Journal of Medicinal Plants Research Vol. 5(16), pp. 3823-3826, 18 August, 2011 Available online at http://www.academicjournals.org/JMPR ISSN 1996-0875 2011 Academic Journals

Full Length Research Paper

Prevalence of Helicobacter pylori in gastroenterological disorders in Shifa Ul Mulk Memorial Hospital Karachi,

Pakistan

H. M. Asif1,2, Khan Usmanghani1, Naveed Akhtar2, M. Uzair3, Pervaiz Akhtar Shah4, M. Akram1* and Zahoor-ul-Hasan1

1Department of Clinical Sciences, Faculty of Eastern Medicine, Hamdard University, Karachi, Pakistan. 2Faculty of Pharmacy and Alternative Medicine, The Islamia University of Bahawalpur, Pakistan.

3Faculty of Pharmacy, Bahauddin Zakariya University Multan, Pakistan. 4University college of Pharmacy, The University of Punjab Lahore, Pakistan.

Accepted 9 June, 2011

Prevalence of Helicobacter pylori (H. pylori) is very high and well documented in gastroenterological disorders like gastritis, gastric carcinoma, peptic ulcer disease, and non ulcer dyspepsia and gastroesophageal reflux disease. More than 50% of the world's population harbor H. pylori in their upper gastrointestinal tract. Infection is more prevalent in developing countries, and incidence is decreasing in Western countries. Our present study aims to review the recent H. pylori prevalence in gastroenterological disorders in Shifa Ul Mulk Memorial Hospital Karachi, Pakistan. Over a 9-month period, ninety seven patients of more than twelve years of age, with varied socioeconomic background, presented to the out patent department (OPD) with dyspeptic symptoms suggestive of gastroduodenal disease of more than two weeks duration were included in the study. All patients underwent endoscopy for the diagnosis of gastroduodenal diseases and biopsies were taken for histopathology and rapid urease test. Patient with history of intake of NSAIDs, steroids, alcohol, active bleeding, recent use of antibiotics or proton pump inhibitors were excluded. Out of ninety seven patients; 54 (55.6%) had chronic gastritis, 18 gastric ulcer (18.55%), 10 duodenal ulcer (10.3%) and 07 with combined gastric and duodenal ulcers (7.21%), 01 (1%) adenocarcinoma and 07 (7.21%) had no pathology. Overall H. pylori prevalence was 87.03% (47/54) in chronic gastritis, 66.66% (12/18) in gastric ulcer, 60.0% (6/10) in duodenal ulcer, 71.42% (5/7) in combined gastric and duodenal ulcers, 100% (1/1) in adenocarcinoma and 28.57% (2/5) with no pathology was recorded, respectively. The prevalence of H. pylori among our chronic gastritis and peptic ulcer patients is slightly higher compared to overseas studies but when compared indirectly to a previous local study, there was not much differences.

Key words: Helicobacter pylori, gastroenterological disorders, prevalence, Pakistan.

INTRODUCTION

Helicobacter pylori are a helix-shaped Gram-negative bacterium, about 3 m long with a diameter of about 0.5 m. It is microaerophilic that can inhabit various areas of the stomach, particularly the antrum (Marshall and Warren, 1984). Prevalence of H. pylori is very high and well documented in gastroenterological disorders like gastritis, gastric carcinoma, peptic ulcer disease, non ulcer dyspepsia and gastroesophageal reflux disease. It

*Corresponding author. E-mail: makram_0451@hotmail.com.

causes a chronic low-level inflammation of the stomach lining and is strongly linked to the development of duodenal and gastric ulcers and stomach cancer (Howden, 1996). Over 80% of individuals infected with the bacteria are asymptomatic. The cagA gene codes for one of the major H. pylori virulence proteins. Bacterial strains that have the cagA gene are associated with an ability to cause ulcers (Baldwin et al., 2007). At least, half the world's population is infected by the bacterium, making it the most widespread infection in the world. Rate of actual infection vary from nation to nation; the people in developing countries has much higher infection

3824 J. Med. Plant. Res.

Table 1. Distribution of patients with gastro duodenal diseases.

Disease Male [n (%)] Female [n (%)] Total [n (%)] Chronic gastritis 32 (59.25) 22 (40.74) 54 (55.6) Gastric ulcer 10 (55.55) 8 (44.44) 18 (18.55) Duodenal ulcer 07 (70) 03 (30) 10 (10.3) Combined GU and DU 05 (71.42) 02 (28.57) 07 (7.2) Adenocarcinoma 01 (100) 00 (0) 01 (100) No pathology 03 (42.85) 04 (57.14) 07 (7.21) Total 58 (59.79) 39 (40.20) 97

rates than the developed countries where infection rates are documented to be around 25%. Infections are usually acquired in early childhood in all countries. However, the infection rate of children in developing countries is higher than in developed countries, probably due to poor sanitary conditions. In developed nations, it is currently uncommon to find infected children, but the percentage of infected people increases with age, with about 50% infected for those over the age of 60 compared with around 10% between 18 and 30 years (Malaty, 2007).

In Pakistan, H. pylori infection is strongly associated with peptic ulcer disease and gastritis. H pylori infection rate increases with advancement of age and lowering of socioeconomic status in Pakistan (Qureshi et al., 1999). Previous data shows overall exposure rate to H. pylori in children was 33% while in adults 85% cases of duodenal ulcer were due to H. pylori infection (Qureshi et al., 1999; Kazi et al., 1990). Peptic ulcer disease occurred predominantly between 30 to 50 years of age with a male-female ratio of 6:1. History of NSAID intake was present in only 5% of these cases (Ahmed et al., 1990). The aim of our study was to determine the prevalence of H. pylori in gastroenterological disorders in Shifa Ul Mulk Memorial Hospital Karachi, Pakistan.

MATERIAL AND METHODS

From February 2009 to December 2009, consecutive patients who underwent oesophagogastroduodenoscopy (OGD) and diagnosed with positive H. pylori at Shifa Ul Mulk Memorial Hospital for Eastern Medicine, Hamdard University Karachi, Pakistan were considered for inclusion into the study. Ninety seven patients more than twelve years of age, with varied socioeconomic background, presenting to the OPD with dyspeptic symptoms suggestive of gastroduodenal disease of more than two weeks duration were included in the study. Symptoms included pain, burning in epigastrium and retrosternal area, vomiting, bloating, water brash and anorexia.

Those patients with less than 6 weeks history of intake of NSAIDs, steroids, alcohol, antibiotic and antisecretory drugs, active bleeding, hypertensive, diabetic patients and with chronic liver disease and chronic renal failure were excluded from the study. All the patients were subjected to oesophagogastroduodenoscopy. Biopsies were taken from abnormal sites. Specimens were examined for histopathology, culture of H. pylori and rapid urease test. Diagnosis of H. pylori was confirmed by microscopic

examination of the biopsy specimen after staining with Toluidine blue. Variables recorded included age, gender, socioeconomic status, presenting complaints, history of medication or alcohol intake, clinical and biochemical data suggestive of chronic liver disease and chronic renal failure.

Statistical analysis

Fisher exact test (2-tailed test) was used to assess the independent effect of age, sex and NSAID use on H. pylori prevalence. Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) Version 17.0. Statistical significance is taken at 0.05.

RESULTS

109 patients with dyspeptic symptoms were eligible for the study during the nine-month period. 5 patients were excluded because of a past history of peptic ulcer and 4 patients because of recent antibiotic use. Of the 100 patients selected, 3 patients were further excluded due to missing data on H. pylori status (H. pylori status was either not documented or not established). Data analysis was then carried out on the remaining 97 patients. Among these patients studied, 54 (55.6%) had chronic gastritis, 18 gastric ulcer (18.55%), 10 duodenal ulcer (10.3%) and 07 with combined gastric and duodenal ulcers (7.21%), 01 (1%) adenocarcinoma and 07 (7.21%) had no pathology as shown in Table 1 and Graph 1.

DISCUSSION

Prevalence

Overall H. pylori prevalence was 87.03% (47/54) in chronic gastritis, 66.66% (12/18) in gastric ulcer, 60.0% (6/10) in duodenal ulcer and 100% (1/1) in adenocarcinoma respectively as shown in Table 2. The local H. pylori prevalence rate was higher than some overseas prevalence studies. Low H. pylori prevalence in some geographical regions had been described (Schubert et al., 1999). Apart from genetic and socio-economic factors, several other possibilities may account

Asif et al. 3825

0

5

10

15

20

25

30

35

Ch

. g

astritis

G. ulce

r

D. ulcer

Co

mbin

ed

Carcin

om

a

No

Path

ology

Male

Female

Graph 1. Distribution of patients with gastroduodenal diseases

Table 2. Prevalence of H. pylori in gastroenterological disorders.

Disease Total patient H. pylori positive Prevalence (%) Chronic gastritis 54 47 87.03 Gastric ulcer 18 12 66.66 Duodenal ulcer 10 06 60.0 Combined GU and DU 07 05 71.42 Adenocarcinoma 01 01 100 No pathology 07 02 28.57 Total 97 73 75.25

for the variations in prevalence in different studies (Xia et al., 1999). Our study demonstrated that gender had an influence on H. pylori infection rate in gastroenterological disorders and it appeared that females were less likely to be infected with H. pylori than males. The discrepancy of male dominance and younger age was probably because of society being male dominant with social norms giving less chance to the females to be investigated by specialists. Results of our study are comparable to some local studies (Kazi et al., 1990) but no much difference in prevalence has been recorded. Also, some cases of H. pylori infection might have been missed on both rapid urease test and histopathology. It is also known that in some of the critically ill patients with co-morbid conditions, stress related ulcers may occur. However,

none of our patients was critically ill or from intensive care units. This can be explained by H pylori, host and environmental factors all having a role in gastroenterological diseases especially peptic ulcer disease. Prevalence of lymphoma, gastric carcinoma and ulcer was low as compared to gastritis and duodenal ulcer as most of our patients were young with duration of symptoms not long enough to develop these complications. Age-related increase in H. pylori prevalence is due to the fact that infection is usually acquired in childhood and carried for life, rather than a higher risk of H. pylori associated with peptic ulcer disease in the older generation.

We did not find any association between risk factors such as smoking and alcohol intake with peptic ulcer

3826 J. Med. Plant. Res.

disease in any group. Abdominal pain and retrograde burning sensation were frequent in all groups. In early diagnosed cases, H. pylori can be eradicated and may lead to decrease mortality, morbidity of peptic ulcer disease and gastric carcinoma. Some studies suggest that triple therapy (2 antibiotic agents and at least 1 adjunctive agent for 14 days) or quadruple therapies (2 antibiotics, 2 adjunctive agents for 07 days) are the drug of choices in the emerging therapies can significantly reduce ulcer recurrence and its completions especially in patients present with ulcer complications (Megraud and Marshall, 2000). In conclusion, we found H. pylori prevalence was 87.03% in chronic gastritis, 66.66% in gastric ulcer, 60.0% in duodenal ulcer and 100% in adenocarcinoma, respectively.

REFERENCES

Ahmed W, Quereshi H, Alam SE, Zuberi SJ (1990). Patterns of duodenal ulcer in Karachi. J. Pak. Med. Assoc., 40: 212-215.

Baldwin DN, Shepherd B, Kraemer P (2007). "Identification of Helicobacter pylori genes that contribute to stomach colonization". Infect. Immun., 75(2): 1005-1016.

Howden CW (1996). Clinical expressions of Helicobacter pylori infection. Am. J. Med., 100: S27-34.

Kazi JI, Jafarey NA, Alam SM, Zuberi SJ, Kazi AM, Qureshi H, Ahmed W (1990). Association of Helicobacter pylori with acid peptic disease in Karachi. J. Pak. Med. Assoc., 40: 240-241.

Malaty HM (2007). "Epidemiology of Helicobacter pylori infection". Best Pract. Res. Clin. Gastroenterol., 21(2): 205-214.

Marshall BJ, Warren JR (1984). Unidentified curved bacilli in the stomach of patients with gastritis and peptic ulceration. Lancet, 1: 1311-1315.

Megraud F, Marshall BJ (2000). How to treat Helicobacter pylori. First-line, second-line, and future therapies. Gastroenterol. Clin. North Am., 29: 759-773.

Qureshi H, Hafiz S, Medhi I (1999). H pylori IgG antibodies in children. J. Pak. Med. Assoc., 49: 143-144.

Schubert M, DeWitt JM, Taylor CA (1999). Prospective evaluation of the prevalence of Helicobacter pylori in duodenal and gastric ulcer: Is its role overstated? Digestive Diseases Week, A244: 1361.

Xia HHX, Phung N, Kalandar J, Talley NJ (1999). Characteristic of Helicobacter pylori positive and negative peptic ulcer disease. Digestive Diseases Week, A245: 1365.