96:1741. 2. Leodolter A et al. Am J Gastroenterol. 1999;94:2100.

 LABORATORY DIAGNOSIS
• Diagnosed by Invasive and Non Invasive tests
• Invasive, Endoscopic Biopsy of Gastric mucosa
• Microscopy – Biopsy
• Culture
• Staining by special stains
• Gram staining
• Culture more sensitive 3 – 7 days
• Biopsy testing for urease detection in urea medium

DR.T.V.RAO MD 32
 Laboratory Identification
 Recovered from or detected in endoscopic antral
gastric biopsy material; Multiple biopsies are taken
 Many different transport media
 Culture media containing whole or lysed blood
 Microaerophilic
 Grow well at 37oC, but not at 25 nor 42oC
 Like Campylobacter, does not use carbohydrates,
neither fermentatively nor oxidatively
 DIAGNOSIS BY NON INVASIVE
METHODS
• Serology ELISA
• Urea breath test patient
swallows urea solution
In this test patient drinks
urea solutions labeled with
an isotope carbon
If H.pylori is present in the
urea is converted to
ammonia and co2 in the
breath measured.

DR.T.V.RAO MD 34
 SUGGESTED GUIDELINES FOR
TREATMENT OF PATIENTS WITH GI OR ULCER
DISEASE

History & Physical Exam

Peptic ulcer Undifferentiated Symptoms Use of NSAIDs

disease dyspepsia of GERD or aspirin

Positive Test for H. pylori

Eradication
therapy

Confirmation of cure

Malfertheiner P, et al. Aliment Pharmacol Ther. 2002;16:167.

 SUGGESTED GUIDELINES FOR
TREATMENT OF PATIENTS WITH GI OR ULCER
DISEASE

History & Physical Exam

Peptic ulcer Undifferentiated Symptoms Use of NSAIDs

disease dyspepsia of GERD or aspirin

Positive Test for H. pylori Negative

Eradication Treat for PUD,

therapy Initiate PPI therapy,
or discontinue NSAIDs
Confirmation of cure

Malfertheiner P, et al. Aliment Pharmacol Ther. 2002;16:167.

 TREATMENT
• Use of antibiotics, bismuth salts
• Ingestion of Bismuth subsalicylate
• Antibiotics Tetracycline's and metronidazole for two
weeks
• Use of Omeprazole
• Clarithromycin
• Do not treat for Asymptomatic colonization
• Drug resistance is a growing problem

DR.T.V.RAO MD 37
 EMERGING DRUG RESISTANCE IN H.PYLORI
• Antibiotic treatment does not always
completely inhibit or kill H. pylori
with potential for antibiotic
resistance. Resistance to antibiotics
is the single most important factor
for declining H. pylori eradication
rates.
• In Japan, resistance to antibiotic
drugs has increased 400% while in
Taiwan, it is 500%. This means that
those who are infected while in
these countries may find the
bacterium rather resistant to their
antibiotic treatments.

DR.T.V.RAO MD 38
EPIDEMIOLOGY OF HELICOBACTER INFECTIONS
• Developed Countries:
• United States: 30% of total population infected
• Of those, ~1% per year develop duodenal ulcer
• ~1/3 eventually have peptic ulcer disease(PUD)
• 70% gastric ulcer cases colonized with H. pylori
• Low socioeconomic status predicts H. pylori infection
• Developing Countries:
• Hyperendemic
• About 10% acquisition rate per year for children between 2 and 8 years
of age
• Most adults infected but no disease
• Protective immunity from multiple childhood infections
DR.T.V.RAO MD 39
 H.PYLORI CONTINUES TO BE AN
IMPORTANT PATHOGEN

• H. pylori is a transmissible, infectious disease with

potentially serious outcomes
• H. pylori infection may be asymptomatic or cause
dyspepsia
• Eradication therapy can cure H. pylori infection and
prevent morbidity and downstream events such as PUD
and gastric cancer
• Patients with symptoms of upper-GI disease, and who
use aspirin or NSAIDs should be tested for H. pylori
infection