Study on helicobacter pylori infection in cirrhotic patients – Duong Quang Huy

Journal of military pharmaco-medicine n o 7-2018 119 STUDY ON HELICOBACTER PYLORI INFECTION IN CIRRHOTIC PATIENTS Duong Quang Huy*; Hoang Van Quan* SUMMARY Objectives: To evaluate Helicobacter pylori infection and its relation with severity of cirrhosis, portal hypertension in cirrhotic patients. Subjects and methods: Prospective, cross-sectional descriptive study was carried out on 65 cirrhotic patients at the Digestive Department, 103 Military Hospital. Diagnosing and evaluating severity of Helicobacter pylori infection at gastric mucosa by histopathological method. Results: Prevalence of Helicobacter pylori in cirrhotic patients was 47.7%. Among those, mild Helicobacter pylori infection was predominant with 22/31 (71.0%) patients. There was no relationship between Helicobacter pylori infection and severity of cirrhosis according to Child-Pugh classification, as well as several signs of portal hypertension in cirrhotic patients. Conclusion: Helicobacter pylori infection was not popular in cirrhotic patients and not impacted by liver dysfunction and portal hypertension. * Keywords: Cirrhosis; Helicobacter pylori infection. INTRODUCTION Cirrhosis is a quite popular disease in many countries in the world, including Vietnam. Its main causes are hepatitis B/C virus infection and alcohol abuse. It tends to increase at present because rate of people who have been infected with hepatitis virus and drink alcohol and beer excessively remains very highly [1]. There are two stages of cirrhosis: Compensated phase is often asymptomatic, followed by decompensated cirrhosis with many complications of liver failure and portal hypertension such as variceal heamorrhage, hepatic encephalopathy, hepatorenal syndrome, hepato-pulmonary syndrome Besides, along with the development of digestive endoscopy for over 30 years, the impact of cirrhosis on the gastrointestinal mucosa is also increasingly recorded such as portal hypertensive gastropathy (PHG), gastric antral vascular ectasia (GAVE), gastric erosion, gastric and duodenal ulcer. Out of these lesions, PHG is the clinically important gastric mucosal lesion (occurring in more than 50% of cirrhotic patients) because it may cause acute and chronic gastrointestinal mucosal bleeding leading to iron deficiency anemia and decompensation of cirrhosis [3]. Cirrhosis causes changes in the structure of the gastric mucosa and whether it affects colonization of Helicobacter pylori (H. pylori) at here or not?. What is the role of H. pylori in the pathogenesis of gastric mucosal lesions in cirrhotic patients?. These issues have not been really interested in researching in Vietnam. Therefore, we conducted this study with aims: * 103 Military Hospital Corresponding author: Duong Quang Huy (huyduonghvqy@gmail.com) Date received: 21/03/2018 Date accepted: 22/08/2018 Journal of military pharmaco-medicine n o 7-2018 120 To survey prevalence of H. pylori infection at gastric mucosa and its relationship with severity of cirrhosis and several symptoms of portal hypertension in cirrhotic patients. SUBJECTS AND METHODS 1. Subjects. - The study was conducted on 65 cirrhotic patients who hospitalized and treated at the Digestive Department, 103 Military Hospital from September 2016 to June 2017. - The diagnosis of cirrhosis was made by a combination of impairment of liver function, presence of portal hypertension and changes in hepatic morphology in abdominal ultrasound. - Exclusion criteria: + Primary or secondary hepatic malignancy. + Recent acute gastrointestinal bleeding (within 2 weeks). + Intake of antibiotics (up to 1 month) or prior therapy for eradication of H. pylori. + Treatment of proton pump inhibitors drugs (within 2 weeks). + Contraindication for endoscopy. + Refusal of participation. 2. Methods. - Study design: Prospective, cross- sectional descriptive study. - All patients enrolled in the present study were clinically examined and indicated the full laboratory tests to determine hepatic dysfunction and portal hypertension (ascites, splenomegaly, abdominal wall veins). - The severity of cirrhosis was assessed using the Child-Pugh classification (1973). - Upper gastrointestinal endoscopy was performed for all patients at the endoscopy room, 103 Military Hospital on the machine Olympus EVIS EXTRA II CV180. Determining and evaluating the grade of esophageal varices according to the Japan Society for Portal Hypertension (2010): No varicose appearance (F0), grade 1 (F1), grade 2 (F2), grade 3 (F3) [1]. Two biopsy specimens were taken from gastric antrum and body for histopathologic examination. The specimens were preserved in formaldehyde solution (10%) and were stained by Giemsa and Hematoxylin- eosin stain. On optical microscope with magnification 1,000 times, H. pylori is bacterial plaque (S or C - shaped) with 1 to 6 hairs in the head, locating in the mucus layer or in the interstitium between gastric mucosal epithelial cells [5]. - Evaluating severity of H. pylori infection on histopathology according to Polat F.R (2012) [5]: + Mild H. pylori infection (+): 1 - 10 H. pylori bacteria per area. + Moderate H. pylori infection (++): 10 - 30 H. pylori bacteria per area. + Severe H. pylori infection (+++): > 30 H. pylori bacteria per area. - Statistical analysis: Statistical analysis was made with the SPSS statistics version 18.0. Journal of military pharmaco-medicine n o 7-2018 121 RESULTS Table 1: Characteristics of age, gender, severity of cirrhosis and some signs of portal hypertension in study group. Patient characteristics X ± SD or n (%) Mean age 55.0 ± 11.2 Male 60 (92.3%) Gender Female 5 (7.7%) Child-Pugh A 12 (18.5%) Child-Pugh B 26 (40.0%) Severity of cirrhosis Child-Pugh C 27 (41.5%) Splenomegaly 23 (67.6%) Ascites 21 (61.8%) Portal hypertension syndrome Esophageal varice (F1/F2/F3) 65 (100%) (5.9%/38.2%/55.9%) 100% of patients had esophageal varices on doing upper gastrointestinal endoscopy. Among those who had esophageal varices, grade 3 (F3) and grade 2 (F2) were common. Our results were consistent with other studies in Vietnam which showed that cirrhosis was more common in middle age, more males than females, and admitted to hospital with severe disease which had complications [10]. Table 2: Rate and severity of H. pylori infection in cirrhotic patients. H. pylori infection n = 65 % -ve 34 52.3 +ve 31 47.7 (+) 22 71.0 (++) 5 16.1 Severity of H.pylori infection (n = 31) (+++) 4 12.9 47.7% of cirrhotic patients in the study were found H. pylori infection in histopathology, among those, mild H. pylori infection were the most common (71.0%). In contrast, severe H. pylori infection accounted for low percentage with 12.9%. In fact, there are many researches which determined rate of H. pylori infection in cirrhotic patients. The results showed that the prevalence of H. pylori infection quite fluctuated. Abbas et al (2014) studied 140 cirrhotic patients, showed that rate of H. pylori infection determined by histopathology and PCR were 62.1% [2]. It was similar to result of Safwat et al (2015) studying 80 patients with hepatitis C virus-related cirrhosis (60.0%) [7]. Evaluating rate of H. pylori infection by serological method on 140 cirrhotic patients, Sathar et al (2014) found that rate of H. pylori infection was only 35.7% [8]. That was much less than Journal of military pharmaco-medicine n o 7-2018 122 result of Tsai C.J (1998) (76.2%) [6]. The reason there was significantly difference between studies was that group of selected cirrhotic patients was not heterogeneous (differences from severity of liver failure, portal hypertension, causes of cirrhosis...) and especially the method of determining H. pylori infection. Rate of H. pylori infection in cirrhotic patients in our study was significantly lower than that of group without cirrhosis in study of Nguyen T.L et al (2010) (47.7% and 66.5%, respectively) [4]. This finding has been explained by many authors. The reason was that cirrhosis made the gastric mucosa congested, which can lead to anemia, degeneration and necrosis of the epithelial cells. These were unsuitable factors for the residence and development of H. pylori [2, 7, 8]. Table 3: Relationship between severity of cirrhosis and H. pylori infection. H. pylori infection Severity of cirrhosis -ve +ve p-value Child-Pugh A (n = 12) 7 (20.6) 5 (16.1) Child-Pugh B (n = 26) 13 (38.2) 13 (41.9) Child-Pugh C (n = 27) 14 (41.2) 13 (41.9) > 0.05 In view of the relationship between severity of cirrhosis and H. pylori infection, results of researches are conflicting. Safwat et al (2015) showed the results which were similar to our study, there was not statistical significant difference in mean Child-Pugh and MELD score between cirrhosis group with and without H. pylori infection (8.6 ± 1.7 vs. 8.5 ± 1.0 and 17.1 ± 6.2 vs. 19.4 ± 4.4, respectively, p > 0.05) [7], while Abbas et al (2014) found that there was significant difference in rate of H. pylori infection between severity of cirrhosis according to Child- Pugh classification (p = 0.002) [2]. The above controversial results suggest that further prospective studies with a large number of patients are needed to validate the association between H. pylori infection and severity of cirrhosis. Table 4: Relationship between H. pylori infection and signs of portal hypertension syndrome. H. pylori infection Portal hypertension syndrome -ve +ve p-value Absent 13 (38.2) 13 (41.9) Ascites Present 21 (61.8) 18 (58.1) > 0.05 Absent 12 (35.3) 17 (54.8) Splenomegaly Present 22 (64.7) 14 (45.2) > 0.05 F1 2 (5.9) 7 (22.6) F2 13 (38.2) 7 (22.6) Grade of esophageal varices F3 19 (55.9) 17 (58.4) > 0.05 Journal of military pharmaco-medicine n o 7-2018 123 Portal hypertension is one of the most important factors causing structural changes in the gastric mucosa. As a result, it might affect the viability and development of H. pylori [3]. However, our results did not show a significant relationship between some signs of portal hypertension (ascites, splenomegaly, esophageal varices) and H. pylori infection (p > 0.05) that was in agreement with results of the previous studies in the world [2, 7]. This showed that pathogenesis of gastropathy in cirrhosis, as well as colonization of H. pylori in gastric mucosa is complex. CONCLUSION Studying H. pylori infection by histopathology in 65 cirrhotic patients, we found that: - Rate of H. pylori infection in cirrhotic patients were 47.7%. Among those, mild H. pylori infection was common with 22/31 (71.0%) patients. - There was no relationship between H. pylori infection and severity of cirrhosis according to Child-Pugh classification, some signs of portal hypertension in cirrhotic patients. REFERENCES 1. Tran Pham Chi. Study on the efficacy of esophageal varices ligation plus propranolol in the prevention of recurrent bleeding and impacting on portal hypertensive gastropathy in cirrhosis. PhD Thesis in Medicine. Hue University of Medicine and Pharmacy. 2014. 2. Abbas Z, Yakoob J, Usman M.W et al. Effect of Helicobacter pylori and its virulence factors on portal hypertensive gastropathy and IL-8, IL-10 and tumor necrosis factor-alpha levels. Saudi J Gastroenterol. 2014, 20 (2), pp.120-127. 3. Eleftheriadis E. Portal hypertensive gastropathy. Annals of Gastroenterology. 2001, 14 (3), pp.196-204. 4. Nguyen T.L, Uchida T, Tsukamoto Y et al. Helicobacter pylori infection and gastroduodenal diseases in Vietnam: A cross-sectional, hospital-based study. BMC Gastroenterol. 2010, 10, p.114. 5. Polat F.R, Polat S. The effect of Helicobacter pylori on gastroesophageal reflux disease. JSLS. 2012, 16 (2), pp.260-263. 6. Tsai C.J. Helicobacter pylori infection and peptic ulcer disease in cirrhosis. Dig Dis Sci. 1998, 43 (6), pp.1219-1225. 7. Safwat E, Hussein H, Hakim S.A. Helicobacter pylori in Egyptian with HCV- related liver cirrhosis and portal hypertensive gastropathy: Prevalence and relation to disease severity. Life Science Journal. 2015, 12 (3), pp.168-172. 8. Sathar S.A, Kunnathuparambil S.G, Sreesh S et al. Helicobacter pylori infection in patients with liver cirrhosis: Prevalence and association with portal hypertensive gastropathy. Annals of Gastroenterol. 2014, 27, pp.48-52.