AI
Volume 14
Supplement 1
September 2009
ISSN 1083-4389
EDITOR: David Y. Graham, M.D.
The Year in Helicobacter 2009
Guest Editors: Francis Megrand and Peter Malfertheiner
• more than 2.2 million INFAI tests performed in Europe
• approved for children from the age of three
• special test for patients with dyspepsia taking PPIs
• cost-effective CLINIPAC 50 version for use in hospitals
Helicobacter
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VOLUME 14
SUPPLEMENT 1
SEPTEMBER 2009
The Year in Helicobacter 2009
Guest Editors: Francis Mégraud and Peter Malfertheiner
EUROPEAN HELICOBACTER STUDY GROUP
MEMBERS:
Leif Andersen
Anthony Axonz
Giovanni Gasbarrini
Javier Gisbert
Alexander M. Hirschl
Ernst Kuipers
José Machado
Peter Malfertheiner
Francis Mégraud
Colm O’Morain
Ari Ristimaki
Theodore Rokkas
Torkel Wadström
Denmark
United Kingdom
Italy
Spain
Austria
the Netherlands
Portugal
Germany
France
Ireland
Finland
Greece
Sweden
EMERITUS MEMBERS:
Michel Deltenre
Pierre Michetti
Jose M. Pajares Garcia
Ashley Price
Belgium
Switzerland
Spain
United Kingdom
Mario Quina
Erik Rauws
Pentti Sipponen
Portugal
the Netherlands
Finland
HONORARY MEMBERS:
James Fox
David Y. Graham
Adrian Lee
Barry Marshall
Guido Tytgat
USA
USA
Australia
Australia
the Netherlands
CORRESPONDING FELLOWS:
Niyaz Ahmed
Luis Vaz Coehlo
Toshio Fujioka
Hyun Chae Jung
Varocha Mahachai
Yaron Niv
Shu Dong Xiao
India
Brazil
Japan
Korea
Thailand
Israel
China
Helicobacter
VOLUME 14
SUPPLEMENT 1
SEPTEMBER 2009
CONTE NTS
1
8
15
21
29
36
41
46
52
58
69
RE VIEW A RT IC L ES
The Epidemiology of Helicobacter pylori and Public Health Implications
N. F. Azevedo, J. Huntington and K. J. Goodman
Diagnosis of Helicobacter pylori Infection
L. Monteiro, M. Oleastro, P. Lehours and F. Mégraud
Pathogenesis of Helicobacter pylori Infection
A. C. Costa, C. Figueiredo and E. Touati
Inflammation, Immunity, and Vaccines for Helicobacter pylori
M. M. D’Elios and L. P. Andersen
Helicobacter pylori and Non-malignant Diseases
T. Furuta and J.-C. Delchier
Basic Aspects of Gastric Cancer
M. Correia, J. C. Machado and A. Ristimäki
Helicobacter pylori and Clinical Aspects of Gastric Cancer
J. Bornschein, T. Rokkas, M. Selgrad and P. Malfertheiner
Treatment of Helicobacter pylori Infection
A. O’Connor, J. Gisbert and C. O’Morain
Helicobacter pylori Infection in Pediatrics
A. Kindermann and A. I. Lopes
Helicobacters and Extragastric Diseases
R. Pellicano, F. Franceschi, G. Saracco, S. Fagoonee, D. Roccarina and A. Gasbarrini
Helicobacter spp. Other Than Helicobacter pylori
A. S. Okoli, A. Menard and G. L. Mendz
Helicobacter ISSN 1523-5378
The Epidemiology of Helicobacter pylori and Public Health
Implications
Nuno F. Azevedo,* Janis Huntington and Karen J. Goodman
*LEPAE, Department of Chemical Engineering, Faculty of Engineering, University of Porto, Porto, Portugal, Division of Gastroenterology, Department of Medicine & Department of Public Health Sciences, Zeidler Ledcor Centre, University of Alberta, Edmonton, AB, Canada
Keywords
H. pylori, prevalence, transmission, risk
factors, public health policy
Reprint requests to: Karen Goodman, Division
of Gastroenterology, Zeidler Ledcor Centre,
University of Alberta, Edmonton AB Canada
T6G 2X8. E-mail: kgoodman@ualberta.ca
Abstract
This article presents a review of the literature on the epidemiology and public health implications of Helicobacter pylori infection published from April
2008 through to March 2009. The authors used MeSH terms ‘‘Helicobacter
infections epidemiology,’’ ‘‘Helicobacter infections prevention and control’’
to search multiple databases (PubMed, Embase, Cochrane, Cochrane Library,
EBMR, BIOSIS), and independently searched PubMed using the term ‘‘Helicobacter’’ with ‘‘Epidemiology,’’ ‘‘Transmission,’’ ‘‘Prevalence’’ or ‘‘Environment.’’ Articles without topical relevance were excluded. Two additional
papers known to the authors were added. The identified literature is summarized by subtopic: reviews; prevalence; incidence; transmission; risk factors; and public health policy.
This article presents a review of the literature on the
epidemiology and public health implications of Helicobacter pylori infection published from April 2008
through March 2009. The authors used MeSH terms
‘‘Helicobacter infections ⁄ epidemiology,’’ ‘‘Helicobacter
infections ⁄ prevention and control’’ to search multiple
databases (PubMed, Embase, Cochrane, Cochrane
Library, EBMR, BIOSIS), and independently searched
PubMed using the term ‘‘Helicobacter’’ with ‘‘Epidemiology,’’ ‘‘Transmission,’’ ‘‘Prevalence,’’ or ‘‘Environment.’’ Papers without topical relevance were excluded.
Two additional papers known to the authors were
added. The identified literature is summarized below by
subtopic: reviews; prevalence; incidence; transmission;
risk factors; and public health policy.
Reviews
The search identified six review papers. Bruce and Maaroos summarized studies on the epidemiology of H.
pylori infection published in peer-reviewed journals [1].
Daugule and Rowland summarized articles on the epidemiology of H. pylori infection in children [2]. Tan
et al. examined the changing H. pylori epidemiology in
Asia [3]. All three of these reviews noted that the prevalence of H. pylori infection was decreasing globally.
Goodman et al. reviewed studies of H. pylori infection
in Canadian and related Arctic Aboriginal populations,
revealing a relatively high prevalence of the infection
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 1–7
and occurrence of associated disease in these groups
[4]. Zhang et al. summarized 1986–2008 publications
on re-infection, recurrence, or recrudescence of H.
pylori identified in Medline, concluding that re-infection
was not a major concern in clinical settings [5]. A
review presenting Asia-Pacific consensus guidelines on
gastric cancer prevention concluded that H. pylori
screening and treatment strategies aimed at high-risk
populations will probably reduce gastric cancer incidence and were therefore recommended [6].
Prevalence
The search identified 16 population-based prevalence
studies from 12 countries, primarily from Asia and the
Middle East [7–22]. Details from these studies grouped
by H. pylori detection method are presented in Table 1.
Among the noninvasive detection methods that are
practical for population-based studies, the urea breath
test (UBT) and stool antigen tests (SAT) are considered
most accurate, while serology is the least costly and
most widely available. Helicobacter pylori seroprevalence
studies test most commonly for IgG which have the disadvantage of not differentiating current from past infection; whereas H. pylori IgG antibodies often decline to
negative levels once the infection has resolved, the
frequency and timing of this occurrence differs substantially across populations [23]. Furthermore, seronegativity is common in preschool-aged children
1
Azevedo et al.
Epidemiology of H. pylori infection
Table 1 Population-based studies of Helicobacter pylori prevalence according to detection method, published between April 2008 and March
2009
Detection
method
Location ⁄ population
Subject selection
Malaysia, blood donors
Not specified
Moujaber
Serum IgG
and IgA
Serum IgG
Australia, lab patients
Nouraie
Serum IgG
Iran, households
Monno
Serum IgG
Albania, diverse groups
Kaya
Siai
Serum IgG
Serum IgG
Turkey, asymptomatic people
Tunisia, first grade students
Cheng
Tam
Mohammad
Kori
Cherian
UBT
UBT
UBT
SAT
SAT
China, rural and urban
China, school children
Egypt
Israel, daycare children
Australia, African refugees
Yücel
SAT
Turkey, university students
Shi
Serum IgG
and UBT
UBT, biopsyd
China, rural
Age-stratified random
sampling from 8000 banked
diagnostic lab samples
One randomly sampled
individual from each
randomly sampled
household
Random sampling, healthcare
workers and military
conscripts; consecutive
sampling, pregnant women
Not specified
Random sampling from
school list of 10,703 first
graders
Not specified
Random sampling from schools
Not specified
Not specified
All presenting for health
assessment during study
period
Random sampling from
unspecified number of
volunteers
Cluster sampling
First author
Sasidharan
Zagari
Mishra
PCR on saliva
and stool
Naito
Urinary IgG
Italy, residents of two
northern villages
India, university employee
families and urban slum
dwellers
Japan, Tokyo school children
Recruited from participants
in earlier population-based
survey
Not specified
Not specified
Age range
(years)
Number
tested
Prevalence
10–70
5370
14.2a
1–59
2413
15.4
18–65
851
68.3
16–64
1088
70.7
0.5–17
6–7
288
1055
23.9
51.4
1232
2480
286
316
193
46.8
13.1
72.4
24.7
82
2–79
6–19
6–15
0.25–5
<16
Mean = 21b
200
5–100
1371
62.1c
‡32 (mean = 59b)
1033
58
63
0.67–60
245
45.7 (saliva)
42.8 (stool)
4
452
5.3 (time 1)e
6.7 (time 2)
4.7 (time 1)
4.0 (time 2)
4.0 (time 1)
4.6 (time 2)
7
10
a
Not specified if prevalence was based on positivity on one or both tests.
Range not specified.
c
Prevalence based on positivity on one or both tests.
d
Positivity defined by positive on at least two of UBT, histology, rapid urease test.
e
Times 1 and 2 were approximately 12 months apart.
b
demonstrated by other methods to have H. pylori infection [24]. One study from India used PCR on saliva and
stool samples [11]; it has been noted that interpretation
of PCR-based results is problematic [23]. One study of
Japanese school children tested twice over a 12-month
2
interval used a urine test for H. pylori IgG [15]. Urine
tests for H. pylori infection are not widely used and
information about their reliability is limited. Few population-based studies have used endoscopic procedures to
evaluate gastrointestinal conditions; a study of adults
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 1–7
Azevedo et al.
from two villages in northern Italy classified H. pylori
status using the UBT and evaluation of gastric biopsies
[22].
The reported prevalence ranged from 4% in Japanese
children to 82% in African refugee children in Australia
[8,15]. A prevalence of 15% or lower was reported for
Australian lab patients, Malaysian blood donors, and
Chinese and Japanese school children [14,15,17,20]. A
prevalence of 24–25% was reported for Israeli children
attending daycare centers and unspecified individuals
from Turkey [10,21]. Among the Italian villagers (mean
age = 59 years), the prevalence was 58%, considerably
higher than the 34% observed in an earlier similar
study of adults in northern Swedish communities
(mean age = 52 years) [25]. A prevalence of 60% or
more was reported for groups in Albania, Egypt, Iran,
Turkey, and China [7,9,12,13,16,18].
Incidence
Only three studies examined rates of onset of new
H. pylori infections or reinfections. A Bangladeshi study
examined new infections from birth to 2 years of age in
258 children [26]. They observed that few children
(number not reported but less than 15% by serum IgG,
IgA and ⁄ or SAT) showed evidence of infection at
6 months of age, but by 2 years positivity was 49% by
SAT and around 60% (number not reported) by IgG
and ⁄ or IgA. The Japanese study that used urine tests at
two time points examined rates of acquisition and loss
of infection in 452 children [15]. They reported that
the 12-month incidence decreased with age, 2.6%
among 4-year-olds, 1.3% among 7-year-olds, and
0.65% among 10-year-olds, while rates of apparent
infection loss were 1.3%, 2%, and 0 in the 4-, 7- and
10-year-old groups, respectively. Statistical precision for
the age-specific incidence comparisons was not
reported. An Israeli study examined rates of new infection in adult dyspeptic patients (n = 39) who had a
negative H. pylori test 7 years earlier and re-infection in
adult patients (n = 26) after successful H. pylori therapy
[27]. One patient in each group had a positive UBT;
however, the small sample makes estimates of incidence rates highly imprecise.
Transmission
The high number of papers published on H. pylori transmission during the last year reveal the information gaps
and inconsistent results that continue to hamper our
understanding of how this organism spreads. Intrafamilial transmission, by direct person-to-person contact, has long been thought to be a major mode of
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 1–7
Epidemiology of H. pylori infection
transmission [28,29]. Weyermann et al. tried to determine the independent contribution of mothers, fathers,
and siblings to acquisition of H. pylori during childhood
in a German population [30]. Helicobacter pylori status
was based on 13C-UBT and ⁄ or monoclonal SAT performed on stool samples, which lack information on
the genetic similarity of strains from different family
members. Adjusting for the siblings’ and father’s
H. pylori status, the odds ratio (OR) for the effect on the
index child of the mother being infected was 13 (95%
confidence interval (CI), 3–55). The authors extracted
data from similar studies to estimate the odds of infection adjusted for the infection status of other family
members, concluding that after adjustment for maternal
infection status, the OR among children for having an
infected sibling or father decreased substantially in the
German population and others. It should be noted that
siblings’ infection status appears to matter in populations where large families are common [31], and that
the mother’s infection status may be more strongly
associated than other family members with household
hygiene and other risk factors.
Using genotyping methods, assessments of the relatedness of family members’ H. pylori strains were
performed in Japan, Bangladesh, and Peru [32–34].
Child–mother strain pairs matched for 69, 46, and 30%
of the studied populations, respectively. As with studies
of family members’ general infection status, these
results suggest varying contributions of mother-to-child
(and overall intra-familial) transmission in developing
and developed countries, as a consequence of different
living conditions and age-specific infection patterns. In
a larger study that estimated the similarity of sequences
in populations of South Africa, the United Kingdom,
the United States, Korea, and Colombia, the conclusion
was similar, and variability of strains within families
was higher in rural than in urban areas [35]. As the
authors pointed out, H. pylori research relying on genotyping would benefit from more thorough attempts to
identify multiple strains in individuals, which would be
of particular relevance for better understanding modes
of transmission.
Direct person-to-person transmission may occur via
the oral–oral, fecal–oral, or gastro-oral route. Burgers
et al. tested for the concurrent presence of H. pylori in
the mouth and stomach of 94 individuals [36]. Helicobacter pylori was detected in the oral cavities of 17% of
gastric biopsy patients, some of whom did not show
evidence of stomach colonization. However, the presence of organisms in a particular location is not clear
evidence that transmission commonly occurs via the
corresponding pathway. Tonsils have been proposed
as an extra-gastroduodenal reservoir for the bacterium,
3
Azevedo et al.
Epidemiology of H. pylori infection
but one study observed that tonsil removal did not
appear to affect the risk of H. pylori transmission [37].
The role of external reservoirs in H. pylori transmission
has not been ruled out, particularly in rural and developing areas [38]. Water has been one of the most well-studied ecosystems for H. pylori survival outside the human
digestive tract. A Japanese study compared H. pylori prevalence in three populations with different drinking water
sources (two with river water, one with groundwater)
[39]; while the population with the groundwater source
had a much lower prevalence, the small numbers in this
ecologic comparison limit its value. Other studies
attempting to identify H. pylori DNA in water provide
conflicting evidence [40,41]. In Mexico, Mazari-Hiriart
et al. detected the 16S rRNA and cagA genes of H. pylori
in 44% and 14%, respectively, of samples from ground
and surface water [41]. In contrast, Bockelman et al.
were unable to detect the H. pylori 16S rRNA gene in
samples from artificial recharge systems in Spain, Italy,
and Belgium [40]. The inconsistent results may reflect
different water treatment modalities and ⁄ or variations in
PCR procedures (e.g. DNA isolation methods, primer
sequences, and application of nested or quantitativePCR). Research in this area would benefit from identification of the optimal techniques for reliable assessment
of the presence or absence of H. pylori DNA in suspected
environmental reservoirs. It should be noted, however,
that demonstration of DNA in a potential environmental
reservoir is not clear evidence of the transmissibility of
the organisms, which may or may not be viable. Culture
of H. pylori organisms from these sources would provide
stronger evidence.
From one of the few studies based on culture of
H. pylori outside the human digestive tract, Cellini et al.
characterized one strain found in marine zooplankton
[42]. This environmental strain was able to form biofilms in a more structured way than clinical strains. Biofilms are a possible microenvironment where H. pylori
may subsist in water systems, and another study showed
that a cultured strain of clinical origin incorporated in
mature, multispecies biofilms formed in a model reactor
simulating unchlorinated drinking water distribution
systems [43]. Another microenvironment that may promote H. pylori survival in water is the intracellular habitat of protozoa. However, when studying the spatial
distribution of Helicobacter spp. and Acanthamoeba in river
water samples, Kawaguchi et al. did not detect a clear
association between the two microorganisms [44].
Two other possible extra-human reservoirs assessed
this year were food and the digestive tract of animals
[45,46]. When testing raw milk for the presence of the
H. pylori glmM gene, Quaglia et al. were able to amplify
glmM in 34.7% of the samples using a nested-PCR
4
approach [46]. Ghil et al. assessed the prevalence of Helicobacter spp. in feces and saliva from cats in Korea
[45]. Despite detecting the presence of Helicobacter spp.
in 77.6% of the cats using genus-specific primers, all
species-specific PCR for H. pylori were negative. As long
as there is no consensus on the reliability of particular
PCR methods and a valid assessment of the physiologic
status of H. pylori found in these environments, it is not
possible to clarify the role of particular external reservoirs in H. pylori transmission.
Risk Factors
Most reports on risk factors focused on socioeconomic
indicators. Most of the studies examined cross-sectional
associations between exposures of interest and being
infected at the time of screening, which cannot differentiate determinants of acquisition from determinants
of persistent infection. Among Israeli children in day
care, low socioeconomic status was associated with
H. pylori infection [10]; this study collected data on
family size, residential crowding, parent’s education,
and country of birth, but the basis for classifying low
status was not specified. Among Egyptian children,
H. pylori prevalence was highest in children attending
school in deprived areas [12]; residents of Cairo had the
highest prevalence among the locations studied. A
study of mainly university employees in India demonstrated a relationship between living in semi-urban
slums and H. pylori status classified by PCR-based stool
and saliva tests [11]; other factors were not controlled
in this comparison. A Chinese study of 2480 schoolaged children identified an association with lack of formal education of the mother, and an Iranian study of
851 individuals found low education of the mother,
father, and subject to be associated with H. pylori infection [16,20]. A study of Turkish university students
observed little relationship to H. pylori status of parents’
education level, number of family members, and
income level [21]. The authors noted that selection of
youth who were mainly from state dormitories, which
is determined by parent’s income level, was a limitation
of their study. A Chinese study of 1457 individuals
identified associations with low education, low family
income, and not cleaning a cup after use [18].
A few reports in addition to the Israeli and Turkish
studies examined family size. Two studies of child populations observed in multivariable analyses that a
household size greater than five was associated with
H. pylori infection [19,20]. Two studies of adult populations also observed that household size greater than five
during childhood was associated with H. pylori infection
when other factors were not controlled, but this
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 1–7
Azevedo et al.
relationship did not appear independent of other factors
in multivariable analyses [16,18].
Two studies examined occupational exposures that
increase the risk of infection. In a Belgian study, 587
employees of institutions for children with intellectual
disabilities were compared with 390 employees of companies that do not serve children [47]. Assessed H.
pylori risk factors included parent’s education level,
number of household members during childhood, number of children sharing a room in childhood, and travel
to tropical regions along with occupational exposures,
such as personal contact, fecal contact, and washing
and feeding of inhabitants. In a multivariable logistic
regression model, only fecal contact was associated with
a clear increase in the odds of H. pylori infection (OR,
4.0; 95% CI 1.7–9.5). A study of Swiss workers used a
prospective cohort design to examine incidence of
H. pylori IgG and IgA seroconversion in relation to sewage exposure [48]; 332 workers exposed to sewage and
446 nonexposed workers were tested at baseline and
five time points at approximately 1 year intervals. Using
seroconversion as an endpoint for survival analysis, no
clear effect of exposure to sewage was observed, when
controlling for education level, nationality, country of
childhood, smoking, and alcohol intake.
The Tunisian study of 1055 first grade students identified bed sharing and bottle weaning after 18 months as
risk factors [19]. The Turkish study observed little relationship to H. pylori infection of various hygiene practices
or smoking, alcohol, coffee or tea consumption [21]. A
study of 1391 Albanian individuals did not collect data
on number in household, and in a multivariable analysis
only female gender and age greater than 40 were associated with H. pylori seropositivity [13]. Among African
refugee children in Australia, ethnicity, country of transit
and pre-migration anti-malarial treatment were associated with H. pylori infection, but in a multivariable logistic regression model, only pre-migration anti-malarial
treatment appeared to retain an independent association,
in the direction of reduced odds of infection [8].
Public Health Policy
Evidence from epidemiologic research provides the basis
for disease control and prevention policy. In particular,
the identification of high-prevalence populations helps
identify target communities for cost-effective interventions, and the identification of modifiable risk factors
yields potentially effective interventions. While the epidemiologic research on H. pylori has gone a long way
toward identifying high-prevalence communities
around the world, including some within countries
where average prevalence is low, little work has been
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 1–7
Epidemiology of H. pylori infection
done on interventions aimed at interrupting transmission (i.e. primary prevention of H. pylori infection), and
the search for this review identified no such reports. A
modest amount of prevention research has focused on
H. pylori infection as a modifiable risk factor for associated digestive diseases (i.e. tertiary prevention of complications from H. pylori infection), including four
reports published in the last year on screening and
treatment strategies in targeted populations.
A community-based H. pylori screening and treatment
program in Denmark randomized 20,011 40 to 64-yearold residents of Odense identified by civil registration
number to H. pylori screening and treatment (screened
group) or no intervention [49]. After 5 years, investigators estimated the effect of the program on rates of dyspepsia and peptic ulcers, drug use, doctor visits, and
health related-quality of life. The most noteworthy benefit of the program was a 33% lower incidence of peptic ulcers. A modest reduction in dyspepsia was
observed in the screened group, but this was similar in
magnitude to an unexplained excess prevalence of dyspepsia in the screened group at baseline. The authors
reported that the cost of dyspepsia-related health care
was lower in the screened group, but the savings were
exceeded by the cost of screening and treatment. However, the authors did not estimate the cost-effectiveness
of the program for disease prevention, for example, the
cost per peptic ulcer prevented. While the intervention
was not cost saving, data in the report suggest that the
total expenditure could be considered reasonable for
the number of peptic ulcer cases prevented.
Another study examined the cost-effectiveness of
H. pylori treatment in H. pylori-positive long-term proton pump inhibitor (PPI) users in the UK randomly
assigned to anti-H. pylori therapy (n = 93) or placebo
(n = 91) [50]. After 2 years, the treatment group had
substantially fewer prescriptions, GP consultations and
GI-related home visits, upper endoscopies, abdomen ⁄ pelvis ultrasound scans, and dyspepsia symptoms,
although heartburn symptoms increased. The average
cost savings per patient during 2 years after subtracting
the cost of screening and treatment was £93. The
authors concluded that H. pylori treatment in long-term
PPI users is an economically dominant strategy that
reduces healthcare costs and symptom severity.
Two studies estimated the cost-effectiveness of population-based H. pylori screening and treatment for gastric cancer prevention, in a high-risk region of China
and the male Chinese population of Singapore [51,52].
Xie et al. assessed one-time screening and treatment
with either serology or UBT in terms of cost per gastric
cancer case prevented, life-year saved and qualityadjusted life year gained [52]. Yeh et al. assessed
5
Epidemiology of H. pylori infection
one-time screening with serology and treatment, as
well as strategies of re-screening of seronegatives and
universal treatment without screening in terms of
gastric cancer risk reduction and cost per year of life
saved [51]. Both analyses showed that the evaluated
strategies were reasonably cost-effective compared to
no intervention, and that this conclusion is robust to
reasonable ranges for uncertain input values pertaining
to factors such as screening method accuracy, treatment
success rates, the fraction of gastric cancer prevented by
H. pylori elimination, and the optimal target age group
(e.g. before precancerous lesions typically develop).
Emerging evidence from gastric cancer prevention trials
is revealing more about the latter two factors [6].
These studies strengthen a growing body of evidence
that most H. pylori screening and treatment strategies
considered are cost-effective for prevention of H. pyloriassociated disease in most population studied. They are
less compelling, however, for comparing alternative
strategies, particularly in light of uncertain inputs.
Future research in this area should focus on whether it
is worth the incremental cost to save additional lives
with more costly strategies such as using the UBT
rather than serology for screening, screening more than
once, or targeting younger populations, and should
identify the variables to which such choices are
sensitive.
Conflicts of Interest
The authors have declared no conflicts of interest.
References
1 Bruce MG, Maaroos HI. Epidemiology of Helicobacter pylori
infection. Helicobacter 2008;13(Suppl. 1):1–6.
2 Daugule I, Rowland M. Helicobacter pylori infection in children.
Helicobacter 2008;13(Suppl. 1):41–46.
3 Tan HJ, Goh KL. Changing epidemiology of Helicobacter pylori
in Asia. J Dig Dis 2008;9:186–9.
4 Goodman KJ, Jacobson K, Veldhuyzen van Zanten S. Helicobacter pylori infection in Canadian and related Arctic Aboriginal
populations. Can J Gastroenterol 2008;22:289–95.
5 Zhang YY, Xia HH, Zhuang ZH, Zhong J. Review article: ‘true’
re-infection of Helicobacter pylori after successful eradication –
worldwide annual rates, risk factors and clinical implications.
Aliment Pharmacol Ther 2009;29:145–60.
6 Fock KM, Talley N, Moayyedi P, et al. Asia-Pacific consensus
guidelines on gastric cancer prevention. J Gastroenterol Hepatol
2008;23:351–65.
7 Cheng H, Hu F, Zhang L, Yang G, Ma J, Hu J, et al. Prevalence
of Helicobacter pylori infection and identification of risk factors
in rural and urban Beijing, China. Helicobacter 2009;14:128–33.
8 Cherian S, Forbes D, Sanfilippo F, Cook A, Burgner D. The
epidemiology of Helicobacter pylori infection in African refugee
children resettled in Australia. Med J Aust 2008;189:438–41.
6
Azevedo et al.
9 Kaya AD, Gencay E, Ozturk CE, Yavuz T. Seroprevalence of
Helicobacter pylori infection in children in northwest region of
Turkey: relationship with iron deficiency anemia. J Trop Pediatr
2008;54:353–4.
10 Kori M, Goldstein E, Granot E. Helicobacter pylori infection in
young children detected by a monoclonal stool antigen immunoassay. Pediatr Infect Dis J 2009;28:157–9.
11 Mishra S, Singh V, Rao GR, Dixit VK, Gulati AK, Nath G. Prevalence of Helicobacter pylori in asymptomatic subjects – a nested
PCR based study. Infect Genet Evol 2008;8:815–9.
12 Mohammad MA, Hussein L, Coward A, Jackson SJ. Prevalence
of Helicobacter pylori infection among Egyptian children: impact
of social background and effect on growth. Public Health Nutr
2008;11:230–6.
13 Monno R, Volpe A, Basho M, Fumarola L, Trerotoli P, Kondili
LA, et al. Helicobacter pylori seroprevalence in selected groups of
Albanian volunteers. Infection 2008;36:345–50.
14 Moujaber T, MacIntyre CR, Backhouse J, Gidding H, Quinn H,
Gilbert GL. The seroepidemiology of Helicobacter pylori infection
in Australia. Int J Infect Dis 2008;12:500–4.
15 Naito Y, Shimizu T, Haruna H, Fujii T, Kudo T, Shoji H, et al.
Changes in the presence of urine Helicobacter pylori antibody in
Japanese children in three different age groups. Pediatr Int
2008;50:291–4.
16 Nouraie M, Latifi-Navid S, Rezvan H, Radmard AR, Maghsudlu
M, Zaer-Rezaii H, et al. Childhood hygienic practice and family
education status determine the prevalence of Helicobacter pylori
infection in Iran. Helicobacter 2009;14:40–6.
17 Sasidharan S, Uyub AM. Prevalence of Helicobacter pylori infection among asymptomatic healthy blood donors in Northern
Peninsular Malaysia. Trans R Soc Trop Med Hyg 2009;103:
395–8.
18 Shi R, Xu S, Zhang H, Ding Y, Sun G, Huang X, et al. Prevalence and risk factors for Helicobacter pylori infection in Chinese
populations. Helicobacter 2008;13:157–65.
19 Siai K, Ghozzi M, Ezzine H, Medjahed N, Azzouz MM. Prevalence and risk factors of Helicobacter pylori infection in Tunisian
children: 1055 children in Cap-Bon (northeastern Tunisia). Gastroenterol Clin Biol 2008;32:881–6.
20 Tam YH, Yeung CK, Lee KH, Sihoe JD, Chan KW, Cheung ST,
et al. A population-based study of Helicobacter pylori infection in
Chinese children resident in Hong Kong: prevalence and potential risk factors. Helicobacter 2008;13:219–24.
21 Yucel T, Aygin D, Sen S, Yucel O. The prevalence of Helicobacter
pylori and related factors among university students in Turkey.
Jpn J Infect Dis 2008;61:179–83.
22 Zagari RM, Fuccio L, Wallander MA, Johansson S, Fiocca R,
Casanova S, et al. Gastro-oesophageal reflux symptoms,
oesophagitis and Barrett’s oesophagus in the general population: the Loiano-Monghidoro study. Gut 2008;57:1354–9.
23 Goodman KJ, Cockburn M. The role of epidemiology in understanding the health effects of Helicobacter pylori. Epidemiology
2001;12:266–71.
24 Nurgalieva Z, Goodman KJ, Phillips CV, Fischbach L, de la Rosa
JM, Gold BD. Correspondence between Helicobacter pylori antibodies and urea breath test results in a US-Mexico birth cohort.
Paediatr Perinat Epidemiol 2008;22:302–12.
25 Ronkainen J, Aro P, Storskrubb T, Johansson SE, Lind T,
Bolling-Sternevald E, et al. High prevalence of gastroesophageal
reflux symptoms and esophagitis with or without symptoms in
the general adult Swedish population: a Kalixanda study
report. Scand J Gastroenterol 2005;40:275–85.
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 1–7
Azevedo et al.
26 Bhuiyan TR, Qadri F, Saha A, Svennerholm AM. Infection by
Helicobacter Pylori in Bangladeshi children from birth to two
years, relation to blood group, nutritional status, and seasonality.
Pediatr Infect Dis J 2009;28:79–85.
27 Niv Y, Hazazi R, Waked A, Lederfein T, Achiel K. Helicobacter
pylori recurrence and infection rate in Israeli adults. Dig Dis Sci
2008;53:1211–4.
28 Goodman KJ, Correa P. The transmission of Helicobacter pylori.
A critical review of the evidence. Int J Epidemiol 1995;24:
875–87.
29 Kivi M, Tindberg Y. Helicobacter pylori occurrence and transmission: a family affair? Scand J Infect Dis 2006;38:407–17.
30 Weyermann M, Rothenbacher D, Brenner H. Acquisition of Helicobacter pylori infection in early childhood: independent contributions of infected mothers, fathers, and siblings. Am J
Gastroenterol 2009;104:182–9.
31 Goodman KJ, Correa P. Transmission of Helicobacter pylori
among siblings. Lancet 2000;355:358–62.
32 Herrera PM, Mendez M, Velapatio B, Santivaez L, Balqui J,
Finger SA, et al. DNA-level diversity and relatedness of Helicobacter pylori strains in shantytown families in Peru and transmission in a developing-country setting. J Clin Microbiol
2008;46:3912–8.
33 Konno M, Yokota S, Suga T, Takahashi M, Sato K, Fujii N. Predominance of mother-to-child transmission of Helicobacter pylori
infection detected by random amplified polymorphic DNA fingerprinting analysis in Japanese families. Pediatr Infect Dis J
2008;27:999–1003.
34 Nahar S, Kibria KM, Hossain ME, Sultana J, Sarker SA, Engstrand L, et al. Evidence of intra-familial transmission of
Helicobacter pylori by PCR-based RAPD fingerprinting in Bangladesh. Eur J Clin Microbiol Infect Dis 2009;28:767–73.
35 Schwarz S, Morelli G, Kusecek B, Manica A, Balloux F, Owen
RJ, et al. Horizontal versus familial transmission of Helicobacter
pylori. PLoS Pathog 2008;4:e1000180.
36 Burgers R, Schneider-Brachert W, Reischl U, Behr A, Hiller
KA, Lehn N, et al. Helicobacter pylori in human oral cavity and
stomach. Eur J Oral Sci 2008;116:297–304.
37 Kara CO, Yilmaz M, Kirac S. Tonsillectomy does not decrease
the risk of Helicobacter pylori transmission. J Clin Gastroenterol
2008;42:326–7.
38 Azevedo NF, Guimaraes N, Figueiredo C, Keevil CW, Vieira
MJ. A new model for the transmission of Helicobacter pylori: role
of environmental reservoirs as gene pools to increase strain
diversity. Crit Rev Microbiol 2007;33:157–69.
39 Fujimura S, Kato S, Watanabe A. Water source as a Helicobacter
pylori transmission route: a 3-year follow-up study of Japanese
children living in a unique district. J Med Microbiol
2008;57:909–10.
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 1–7
Epidemiology of H. pylori infection
40 Bockelmann U, Dorries HH, Ayuso-Gabella MN, Salgot de Marcay M, Tandoi V, Levantesi C, et al. Quantitative PCR monitoring of antibiotic resistance genes and bacterial pathogens in
three European artificial groundwater recharge systems. Appl
Environ Microbiol 2009;75:154–63.
41 Mazari-Hiriart M, Ponce-de-Leon S, Lopez-Vidal Y, Islas-Macias
P, Amieva-Fernandez RI, Quinones-Falconi F. Microbiological
implications of periurban agriculture and water reuse in Mexico City. PLoS ONE 2008;3:e2305.
42 Cellini L, Grande R, Di Campli E, Di Bartolomeo S, Di Giulio
M, Traini T, et al. Characterization of an Helicobacter pylori environmental strain. J Appl Microbiol 2008;105:761–9.
43 Giao MS, Azevedo NF, Wilks SA, Vieira MJ, Keevil CW. Persistence of Helicobacter pylori in heterotrophic drinking-water biofilms. Appl Environ Microbiol 2008;74:5898–904.
44 Kawaguchi K, Matsuo J, Osaki T, Kamiya S, Yamaguchi H.
Prevalence of Helicobacter and Acanthamoeba in natural environment. Lett Appl Microbiol 2009;48:465–71.
45 Ghil HM, Yoo JH, Jung WS, Chung TH, Youn HY, Hwang CY.
Survey of Helicobacter infection in domestic and feral cats in
Korea. J Vet Sci 2009;10:67–72.
46 Quaglia NC, Darnbrosio A, Nonnanno G, Parisi A, Patrono R,
Ranieri G, et al. High occurrence of Helicobacter pylori in raw
goat, sheep and cow milk inferred by glmM gene: a risk of
food-borne infection? Int J Food Microbiol 2008;124:43–47.
47 De Schryver A, Cornelis K, Van Winckel M, Moens G, Devlies
G, Derthoo D, et al. The occupational risk of Helicobacter pylori
infection among workers in institutions for people with intellectual disability. Occup Environ Med 2008;65:587–91.
48 Tschopp A, Joller H, Jeggli S, Widmeier S, Steffen R, Hilfiker S,
et al. Hepatitis E, Helicobacter pylori and peptic ulcers in workers
exposed to sewage: a prospective cohort study. Occup Environ
Med 2009;66:45–50.
49 Hansen JM, Wildner-Christensen M, Hallas J, Schaffalitzky de
Muckadell OB. Effect of a community screening for Helicobacter
pylori: a 5-Yr follow-up study. Am J Gastroenterol
2008;103:1106–13.
50 Mason JM, Raghunath AS, Hungin AP, Jackson W. Helicobacter
pylori eradication in long-term proton pump inhibitor users is
highly cost-effective: economic analysis of the HELPUP trial.
Aliment Pharmacol Ther 2008;28:1297–303.
51 Yeh JM, Kuntz KM, Ezzati M, Goldie SJ. Exploring the costeffectiveness of Helicobacter pylori screening to prevent gastric
cancer in China in anticipation of clinical trial results. Int J Cancer 2009;124:157–66.
52 Xie F, Luo N, Lee HP. Cost effectiveness analysis of populationbased serology screening and (13)C-Urea breath test for Helicobacter pylori to prevent gastric cancer: a Markov model. World J
Gastroenterol 2008;14:3021–7.
7
Helicobacter ISSN 1523-5378
Diagnosis of Helicobacter pylori Infection
Lurdes Monteiro,* Mónica Oleastro,* Philippe Lehours
à
and Francis Mégraud
à
*Departamento de Doenças Infecciosas, Instituto Nacional Saúde Dr Ricardo Jorge, Lisboa, Portugal, INSERM U853, F 33076 Bordeaux, àUniversité
Victor Segalen Bordeaux 2, Laboratoire de Bactériologie, F33076 Bordeaux, France
Keywords
Urease test, histology, culture, stool antigen
test, urea breath test, molecular methods,
antimicrobial susceptibility testing.
Reprint requests to: Francis Mégraud, Laboratoire de Bactériologie, Université Victor
Segalen Bordeaux 2, Bat. 2B RDC Zone Nord,
33076 Bordeaux cedex, France.
E-mail: francis.megraud@chu-bordeaux.fr
Abstract
The articles published this last year in the field of Helicobacter pylori diagnosis
reported the development of in vivo histology, small improvements in some
invasive methods (urease test, culture, and histology) and new kits for the
stool antigen tests. They also contributed to increasing our knowledge, by
further exploration into specific conditions for the urea breath test and into
the significance of cagA antibodies. The role of serum markers of atrophy
was also confirmed. Molecular methods are still being developed for direct
genotyping, detection of H. pylori and its clarithromycin resistance, either by
polymerase chain reaction or fluorescent in-situ hybridization. For the first
time, there was a report on a possible interest of magnetic resonance
spectroscopy.
A variety of tests for detecting Helicobacter pylori infection since the discovery of this pathogen have been
described. While there has been no recent breakthrough in this topic, a number of original articles coming especially from emerging countries were published
last year on the different molecular and nonmolecular
diagnostic tests for H. pylori.
Non-molecular Methods
Invasive Tests
Graham et al. published a review article providing recommendations regarding when endoscopic gastric
mucosa assessment must be preferred rather than noninvasive methods [1].
Endoscopy
To obtain biopsies, an upper digestive endoscopy must
be performed. Cho et al. proposed a new method of
standard endoscopic diagnosis of H. pylori: the phenol
red mucosal pH test. A 0.1% phenol red solution was
sprayed on the gastric mucosa. The extent of staining,
expressed as a staining score, was positively correlated
with the urea breath test (UBT) values and with
H. pylori density as measured by histology. The pH measured in this study with an antimony electrode was
significantly higher in H. pylori infected mucosa.
Therefore, endoscopic phenol red staining may be an
8
alternative method for the diagnosis of H. pylori infection [2].
The new methods of magnifying endoscopy currently
developed have an added value compared to standard
endoscopy, i.e. the possibility of performing in vivo histology. A prospective study on 129 patients performed
in Turkey confirmed that the new method of high resolution magnifying endoscopy is superior to standard
endoscopy for the diagnosis of H. pylori gastritis, and
identification of specific histopathologic features, such
as atrophy and intestinal metaplasia seems possible [3].
In a review of confocal laser endomicroscopy, Kiesslich et al. highlighted the possibility of virtual histology
and its role in diagnosing H. pylori gastritis and targeting
biopsy specimens [4].
Interestingly, Kim et al. studied the sites for performing biopsies to detect H. pylori in 194 patients with gastric cancer. They found that the best site was the upper
body greater curvature (sensitivity of histology: 95.1%;
95% CI: 89.6–98.2), probably due to the proportion of
atrophy and intestinal metaplasia, which were significantly lower than in the antrum and in the upper body
lesser curvature which were also tested [5].
Histology
An alternative to Giemsa staining has been proposed in
Thailand [6]. A mixture of carbol fuschin and alcian
blue staining was compared blindly to Giemsa and
hematoxylin & eosin staining on 423 histologic
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 8–14
Monteiro et al.
preparations. They found the same rate of positive samples and highlighted the low cost and simplicity of the
combined staining and its value in identifying goblet
cells in intestinal metaplasia.
The impact of mixed H. pylori infections was studied
in 30 patients by Sheu et al. [7]. They found that the
seven patients with mixed infections had marginally
higher scores of chronic inflammation and H. pylori
density in the corpus and higher rates of intestinal
metaplasia in the antrum (p = .005) compared to the
23 patients with a single strain.
An article referred to the new staging system for atrophy (OLGA) and its application in diagnostic practice
[8]. It was also used to assess atrophic gastritis in 63
H. pylori positive patients with various gastric diseases.
They found the OLGA staging system useful for the
assessment of the severity of atrophic gastritis and simple to use [9]. In another study concerning different
risks of gastric cancer in populations, the OLGA staging
mirrored the gastric cancer incidence [10].
The histogenesis of gastric carcinomas was re-evaluated by Kakinoki et al. [11]. They compared H. pylorinegative and -positive cases and found that carcinoma
cells could occur independently of the intestinal metaplasia. If this finding is confirmed, it would indicate
that intestinal metaplasia is not a precancerous but a
paracancerous lesion.
Urease test
As in previous studies, the sensitivity of the rapid urease test (RUT) was shown to be reduced in patients
with bleeding ulcers but the short-term use of standard
dose proton-pump inhibitor did not have an impact
[12].
As a solution to the low sensitivity of the RUT, some
authors proposed to increase the number of biopsies
tested up to four. Comparing one biopsy to four, the positive results increased from 52 to 96%, respectively [13].
Culture
Because of the slow growth and the particular requirements of H. pylori with regard to culture conditions, this
area still remains a particular challenge. Sainsus et al.
tried to develop a liquid culture medium for the rapid
isolation, identification, and subsequent antibiotic susceptibility testing of H. pylori from biopsy specimens.
They selected Ham’s F12 medium with 5% horse serum
with antibiotics which provided the most rapid and reliable growth. The CIM medium seems a promising solution to solve some of the current problems concerning
H. pylori culture in solid media [14].
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 8–14
H. pylori Diagnosis
Non-invasive Tests
Urea breath test
C-UBT has been shown numerous times to be the
most accurate H. pylori diagnostic test. Several remaining questions were addressed this year. Buzas and
Szeles compared UBT values after first-, second- and
third-line treatments. They found as in previous studies
that higher pretreatment UBT values were associated
with lower eradication rates but interestingly, they also
showed a marked tendency to increase UBT values for
the patients who failed, i.e. from 13.2& (CI: 7.3–19.1)
to 19.2& (CI: 13.4–25.0) after second-line therapy and
to 25.8& (CI: 19.8–31.2) after third-line therapy, but
they could not explain this phenomenon [15]. In
another study, UBT values were also found to be higher
when clarithromycin resistant H. pylori were present,
but not when other resistances occurred [16].
The possibility of false positive results due to urease
positive bacteria from the oral cavity in patients with
atrophic gastritis was highlighted by Osaki et al. indicating that the histologic status of the stomach, i.e. presence or absence of atrophy, must be considered in
interpreting the results [17]. To avoid false positive
results, the capsule UBT can be used [18].
There is another situation where false positive results
may occur, i.e. in children younger than 6 years of age.
The cause may not only be the effect of endogenous
CO2 production but also other unidentified factors [19].
In contrast to the RUT, the UBT was found to be unreliable in patients with Billroth II gastrectomy [20]. Testing for the eradication of H. pylori is an important
aspect of clinical trial design and is of critical importance in the evaluation of new therapies for this pathogen. From the evaluation of Vakil et al. a single UBT,
4 weeks after treatment was as effective as two serial
breath tests in confirming H. pylori eradication and the
incremental cost of the second breath test was very
high with no incremental clinical benefit [21]. A study
performed in Israel to evaluate the indications for UBT
used by primary care doctors and to examine the
appropriateness of these indications to the accepted
guidelines of the Maastricht Consensus Report revealed
a substantial noncompliance with guidelines for
H. pylori testing among primary care doctors in this
country [22].
13
Stool antigen test
Stool antigen detection kits for the diagnosis of H. pylori
infection have been widely used because of their full
noninvasive nature. Mohammadian et al. presented a
simple, rapid, and cost-effective production of a
9
Monteiro et al.
H. pylori Diagnosis
polyclonal antibody against alkyl hydroperoxide reductase (AhpC) of H. pylori for stool-antigen enzyme
immunoassay [23]. Nguyen et al. evaluated the sensitivity and specificity of the new monoclonal antibodybased antigen-in-stool enzyme immunoassay (Premier
Platinum HpSA PLUS; Meridian Bioscience, Cincinnati,
OH, USA) for diagnosis of H. pylori infection in Vietnamese children. The sensitivity was 96.6% (95% CI:
93.3–98.5) and the specificity 94.9% (95% CI: 88.5–
98.3) [24]. In addition, Kuloğlu et al. evaluated the
diagnostic accuracy of a rapid immunochromatographic
stool antigen test (Rapid HpSA; LI_ NEAR Chemical, Barcelona, Spain) and a practical low-dose 14C-UBT (Heliprobe; Kibion, Uppsala, Sweden) in children before
and after eradication therapy. The sensitivity of Rapid
HpSA and 14C-UBT was 65% and 92.5% (p = .0003),
respectively; the specificity of Rapid HpSA and 14C-UBT
was 92.3 and 85.5% (p = .180), respectively. After
eradication therapy, endoscopy, 14C-UBT and Rapid
HpSA were repeated. Both tests had the same specificity
(100%) while the sensitivity of Rapid HpSA and 14CUBT was 60 and 100%, respectively [25]. However, the
most interesting study compared six tests and the
results are reported in Table 1 [26].
Antibody detection
Numerous antibody-based tests have been developed
over the last decades. Leal et al. carried out a systematic
review and meta-analysis to evaluate the performance
of the different antibody-based detection tests available
for H. pylori infection in children by determining sensitivity and specificity as well as additional accuracy values relevant to clinical practice (positive and negative
likelihood ratios (LR+ and LR)) and the diagnostic odds
ratio (DOR)). The results were as follows: (1) western
blot (WB) tests showed high overall performance, sensitivity: 91.3% (95% CI: 88.9–93.3, specificity: 89%
(95% CI:85.7–91.9), LR+: 8.2 (95% CI: 5.1–13.3), LR-2:
0.06 (95% CI: 0.02–0.16), and DOR: 158.8 (95% CI:
57.8–435.8)); (2) enzyme-linked immunosorbent assay
Table 1 Summary of sensitivity and specificity of the stool antigen
tests cited by Blanco et al. [26]
Immunodiagnostic ELISA
HpStAR
HpSA-EIA
H. pylori Lihtest
Immunoland HpSA
RAPID HpStAR
10
Sensitivity
Specificity
87.3
95
92.5
83.6
52.5
78.8
83.3
66.6
72.2
66.6
94.4
55.5
(ELISA)-IgG assays showed low sensitivity: 79.2%
(95% CI: 77.3–81.0) and high specificity: 92.4% (95%
CI: 91.6–93.3); (3) ELISA commercial tests varied
widely in performance (test for heterogeneity,
p = .0001); and (4) in-house ELISA with whole-cell
antigen tests showed the highest overall performance:
sensitivity: 94% (95% CI: 90.2–96.7), specificity: 96.4%
(95% CI: 94.2–97.9), LR+: 19.9 (95% CI: 7.9–49.8),
LR-2: 0.08 (95% CI: 0.04–0.15), DOR: 292.8 (95% CI:
101.8–841.7) [27].
The Pyloriset EIA-G (Orion Diagnostics, Espoo, Finland), which is considered to be one of the most reliable
tests in Europe, was used to detect H. pylori infection in
two groups of peptic ulcer disease patients, one group
vagotomized and the other medically treated, as well as
community controls. Using positive histology and ⁄ or
culture as the gold standard, the sensitivity of the serologic test was good but its specificity poor in contrast to
14
C-UBT results. However, no data were available on
possible antibiotic treatments for these patients [28].
Mohammadi et al. evaluated an in-house ELISA based
on soluble antigenic fractions of H. pylori proteins in
Iran. The sensitivity, specificity, and accuracy were over
90% as was the performance of Helico Blot 2.1 (Genelabs Diagnostics, Singapore) and two foreign commercial
ELISA kits (Trinity kit and IBL kit) while the BioHit kit
(Helsinki, Finland) did not perform as well [29].
Anti-CagA antibodies (detected either by a specific
ELISA or immunoblot) have been described as long
standing antibodies of interest to confirm H. pylori
etiology years after the disappearance of the bacterium.
Recently, Veijola et al. confirmed that CagA antibodies
detected by immunoblot (Helico Blot 2.1) could still be
detected in 87% of the patients 10 years or more after
a successful H. pylori eradication [30]. Studies were performed in several countries with various results. In
Australia, the use of Helicoblot 2.1 detecting CagA antibodies improved the sensitivity of H. pylori detection in
patients with noncardia gastric cancer from 79% with
H. pylori ELISA to 94%. Interestingly, pepsinogen I levels showed the lowest median level to be in cases
which were negative by ELISA but positive by immunoblot [31]. In Mexico, CagA antibodies were associated with young gastric cancer cases only, and were
also a risk factor for intestinal metaplasia [32]. In Estonia, positivity for CagA antibodies was able to predict
the development of atrophy, particularly in the corpus
(OR: 7.0, 1.8–27.7). In addition, the prevalence of anticanalicular antibodies increased with the duration of
the H. pylori gastritis (22–46% in 12 years) [33]. In
contrast, in India, the prevalence of H. pylori detected
by H. pylori serology or CagA antibodies was comparable both in gastric cancer patients and in controls [34].
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 8–14
Monteiro et al.
Serum biomarkers, especially those proposed by BioHit in the GastroPanel (pepsinogen I & II, gastrin 17,
H. pylori Ab) have been tested in comparison to histology. In the Kalixanda study (Northern Sweden), an
overall agreement of 96% was found. Sensitivity and
specificity of the markers for atrophic gastritis were 71
and 98%, respectively [35]. The GastroPanel was also
able to differentiate Japanese patients into two groups
with ‘‘healthy’’ or ‘‘diseased’’ stomachs with a 94%
accuracy. In total, 5% of the patients had advanced
atrophic corpus gastritis [36].
With regard to cost effectiveness, a Markov model
was designed based on 237,900 Chinese males, aged
35–44 years and living in Singapore, who would be
screened and treated with eradication therapy. Serology
appeared to be twice as cost effective as the UBT in
screening this population [37].
From two studies concerning the value of RAPIRUN
test, a urinary antibody test. Nguyen et al. verified that
in the Vietnamese population sensitivity, specificity,
and accuracy of the test were 79.5, 90.7, and 84.5%,
respectively [38]. These values are in accordance with
the overview presented by Yamamoto et al. concerning
the diagnosis of H. pylori infection using the same
detection kit [39]. The development of a model for economic evaluation related to the diagnosis accuracy of
near patient tests used in office laboratories, as opposed
to using hospital-based tests was presented by Fauli
et al. [40].
Molecular Methods
H. pylori Diagnosis
PCR and in situ hybridization, targeting a 76-bp region
of H. pylori 16S rRNA, that is highly conserved in a
large number of H. pylori strains and is specific to this
bacterium. Both approaches were shown to be very
sensitive and specific and combined together can be
used for specific detection, identification and quantification of H. pylori in biological samples, from humans,
animals, or environmental source [42]. In another
study, real-time PCR targeting the 23S rRNA gene
applied on aortic and left internal mammary artery
biopsies, was used to demonstrate, for the first time,
that acute coronary ischemia was significantly more prevalent in H. pylori-positive patients than in H. pylori-negative patients (p = .001), suggesting a pathogenic role of
this bacterium in atherosclerosis [43]. Finally, Gill et al.
developed a nanodiagnostic method using thermophilic
helicase-dependent isothermal amplication of ureC and
gold nanoparticle probes for hybridization and colorimetric detection of H. pylori DNA. This method allowed
the detection of 10 CFU ⁄ mL within less than 1 hour and
provided a sensitivity of 92.5% and a specificity of
95.4%, with culture as the reference [44].
Sugimoto et al. identified 26 sets of primers used to
detect H. pylori. They first tested their detection limit.
Five of the 26 sets with a detection limit <100 CFU ⁄ mL
were then tested further. All produced some false positive results. These results indicate that results of H.
pylori detection by PCR outside of the stomach should
be interpreted with caution. Identification based on the
presence of multiple specific genes could be the way
forward [45].
Detection
Genotyping
Over the last year, novel molecular methods based
mainly on a real-time polymerase chain reaction (PCR)
have been described to improve the detection and characterization of H. pylori. A new multiplex fluorescence
resonance energy transfer real-time PCR, for amplification of H. pylori ureA and human b-globin, was
developed, allowing quantification of the bacterial density by determination of the ureA ⁄ b-globin amount
ratio in gastric biopsies. Using this assay, a significantly
increased bacterial density was found in macroscopic
erosions when compared with the healthy portion of
the stomach (p < .01). This PCR was not able to detect
the ureA gene in H. pylori-positive formalin-fixed paraffin-embedded biopsy sections, probably because DNA
was broken and amplification of a 411-bp fragment was
not possible [41]. To overcome the problem of extensive genetic polymorphism for precise PCR detection
of H. pylori, Liu et al. developed a novel molecular
approach, based on real-time reverse transcriptase (RT)-
Simultaneous genotyping of bacterial and host cells is
sometimes difficult due to the small amounts of sample.
To overcome this problem, Ryberg et al. used the multiple displacement amplification technique on minute
amounts of gastric biopsy specimens. Then, the amplified DNA was used for concurrent PCR-based genotyping, of both H. pylori 16S rRNA, vacA, hsp60, ureI, sod,
ureA and cagA genes, and human cytokine polymorphisms [46]. Puz et al. developed a novel noninvasive
genotyping method, using stool specimens, based on
two H. pylori-specific biprobe real-time PCR assays targeting the glmM and recA genes. Discrimination
between strains is made using the differences in the
melting temperature of the amplicons. The sensitivity of
the assay on stool samples was 92.2% and the specificity was 100%. A discriminatory capacity of 100% was
achieved when the sequence analysis of the glmM
amplicon was performed. Due to its noninvasiveness
and high accuracy in detection and discrimination of
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 8–14
11
H. pylori Diagnosis
H. pylori strains, this genotyping assay has the potential
of being used in large-scale studies, contributing to the
clarification of the transmission pathways of this organism [47]. Paraffin-embedded gastric biopsies were used
for H. pylori genotyping with success (97% of the
cases). The genotyping enabled a comparison of the
prevalence of cagA positive, vacA s1m1 genotypes in
high and low risk areas for gastric cancer in Colombia
(84.3 and 60.5%, respectively) [48].
Kanada et al. evaluated the accuracy of immunohistochemistry for genotyping the cagA East-Asian EPIYA
motif. They used a monoclonal antibody against this
motif and tested it on gastric biopsy samples from Japanese patients. Compared to sequencing of the cagA
3¢-region, containing the EPIYA motifs, the new assay
showed a sensitivity of 93.2% and a specificity of
72.7%, suggesting a further optimization to be useful as
a cagA typing method [49].
Antimicrobial Resistance
With the growing H. pylori resistance to antibiotics,
molecular diagnostic tests for an accurate and rapid
identification of these strains are an attractive alternative to the time consuming culture-based susceptibility
testing. Thus, this is still an emergent field in H. pylori
research, targeting in particular the clarithromycin
resistance-associated gene mutations. A study employing Scorpion primers, which combine a primer and a
probe in a single molecule, was reported by Burucoa
et al. to detect H. pylori and clarithromycin resistance
directly on gastric biopsies. The Scorpion PCR was
highly sensitive and specific (98.3% and 92.5%) in
detecting H. pylori, using culture as the gold standard,
and, as usual, it was more sensitive in detecting mixed
populations with susceptible and resistant strains than
the E-test. Clarithromycin genotypes determined with
Scorpion PCR were concordant with those obtained by
PCR-restriction fragment length polymorphism [50].
Fluorescent in-situ hybridization (FISH) can be used to
identify H. pylori and antibiotic resistance in biopsy
specimens without PCR. Tajbakhsh et al. reported a
FISH procedure targeting the H. pylori ribosomal RNA,
and this assay showed a sensitivity and specificity of
97.9 and 100% respectively, for detection of H. pylori,
when compared to histology. However, the FISH assay,
employing four different probes, one wild type and
three mutated, showed a weak sensitivity in detecting
clarithromycin susceptibility-associated genotypes, as
only 19 of the 47 FISH-positive samples were recognized with these probes [51]. Another study employing
the FISH technology, performed using DNA ProbeMix
targeting the 16S rRNA H. pylori gene, showed a
12
Monteiro et al.
satisfactory sensitivity on both fresh and paraffinembedded biopsies isolated from children (84.1 and
80.7%, respectively), previously diagnosed as H. pyloripositive by histology and RUT. When used to screen
clarithromycin resistance genotypes, using probes targeting the 23S rRNA point mutations, the FISH test was
more sensitive in detecting mixed susceptible and resistant populations than did the agar-dilution method.
The authors emphasize that clarithromycin resistance
should be assessed in biopsies both from the antrum
and the corpus, as in one-third of children with mixed
infection the resistant strains were found in the fundus
only [52]. Woo et al. developed a dual-priming oligonucleotide (DPO)-based multiplex PCR to detect both
H. pylori infection and the most common point mutations occurring in the 23S rRNA conferring resistance
to clarithomycin (A2142G and A2143G), directly on
gastric biopsy specimens. The DPO-based multiplex was
slightly less sensitive in identifying H. pylori-positive
cases than histology, but was able to identify more clarithromycin-resistant strains than the phenotypic methods. This assay proved to be fast, does not require
expensive instrumentation, and can thus be valuable in
countries with high prevalence of clarithromycin resistance [53]. Kawai et al. used fecal specimens to detect
H. pylori and its resistance to clarithromycin using a
nested PCR based on the 23S rRNA gene and sequencing of the amplicons, prior to H. pylori treatment. They
obtained a 94.3% eradication rate in the tailored group
and 71.4% in the control group [54].
Finally, Chisholm et al. assessed the potential benefits
of the application to routine testing, of a novel algorithm comprising a panel of three previously described
PCR assays for detection and antibiotic susceptibility
testing of H. pylori. All culture-negative gastric biopsies
were first tested for H. pylori and Helicobacter heilmanniilike organisms by a multiplex PCR assay targeting vacA
and 16S rRNA genes, respectively. Then, in the positive
cases, antibiotic susceptibility to clarithromycin and tetracycline was assessed by real-time PCR probe hybridization and melting point analysis assays targeting the
23S rRNA and 16S rRNA, respectively. The authors
demonstrated that PCR testing was particularly useful
when H. pylori culture was unsuccessful, due to contamination of the biopsy or when the specimen transportation was delayed. Without this additional testing,
16.9% of all patients examined could have been misdiagnosed as H. pylori negative by culture only [55].
Finally, two articles were published using magnetic resonance spectroscopy (MRS). The first study concerned
gastric biopsies obtained from patients with various diseases studied ex vivo by high resolution – magic angle
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 8–14
Monteiro et al.
spinning – MRS (HR-MAS-MRS) and compared to ultrastructural data. Several amino acids, e.g. glycine, alanine, choline, and triglycerides, were identified as
possible markers of differentiation toward neoplastic
lesions. Such a technique could be applied in vivo [56].
In the second study, the metabolic profile of gerbils
infected or not with H. pylori was studied on urine specimens. Results showed that H. pylori infection disturbs
carbohydrate and amino acid metabolism and modifies
the gut microbiota [57]. This method should open a
new field of exploration of H. pylori infection.
H. pylori Diagnosis
13
14
15
16
Conflicts of Interest
To be confirmed.
17
References
1 Graham DY, Kato M, Asaka M. Gastric endoscopy in the 21st
century: appropriate use of an invasive procedure in the era of
non-invasive testing. Dig Liver Dis 2008;40:497–503.
2 Cho YS, Chae HS, Jang SN, et al. Comparison of the 13C-urea
breath test and the endoscopic phenol red mucosal pH test in
the quantification of Helicobacter pylori infection loading. Korean
J Intern Med 2008;23:134–9.
3 Gonen C, Simsek I, Sarioglu S, Akpinar H. Comparison of high
resolution magnifying endoscopy and standard videoendoscopy
for the diagnosis of Helicobacter pylori gastritis in routine clinical
practice: a prospective study. Helicobacter 2009;14:12–21.
4 Kiesslich R, Goetz M, Neurath MF. Virtual histology. Best Pract
Res Clin Gastroenterol. 2008;22:883–97.
5 Kim CG, Choi IJ, Lee JY, Cho SJ, Nam BH, Kook MC, et al.
Biopsy site for detecting Helicobacter pylori infection in patients
with gastric cancer. J Gastroenterol Hepatol 2009;24:469–74.
6 Yodavudh S, Tangjitgamol S, Puangsa-art S. Mixture of carbol fuchsin and alcian blue staining of gastric tissue for the
identification of Helicobacter pylori and goblet cell intestinal
metaplasia. Southeast Asian J Trop Med Public Health
2008;39:659–66.
7 Sheu SM, Sheu BS, Lu CC, Yang HB, Wu JJ. Mixed infections
of Helicobacter pylori: tissue tropism and histological significance.
Clin Microbiol Infect 2009;15:253–9.
8 Rugge M, Correa P, Di Mario F, El-Omar E, Fiocca R, Geboes
K, et al. OLGA staging for gastritis: a tutorial. Dig Liver Dis
2008;40:650–8.
9 Satoh K, Osawa H, Yoshizawa M, Nakano H, Hirasawa T, Kihira K, et al. Assessment of atrophic gastritis using the OLGA
system. Helicobacter 2008;13:225–9.
10 Rugge M, Kim JG, Mahachai V, Miehlke S, Pennelli G, Russo
VM, et al. OLGA gastritis staging in young adults and
country-specific gastric cancer risk. Int J Surg Pathol 2008;
16:150–4.
11 Kakinoki R, Kushima R, Matsubara A, Saito Y, Okabe H, Fujiyama Y, et al. Re-evaluation of histogenesis of gastric carcinomas: a comparative histopathological study between Helicobacter
pylori-negative and H. pylori-positive cases. Dig Dis Sci
2009;54:614–20.
12 Tang JH, Liu NJ, Cheng HT, Lee CS, Chu YY, Sung KF, et al.
Endoscopic diagnosis of Helicobacter pylori infection by rapid
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 8–14
18
19
20
21
22
23
24
25
26
27
urease test in bleeding peptic ulcers: a prospective case-control
study. J Clin Gastroenterol 2009;43:133–9.
Siddique I, Al-Mekhaizeem K, Alateeqi N, Memon A, Hasan F.
Diagnosis of Helicobacter pylori: improving the sensitivity of
CLOtest by increasing the number of gastric antral biopsies.
J Clin Gastroenterol 2008;42:356–60.
Sainsus N, Cattori V, Lepadatu C, Hofmann-Lehmann R. Liquid
culture medium for the rapid cultivation of Helicobacter pylori
from biopsy specimens. Eur J Clin Microbiol Infect Dis
2008;27:1209–17.
Buzas GM, Szeles I. Interpretation of the 13C-urea breath test
in the choice of second- and third-line eradication of Helicobacter pylori infection. J Gastroenterol 2008;43:108–14.
Kawai T, Kawakami K, Kataoka M, Itoi T, Takei K, Moriyasu F,
et al. A study of the relationship between Helicobacter pylori
microbial susceptibility, 13C-urea breath test values. Hepatogastroenterology 2008;83:786–90.
Osaki T, Mabe K, Hanawa T, Kamiya S. Urease-positive bacteria
in the stomach induce a false-positive reaction in a urea breath
test for diagnosis of Helicobacter pylori infection. J Med Microbiol.
2008;57(Pt 7):814–9.
Peng NJ, Lai KH, Lo GH, Hsu PI. Comparison of noninvasive
diagnostic tests for Helicobacter pylori infection. Med Princ Pract
2009;18:57–61.
Yang HR, Ko JS, Seo JK. Does the diagnostic accuracy of the
13C-urea breath test vary with age even after the application
of urea hydrolysis rate? Helicobacter 2008;13:239–44.
Adamopoulos AB, Stergiou GS, Sakizlis GN, Tiniakos DG, Nasothimiou EG, Sioutis DK, et al. Diagnostic value of rapid urease
test and urea breath test for Helicobacter pylori detection in
patients with Billroth II gastrectomy: a prospective controlled
trial. Dig Liver Dis 2009;41:4–8.
Vakil N, Zullo A, Ricci C, Hassan C, Vaira D. Duplicate breath
testing to confirm eradication of Helicobacter pylori: incremental
benefit and cost in 419 patients. Aliment Pharmacol Ther
2008;12:1304–8.
Noya H, Anat BO, Moshe L, Gennady P, Zamir H, Menachem M.
Do urea breath test (UBT) referrals for Helicobacter pylori testing
match the clinical guidelines in primary care practice? A prospective observational study. J Eval Clin Pract 2008;14:799–802.
Mohammadian T, Doosti M, Paknejad M, Siavoshi F, Massarrat
S, Soukhtanloo M. Production of polyclonal antibody against
alkyl hydroperoxide reductase of Helicobacter pylori and its antigenicity. Hybridoma (Larchmt) 2008;27:481–5.
Nguyen TV, Bengtsson C, Nguyen GK, Granstrom M. Evaluation of a novel monoclonal-based antigen-in-stool enzyme
immunoassay (Premier Platinum HpSA PLUS) for diagnosis of
Helicobacter pylori infection in Vietnamese children. Helicobacter
2008;13:269–73.
Kuloglu Z, Kansu A, Kirsaclioglu CT, Ustundag G, Aysev D,
Ensari A, et al. A rapid lateral flow stool antigen immunoassay
and (14)C-urea breath test for the diagnosis and eradication of
Helicobacter pylori infection in children. Diagn Microbiol Infect Dis
2008;62:351–6.
Blanco S, Forne M, Lacoma A, Prat C, Cuesta MA, Latorre I,
et al. Comparison of stool antigen immunoassay methods for
detecting Helicobacter pylori infection before and after eradication treatment. Diagn Microbiol Infect Dis 2008;61:150–5.
Leal YA, Flores LL, Garcia-Cortes LB, Cedillo-Rivera R, Torres
J. Antibody-based detection tests for the diagnosis of Helicobacter pylori infection in children: a meta-analysis. PLoS ONE
2008;3:e3751.
13
H. pylori Diagnosis
28 Lindsetmo RO, Johnsen R, Eide TJ, Gutteberg T, Husum HH,
Revhaug A. Accuracy of Helicobacter pylori serology in two peptic ulcer populations and in healthy controls. World J Gastroenterol 2008;14:5039–45.
29 Mohammadi M, Talebkhan Y, Khalili G, Mahboudi F, Massarrat S, Zamaninia L, et al. Advantage of using a home-made
ELISA kit for detection of Helicobacter pylori infection over
commercially imported kits. Indian J Med Microbiol 2008;
26:127–31.
30 Veijola L, Oksanen A, Sipponen P, Rautelin H. Evaluation of a
commercial immunoblot, Helicoblot 2.1, for diagnosis of
Helicobacter pylori infection. Clin Vaccine Immunol 2008;15:
1705–10.
31 Mitchell H, English DR, Elliott F, Gengos M, Barrett JH, Giles
GG, et al. Immunoblotting using multiple antigens is essential
to demonstrate the true risk of Helicobacter pylori infection for
gastric cancer. Aliment Pharmacol Ther 2008;28:903–10.
32 Camorlinga-Ponce M, Flores-Luna L, Lazcano-Ponce E,
Herrero R, Bernal-Sahagún F, Abdo-Francis JM, et al. Age
and severity of mucosal lesions influence the performance of
serologic markers in Helicobacter pylori-associated gastroduodenal pathologies. Cancer Epidemiol Biomarkers Prev
2008;17:2498–504.
33 Vorobjova T, Maaroos HI, Uibo R. Immune response to Helicobacter pylori and its association with the dynamics of
chronic gastritis in the antrum and corpus. APMIS
2008;116:465–76.
34 Ghoshal UC, Tiwari S, Dhingra S, Pandey R, Ghoshal U, Tripathi S, et al. Frequency of Helicobacter pylori and CagA antibody in patients with gastric neoplasms and controls: the
Indian enigma. Dig Dis Sci 2008;53:1215–22.
35 Storskrubb T, Aro P, Ronkainen J, Sipponen P, Nyhlin H, Talley
NJ, et al. Serum biomarkers provide an accurate method for
diagnosis of atrophic gastritis in a general population: The
Kalixanda study. Scand J Gastroenterol 2008;43:1448–55.
36 Iijima K, Abe Y, Kikuchi R, Koike T, Ohara S, Sipponen P,
et al. Serum biomarker tests are useful in delineating between
patients with gastric atrophy and normal, healthy stomach.
World J Gastroenterol 2009;15:853–9.
37 Xie F, Luo N, Lee HP. Cost effectiveness analysis of populationbased serology screening and (13)C-Urea breath test for Helicobacter pylori to prevent gastric cancer: a Markov model. World J
Gastroenterol 2008;14:3021–7.
38 Nguyen LT, Uchida T, Tsukamoto Y, Trinh TD, Ta L, Ho DQ,
et al. Evaluation of rapid urine test for the detection of Helicobacter pylori infection in the Vietnamese population. Dig Dis Sci
2009;Epub Feb 25.
39 Yamamoto T, Ishii T, Sanaka M, Kuyama Y. Diagnosis of Helicobacter pylori infection using RAPIRUN H. pylori antibody detection kit. Expert Rev Mol Diagn. 2008;8:565–9.
40 Fauli S, Thue G. Economic consequences of near-patient test
results: the case of tests for the Helicobacter pylori bacterium in
dyspepsia. Eur J Health Econ 2008;9:221–8.
41 Molnar B, Szoke D, Ruzsovics A, Tulassay Z. Significantly elevated Helicobacter pylori density and different genotype distribution in erosions as compared with normal gastric biopsy
specimen detected by quantitative real-time PCR. Eur J Gastroenterol Hepatol 2008;20:305–13.
42 Liu H, Rahman A, Semino-Mora C, Doi SQ, Dubois A. Specific
and sensitive detection of H. pylori in biological specimens by
real-time RT-PCR and in situ hybridization. PLoS ONE
2008;3:e2689.
14
Monteiro et al.
43 Iriz E, Cirak M, Engin E, Zor M, Erer D, Ozdogan M, et al.
Detection of Helicobacter pylori DNA in aortic and left internal
mammary artery biopsies. Tex Heart Inst J 2008;35:130–5.
44 Gill P, Alvandi AH, Abdul-Tehrani H, Sadeghizadeh M. Colorimetric detection of Helicobacter pylori DNA using isothermal helicase-dependent amplification and gold nanoparticle probes.
Diagn Microbiol Infect Dis 2008;62:119–24.
45 Sugimoto M, Wu JY, Abudayyeh S, Hoffman J, Brahem H, AlKhatib K, et al. Unreliability of results of PCR detection of Helicobacter pylori in clinical or environmental samples. J Clin Microbiol 2009;47:738–42.
46 Ryberg A, Borch K, Sun YQ, Monstein HJ. Concurrent genotyping of Helicobacter pylori virulence genes and human cytokine SNP sites using whole genome amplified DNA derived
from minute amounts of gastric biopsy specimen DNA. BMC
Microbiol 2008;8:175.
47 Puz S, Innerhofer A, Ramharter M, Haefner M, Hirschl AM,
Kovach Z, et al. A novel noninvasive genotyping method of
Helicobacter pylori using stool specimens. Gastroenterology
2008;135:1543–51.
48 Sicinschi LA, Correa P, Peek RM Jr, Camargo MC, Delgado A,
Piazuelo MB, et al. Helicobacter pylori genotyping and sequencing using paraffin-embedded biopsies from residents of colombian areas with contrasting gastric cancer risks.Helicobacter
2008;13:135–45.
49 Kanada R, Uchida T, Tsukamoto Y, Nguyen L, Hijiya N, Matsuura K, et al. Genotyping of the cagA gene of Helicobacter pylori
on immunohistochemistry with East Asian CagA-specific antibody. Pathol Int 2008;58:218–25.
50 Burucoa C, Garnier M, Silvain C, Fauchere JL. Quadruplex
real-time PCR assay using allele-specific scorpion primers for
detection of mutations conferring clarithromycin resistance to
Helicobacter pylori. J Clin Microbiol 2008;46:2320–6.
51 Tajbakhsh S, Samarbaf-Zadeh AR, Moosavian M. Comparison
of fluorescent in situ hybridization and histological method for
the diagnosis of Helicobacter pylori in gastric biopsy samples. Med
Sci Monit 2008;14:BR183–7.
52 Caristo E, Parola A, Rapa A, Vivenza D, Raselli B, Dondi E,
et al. Clarithromycin resistance of Helicobacter pylori strains isolated from children’ gastric antrum and fundus as assessed by
fluorescent in-situ hybridization and culture on four-sector agar
plates. Helicobacter 2008;13:557–63.
53 Woo HY, Park DI, Park H, Kim MK, Kim DH, Kim IS, et al.
Dual-priming oligonucleotide-based multiplex PCR for the
detection of Helicobacter pylori and determination of clarithromycin resistance with gastric biopsy specimens. Helicobacter
2009;14:22–28.
54 Kawai T, Yamagishi T, Yagi K, Kataoka M, Kawakami K, Sofuni
A, et al. Tailored eradication therapy based on fecal Helicobacter
pylori clarithromycin sensitivities. J Gastroenterol Hepatol
2008;23(Suppl. 2):S171–4.
55 Chisholm S, Owen R. Application of polymerase chain reaction-based assays for rapid identification and antibiotic resistance screening of Helicobacter pylori in gastric biopsies. Diagn
Microbiol Infect Dis 2008;61:67–71.
56 Calabrese C, Pisi A, Di Febo G, Liguori G, Filippini G, Cervellera M, et al. Biochemical alterations from normal mucosa to
gastric cancer by ex vivo magnetic resonance spectroscopy.
Cancer Epidemiol Biomarkers Prev 2008;17:1386–95.
57 Gao XX, Ge HM, Zheng WF, Tan RX. NMR-based metabonomics for detection of Helicobacter pylori infection in gerbils: which
is more descriptive. Helicobacter 2008;13:103–11.
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 8–14
Helicobacter ISSN 1523-5378
Pathogenesis of Helicobacter pylori Infection
Ana C. Costa,*, Ceu Figueiredo*, and Eliette Touatià
*IPATIMUP - Institute of Molecular Pathology and Immunology of the University of Porto, Porto, Portugal, Medical Faculty of the University of
Porto, Porto, Portugal, àUnité de Pathogenèse de Helicobacter, Institut Pasteur, Paris, France
Keywords
Host cell adherence, colonization, VacA,
CagA, signaling, carcinogenesis, antimicrobial
response.
Reprint requests to: Eliette Touati, Unité de
Pathogenèse de Helicobacter, Institut Pasteur,
28 Rue du Doct Roux, 75015 Paris, France.
E-mail: etouati@pasteur.fr
Abstract
Helicobacter pylori induces chronic inflammation of the gastric mucosa, but
only a proportion of infected individuals develop peptic ulcer disease or gastric carcinoma. Reasons underlying these observations include differences in
bacterial pathogenicity as well as in host susceptibility. Numerous studies
published in the last year provided new insight into H. pylori virulence factors, their interaction with the host and consequences in pathogenesis.
These include the role of bacterial genetic diversity in host colonization and
persistence, outer membrane proteins and modulation of adhesin expression, new aspects of VacA functions, and CagA and its phosphorylationdependent and -independent cellular effects. This article will also review the
recent novel findings on the interactions of H. pylori with diverse host epithelial signaling pathways and events involved in the initiation of carcinogenesis, including genetic instability and dysregulation of DNA repair.
Helicobacter pylori Virulence Factors
Helicobacter pylori Genetic Diversity and Host
Colonization
Helicobacter pylori is characterized by a high level of
genetic diversity which can be important for the adaptation to the host stomach and for the clinical outcome
of the infection. Differences in gene content among H.
pylori isolates in Mexican patients with various gastric
pathologies, including cancer, showed patterns of disease-associated genes [1].
The plasticity of the H. pylori genome derives from its
natural competence for transformation by exogenous
DNA, from recombination and from mutations. These
properties are at the origin of an extensive allelic diversity occurring even in a single host. Insertion of chromosomal DNA fragments of 1300 bp length into the
recipient chromosome, associated with active genetic
recombination, was demonstrated [2]. During homologous recombination, Holliday junctions generated by
the RecG and RuvAB helicases are resolved by RuvC.
The RecG homolog of H. pylori is devoid of resolvase
activity and provides an anti-repair pathway [3]. It was
suggested that competition between repair and antirepair pathways may provide a mechanism to generate
strain diversity and to maximize fitness at the bacterial
population level [3]. After natural transformation of
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 15–20
H. pylori, the import of short DNA fragments (1294 to
3853 bp) interrupted by interspersed sequences of the
recipient (ISR) (mean length of 82 bp) was shown to
result in the formation of complex mosaic alleles [4].
The control of import length and initiation of the ISR
formation was dependent on the DNA glycosylase
MutY, a component of the base excision repair (BER)
pathway.
In vivo, H. pylori is exposed to acidity and oxidative
stress, causing bacterial DNA damage. AddAB have both
nuclease and helicase activities similar to RecBCD.
AddA (HP1553) confers resistance to oxidative stressinduced DNA damage. addA mutants display a significantly reduced DNA recombination frequency. In mice,
AddAB and RecA are required for stomach colonization
[5]. Their role in bacterial adherence is associated with
gene conversion-like events, a mechanism selected in
the host that abolishes BabA-dependent adherence [6].
These data are in support of DNA repair and recombination as essential H. pylori mechanisms to optimize
bacterial adherence to mucosal epithelium and persistent colonization.
Outer Membrane Proteins and Adherence
The H. pylori genome contains about 30 hop gene paralogous encoding outer membrane proteins (OMP).
Mutations in hopQ increased adherence of H. pylori to
15
Costa et al.
H. Pylori Pathogenesis
AGS gastric epithelial cells, CagA translocation into host
cells and cellular alterations, demonstrating the importance of HopQ for bacterial adherence [7]. The hopQ
type I genotype was associated with higher atrophy
scores than the type II genotype and was proposed as a
marker for gastroduodenal diseases [8].
Expression of adhesins might be modulated by
genetic changes. Phase variation via slipped-strand
mispairing in repetitive nucleotide tracts modulate sabA
expression. Goodwin et al. [9] reported that sabA alleles
of multiple length in the polyT and CT repeat tracts
near the sabAB 5¢ end, are found in 25% of clones of
strain 26695. This was also confirmed among multiple
H. pylori isolates from a single patient [9]. This mechanism occurring during chromosomal replication suggests a selective pressure for SabA expression in the
host, allowing bacteria to adapt but also to escape host
immune response. In the same study, transcription of
sabA was repressed by the acid-responsive ArsRS twocomponent signal transduction (TCST) system in vitro
[9]. BabA and SabA bind to the Lewis B (Leb) and to
glycosphingolipids displaying a sialyl-dimeric Lewis X
(sialyl-Lex) respectively. In young mice with early
acquisition of H. pylori infection, a higher sialyl-Lex was
correlated with persistence of stomach colonization
[10]. A cag pathogenicity island (PAI)-dependent overexpression of a GlcNAc transferase (b3GnT5) was
described in gastric carcinoma cell lines and associated
with high H. pylori adherence [11].
Four binding modes for the H. pylori–mucin interaction are likely to play roles in various niches along the
orogastric infection route and vary according to pH,
gastritis status and bacterial strain [12]. Glycoprotein
receptors within the human salivary proteome for the
carbohydrate-binding H. pylori adhesins have been also
identified [13]. Binding of H. pylori to salivary mucin
MUC7 and agglutinin gp340 depended exclusively on
SabA and BabA, respectively. Binding to MUC5B was
mainly due to BabA. SabA was also found to bind the
secretory component of the polymeric Ig receptor (SC)
and Iga-chain (S-IgA-Hc). These interactions can modulate surface or adhesive properties of the bacteria along
the digestive tract. In gastric precancerous lesions and
in gastric carcinoma, the expression of MUC5AC and
MUC6 is altered. Using the Rhesus macaque model,
Cooke et al. investigated the effects on gastric mucins
of experimental challenge with H. pylori during acute
and chronic infection [14]. H. pylori induced gastritis
with an acute and high transient decrease in diversity
and low relative abundance of O-linked mucin oligosaccharides, suggesting that bacteria modulate gastric
mucin glycoproteins during acute infection to promote
colonization and persistent infection.
16
Trefoil factors are involved in repair of the gastrointestinal mucosa. MUC5AC is coexpressed with trefoil
factor family (TFF)1, a member of small cysteine-rich
proteins. Reeves et al. [15] showed binding of the coreoligosaccharide portion (rough form) of H. pylori lipopolysaccharide (RF-LPS) to TFF1, at an optimum pH of
5–6. An increase in pH would cause inappropriate binding of bacteria close to the lumen, leading to removal
by mucus turnover. In patients with active chronic gastritis, a reduced expression of TFF2 was observed, especially in those patients infected with CagA-positive
strains. Authors propose that this reduction in expression could contribute to the damage induced to the gastric mucosa by H. pylori [16].
The Cytotoxin VacA
VacA is an important virulence factor in the pathogenesis of peptic ulceration and gastric cancer. This toxin
can induce multiple cellular activities, including cell
vacuolation, membrane channel formation, disruption
of endosomal ⁄ lysosomal function, apoptosis, and immunomodulation. The mature monomeric form of VacA
has 2 domains - p55 and p33 - important for its cellular
activity. Ivie et al. [17] showed that the N-terminal of
p55 is essential for VacA-induced vacuolation and for
host cell membrane depolarization. This domain is
important for the formation of VacA oligomeric structures, suggesting its role in the formation of anionic
membrane channels. Further insight into the final steps
of vacuole formation by VacA was provided by Mashima et al. [18], by demonstrating that the vesicle
associated membrane protein 7 (VAMP7) is a partner of
Q-SNARE syntaxin 7 in the process of lysosome–endosome fusion.
At the nucleotide level, the vacA intermediate (i)region, which encodes part of the p33 VacA subunit,
displays sequence variation. i1-type strains were associated with gastric carcinoma in an Iranian population
[19], and were an independent predictor of peptic ulcer
disease in an Italian population [20].
In addition to the previously described protein tyrosine phosphatase receptor (RPTP)-a and RPTP-b, Gupta
et al. [21] identified sphingomyelin (SM) as a host cell
receptor for VacA. SM was essential for VacA association with the cell membrane and for toxin-induced vacuolation. VacA binding to specialized membrane
functional domains may have a biological meaning in
cell signaling.
Tegtmeyer et al. [22] showed that VacA can inhibit
some CagA-induced responses on epithelial cells. VacA
inhibited the activation of epidermal growth factor
receptor (EGFR) and HER2 ⁄ Neu, and subsequently
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl.1): 15–20
Costa et al.
Erk1 ⁄ 2 MAP kinase, which are important for cell scattering and elongation. These results are also in agreement with previous findings suggesting that VacA and
CagA downregulate each other’s effects on epithelial
cells, potentially allowing H. pylori interaction with cells
whilst avoiding excessive cellular damage [23].
A novel mechanism underlying H. pylori-induced
inhibition of acid secretion by parietal cells was proposed by Wang et al. [24]. They showed that VacA
interaction with parietal cells promotes calpain-mediated proteolysis of ezrin, disrupting the apical membrane-cytoskeletal interactions and inhibiting gastric
acid secretion, mimicking the hypochlorhydric phenotype observed in H. pylori-infected patients.
Tuo et al. [25] demonstrated that VacA inhibits prostaglandin E2-stimulated duodenal mucosal bicarbonate
secretion by stimulating the release of mucosal histamine. These findings may have pathophysiologic relevance since the inhibitory effect of VacA on
bicarbonate secretion may impair duodenal mucosal
defense against acid injury, contributing to ulcer
development.
The cag Pathogenicity Island and CagA
The cagPAI is a genomic region of 40 Kb containing
about 30 genes encoding a type IV secretion system
(T4SS). To gain more insight into the role of the T4SS
on the outcome of gastric disease, Wiedemann et al.
used the Mongolian gerbil model in a long-term infection experiment (2–64 weeks) [26]. Authors showed
that the T4SS is essential for the induction of an early
and severe corpus inflammation, associated with
increased expression of proinflammatory cytokines and
histopathologic changes such as atrophic gastritis and
metaplasia. At late time points, only animals infected
with T4SS-competent bacteria developed hypochlorhydria and hypergastrinemia in parallel to gastric ulcers
and focal dysplasia. Although gastric adenocarcinoma
was not detected in any of the infected animals, they
show that the Mongolian gerbil model parallels the
multistep process of gastric carcinogenesis that occurs in
humans.
The cagPAI-encoded factor CagD was investigated and
its crystal structure was determined [27]. In contradiction with previous findings [28], CagD was identified as
an essential component of the T4SS that is required for
CagA translocation into host epithelial cells, although
not absolutely necessary for pilus assembly.
CagA, also encoded by the cagPAI, is translocated into
host epithelial cells by the T4SS. Lai et al. [29] showed
that cholesterol-rich raft microdomains of AGS cells are
crucial for efficient T4SS-mediated CagA translocation
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 15–20
H. Pylori Pathogenesis
and phosphorylation, as well as for subsequent CagAinduced actin rearrangements and IL-8 secretion. These
results suggest that H. pylori is able to exploit host cellular cholesterol in ways additional to those for VacA
intoxication and immune evasion.
CagA EPIYA motifs and CagA PhosphorylationDependent Host Cell Effects
After translocation into the host cells, CagA can be
phosphorylated in tyrosine residues within Glu-Pro-IleTyr-Ala (EPIYA) motifs at the polymorphic C-terminus
of the protein. Argent et al. showed by using H. pylori
strains displaying cagA microevolution [30,31], that
strains with additional copies of the EPIYA-C motif significantly induce more IL-8 secretion in AGS cells after
prolonged infection periods. Sequence data analysis also
revealed that Western strains are more likely to
undergo duplication of the EPIYA-C motif than East
Asian strains undergo duplication of the D motif.
Authors speculate that the highly active East Asian
CagA with one D motif has no requirement to increase
its virulence, whereas the less active Western CagA displays a dynamic capacity to increase its number of C
motifs to become more virulent.
Basso et al. [20] showed that the magnitude of risk
for gastric carcinoma and precursor lesions increases
with increasing numbers of EPIYA-C motifs. In a multivariate model also including vacA genotypes and corpus
H. pylori colonization density, the number of EPIYA-C
motifs was an independent predictor of risk for intestinal metaplasia, reinforcing that the characterization of
the EPIYA region is important in defining disease risk.
During the initial stages of infection, CagA is phosphorylated by host Src kinases and later by Abl kinases.
Phosphorylation-dependent effects of CagA include
induction of actin cytoskeleton rearrangements in the
host cell. Phosphorylated CagA has been reported to
interact with the Src homology 2 (SH2) domains of
Shp-2, Csk and Crk (reviewed in [32]). Further insight
into how CagA can induce actin cytoskeleton rearrangements may arise from the work of Selbach et al.
[33]. They have identified by quantitative proteomics
PI3K, Shp-1, Ras-GAP1, and Grb7 as additional cellular
interaction partners of CagA. Their results also indicate
that an individual tyrosine phosphorylation site of CagA
can interact with different cellular SH2 domains, suggesting that H. pylori can manipulate multiple signaling
pathways in parallel.
Botham et al. [34] used a transgenic Drosophila model
with inducible CagA expression to show CagA’s capacity to function as a receptor tyrosine kinase adaptor.
They demonstrated that CagA can substitute for Gab
17
Costa et al.
H. Pylori Pathogenesis
and restore developmental defects caused by the loss of
the Drosophila Gab, including larval lethality and photoreceptor differentiation. Authors also provided evidence
that CagA functions similarly to Gab since it required
the Drosophila SHP-2 to exert its effect on photoreceptor
development.
CagA Phosphorylation-independent Host Cell
Effects
Unphosphorylated CagA can also elicit host cell
responses such as disruption of tight and adherens
junctions, loss of cell polarity, proinflammatory and
mitogenic responses (reviewed in [32]). CagA binds to
and inhibits PAR1b ⁄ MARK2 kinase activity, thereby
disrupting junctional and epithelial cell polarity in epithelial cells (reviewed in [35]). CagA-PAR1b interaction
is mediated by the CagA multimerization (CM) motif.
Lu et al. [36] showed that the CM motif of East Asian
strains binds PAR1b more strongly than that of Western
CagA, and in Western strains the ability to bind PAR1b
is proportional to the number of CM motifs. It was further demonstrated that the level of CagA-PAR1b binding influences the magnitude of junctional defects.
Another phosphorylation-independent cellular effect
of CagA is activation of the STAT3 signaling pathway.
Bronte-Tinkew et al. [37] showed in the Hep-2 cell line
that H. pylori triggers tyrosine phosphorylation, nuclear
translocation and STAT3 transcriptional activity in a
CagA-dependent manner. In contrast to other bacterial
pathogens that modulate STAT3 via autocrine activation by IL-6, H. pylori-mediated STAT3 activation occurs
at the IL-6R level but is independent of the known activation ligands IL-6, IL-11, and LIF.
Bauer et al. [38] described a new mechanism by
which H. pylori can increase the amount of signaling
molecules on the surface of infected cells. Authors present evidence that upon prolonged infection, H. pylori
increases EGFR surface expression by inhibition of
receptor endocytosis and degradation. This occurs in a
CagA-dependent but CagA phosphorylation-independent activation of c-Abl, which in turn phosphorylates
a specific EGFR target site.
Helicobacter pylori and Epithelial Cell
Signaling Pathways
The phosphatidylinositol 3-kinase ⁄ protein kinase B
(PI3K) ⁄ (Akt) signaling pathway regulates diverse biological processes, including cell proliferation, survival,
and migration. Several studies provided evidence that
H. pylori activates the PI3K-Akt signaling pathway in
epithelial cells [39–44]. In keeping with these
18
observations, in the Mongolian gerbil model of infection hyperphosphorylated Akt was predominantly
expressed in the gastric pit cells of H. pylori-infected
animals [44]. However, discrepancies were found
regarding the involvement of bacterial virulence factors
in H. pylori-induced PI3K-Akt signaling. Differences in
cell line models and in strains can strongly contribute
to these discrepancies.
PI3K activity can be induced by receptor tyrosine
kinases. EGFR activation [39–42], but not c-Met [41],
was found to be involved in H. pylori-mediated PI3KAkt signaling and was shown to be important in cell
survival [39,42], migration [39], and IL-8 production
[40].
It was also demonstrated in cell line models that glycogen synthase kinase 3b (GSK3), a downstream target
of Akt, is phosphorylated and inactivated by H. pylori
[40,41,43,44]. In unstimulated cells, GSK3b phosphorylates b-catenin, targeting it for ubiquitinylation and
degradation. Sokolova et al. [41] showed that by suppressing GSK3b activity, H. pylori leads to inhibition of
b-catenin phosphorylation and ubiquitin-dependent
degradation, and to upregulation of T cell factor ⁄ lymphoid enhancer-binding factor (Tcf ⁄ Lef)-dependent
transcription of cyclin D1. GSK3b suppression through
PI3K-Akt activation by H. pylori may also be involved
in NF-jB activation and IL-8 production [40,44].
Early Events in H. pylori-induced
Carcinogenesis
Carcinogenesis results from accumulation of genetic
changes and dysfunction of cellular mechanisms that
normally maintain genome integrity. Machado et al.
[45] showed a dysregulation of DNA repair with
decrease of mismatch repair components during H.
pylori infection, leading to accumulation of genetic
instability in the gastric epithelium. These mechanisms
include induction of a transient mutator phenotype in
the nuclear genome, microsatellite instability (MSI),
and mutations in mitochondrial DNA. In addition, disruption of the balance between cell proliferation and
apoptosis during H. pylori infection may promote gastric
carcinogenesis. Apurinic ⁄ apyrimidinic endonuclease-1
(APE-1) regulates the transcriptional activity of p53.
Bhattacharyya et al. [46] reported an H. pylori-mediated
acetylation of APE-1 that suppressed Bax expression
and prevented p53-mediated apoptosis, with potential
consequences for gastric carcinoma development. These
studies highlight the role of H. pylori in the induction of
genetic instabilities and impairment of DNA repair systems important for promoting the gastric carcinogenic
process.
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl.1): 15–20
Costa et al.
H. Pylori Pathogenesis
Antimicrobial Host Response
The Rhesus macaque model of H. pylori infection displays lesions similar to those found in humans. In this
model, a cagPAI-dependent increase in mucosal inflammation, with an increased expression of antimicrobial
molecules related to b-defensin-2 (BD2) and several
additional innate host defense proteins that may be
important for disease pathogenesis was reported [47].
Human b-defensin-4 (hBD-4) is frequently expressed in
the gastric mucosa with the highest levels detected in
cagA positive H. pylori gastritis [48]. Its induction is
dependent on the activation of the p38 MAP kinase
pathway. These studies demonstrated that H. pylori
induces a differential expression of antimicrobial peptides, which are essential effectors of the innate
immune response with functional relevance in host
defense. These antimicrobial proteins may be less active
against H. pylori than against other microorganisms,
resulting in a modification of the gastric microbiota
composition during host infection [47]. Dicksved et al.
characterized the gastric microbiota of patients with
gastric carcinoma, and demonstrated that it was dominated by different microbial species with a relative low
abundance of H. pylori [49]. Pathogenesis of H. pylori
infection can be also modulated by lower bowel Helicobacters, as suggested by mice experiments showing
an attenuation of the H. pylori-induced gastric proinflammatory lesions in a coinfection with Helicobacter
bilis [50].
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Conflicts of Interest
The authors have declared no conflicts of interest.
References
1 Romo-Gonzalez C, Salama NR, Burgeno-Ferreira J, et al.
Differences in genome content among Helicobacter pylori isolates
from patients with gastritis, duodenal ulcer, or gastric cancer
reveal novel disease-associated genes. Infect Immun
2009;77:2201–11.
2 Lin EA, Zhang XS, Levine SM, et al. Natural transformation of
Helicobacter pylori involves the integration of short DNA fragments interrupted by gaps of variable size. PLoS Pathog
2009;5:e1000337.
3 Kang J, Blaser MJ. Repair and antirepair DNA helicases in Helicobacter pylori. J Bacteriol 2008;190:4218–24.
4 Kulick S, Moccia C, Didelot X, et al. Mosaic DNA imports with
interspersions of recipient sequence after natural transformation of Helicobacter pylori. PLoS ONE 2008;3:e3797.
5 Wang G, Maier RJ. A RecB-like helicase in Helicobacter pylori is
important for DNA repair and host colonization. Infect Immun
2009;77:286–91.
6 Amundsen SK, Fero J, Hansen LM, et al. Helicobacter pylori
AddAB helicase-nuclease and RecA promote recombination-
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 15–20
17
18
19
20
21
22
related DNA repair and survival during stomach colonization.
Mol Microbiol 2008;69:994–1007.
Loh JT, Torres VJ, Algood HM, et al. Helicobacter pylori HopQ
outer membrane protein attenuates bacterial adherence to
gastric epithelial cells. FEMS Microbiol Lett 2008;289:53–8.
Ohno T, Sugimoto M, Nagashima A, et al. Relationship
between Helicobacter pylori hopQ genotype and clinical outcome
in Asian and Western populations. J Gastroenterol Hepatol
2009;24:462–8.
Goodwin AC, Weinberger DM, Ford CB, et al. Expression of
the Helicobacter pylori adhesin SabA is controlled via phase variation and the ArsRS signal transduction system. Microbiology
2008;154:2231–40.
Yang YJ, Yang HB, Wu JJ, Sheu BS. Persistent H. pylori colonization in early acquisition age of mice related with higher gastric sialylated Lewis x, IL-10, but lower interferon-gamma
expressions. J Biomed Sci 2008;16:34.
Marcos NT, Magalhaes A, Ferreira B, et al. Helicobacter pylori
induces beta3GnT5 in human gastric cell lines, modulating
expression of the SabA ligand sialyl-Lewis x. J Clin Invest
2008;118:2325–36.
Linden SK, Wickstrom C, Lindell G, et al. Four modes of adhesion are used during Helicobacter pylori binding to human mucins in the oral and gastric niches. Helicobacter 2008;13:81–93.
Walz A, Odenbreit S, Stühler K, et al. Identification of glycoprotein receptors within the human salivary proteome for the
lectin-like BabA and SabA adhesins of Helicobacter pylori by
fluorescence-based 2-D bacterial overlay. Proteomics 2009;9:
1582–92.
Cooke CL, An HJ, Kim J, et al. Modification of gastric mucin
oligosaccharide expression in rhesus macaques after infection
with Helicobacter pylori. Gastroenterology 2009. doi10.1053/
j.gastro.2009.04.014
Reeves EP, Ali T, Leonard P, et al. Helicobacter pylori lipopolysaccharide interacts with TFF1 in a pH-dependent manner. Gastroenterology 2008;135:2043–54. 54 e1–2.
Michelis R, Sela S, Sbeit W, et al. Decreased TFF2 expression in
the gastric antrum in patients infected with CagA-positive Helicobacter pylori. Isr Med Assoc J 2009;11:11–5.
Ivie SE, McClain MS, Torres VJ, et al. Helicobacter pylori VacA
subdomain required for intracellular toxin activity and assembly of functional oligomeric complexes. Infect Immun
2008;76:2843–51.
Mashima H, Suzuki J, Hirayama T, et al. Involvement of vesicle-associated membrane protein 7 in human gastric epithelial
cell vacuolation induced by Helicobacter pylori-produced VacA.
Infect Immun 2008;76:2296–303.
Hussein NR, Mohammadi M, Talebkhan Y, et al. Differences in
virulence markers between Helicobacter pylori strains from Iraq
and those from Iran: potential importance of regional differences in H. pylori-associated disease. J Clin Microbiol
2008;46:1774–9.
Basso D, Zambon CF, Letley DP, et al. Clinical relevance of Helicobacter pylori cagA and vacA gene polymorphisms. Gastroenterology 2008;135:91–9.
Gupta VR, Patel HK, Kostolansky SS, et al. Sphingomyelin
functions as a novel receptor for Helicobacter pylori VacA. PLoS
Pathog 2008;4:e1000073.
Tegtmeyer N, Zabler D, Schmidt D, et al. Importance of EGF
receptor, HER2 ⁄ Neu and Erk1 ⁄ 2 kinase signalling for host cell
elongation and scattering induced by the Helicobacter pylori
CagA protein: antagonistic effects of the vacuolating cytotoxin
VacA. Cell Microbiol 2009;11:488–505.
19
H. Pylori Pathogenesis
23 Argent RH, Thomas RJ, Letley DP, et al. Functional association
between the Helicobacter pylori virulence factors VacA and CagA.
J Med Microbiol 2008;57:145–50.
24 Wang F, Xia P, Wu F, et al. Helicobacter pylori VacA disrupts apical membrane-cytoskeletal interactions in gastric parietal cells.
J Biol Chem 2008;283:26714–25.
25 Tuo B, Song P, Wen G, et al. Helicobacter pylori vacuolating cytotoxin inhibits duodenal bicarbonate secretion by a histaminedependent mechanism in mice. J Infect Dis 2009;199:505–12.
26 Wiedemann T, Loell E, Mueller S, et al. Helicobacter pylori
cag-Pathogenicity island-dependent early immunological
response triggers later precancerous gastric changes in Mongolian gerbils. PLoS ONE 2009;4:e4754.
27 Cendron L, Couturier M, Angelini A, et al. The Helicobacter
pylori CagD (HP0545, Cag24) protein is essential for CagA
translocation and maximal induction of interleukin-8 secretion.
J Mol Biol 2009;386:204–17.
28 Fischer W, Puls J, Buhrdorf R, et al. Systematic mutagenesis of
the Helicobacter pylori cag pathogenicity island: essential genes
for CagA translocation in host cells and induction of interleukin-8. Mol Microbiol 2001;42:1337–48.
29 Lai CH, Chang YC, Du SY, et al. Cholesterol depletion reduces
Helicobacter pylori CagA translocation and CagA-induced
responses in AGS cells. Infect Immun 2008;76:3293–303.
30 Argent RH, Hale JL, El-Omar EM, Atherton JC. Differences in
Helicobacter pylori CagA tyrosine phosphorylation motif patterns
between western and East Asian strains, and influences on
interleukin-8 secretion. J Med Microbiol 2008;57:1062–7.
31 Argent RH, Thomas RJ, Aviles-Jimenez F, et al. Toxigenic Helicobacter pylori infection precedes gastric hypochlorhydria in cancer relatives, and H. pylori virulence evolves in these families.
Clin Cancer Res 2008;14:2227–35.
32 Backert S, Selbach M. Role of type IV secretion in Helicobacter
pylori pathogenesis. Cell Microbiol 2008;10:1573–81.
33 Selbach M, Paul FE, Brandt S, et al. Host cell interactome of
tyrosine-phosphorylated bacterial proteins. Cell Host Microbe
2009;5:397–403.
34 Botham CM, Wandler AM, Guillemin K. A transgenic Drosophila model demonstrates that the Helicobacter pylori CagA protein
functions as a eukaryotic Gab adaptor. PLoS Pathog
2008;4:e1000064.
35 Hatakeyama M. Linking epithelial polarity and carcinogenesis
by multitasking Helicobacter pylori virulence factor CagA. Oncogene 2008;27:7047–54.
36 Lu HS, Saito Y, Umeda M, et al. Structural and functional
diversity in the PAR1b ⁄ MARK2-binding region of Helicobacter
pylori CagA. Cancer Sci 2008;99:2004–11.
20
Costa et al.
37 Bronte-Tinkew DM, Terebiznik M, Franco A, et al. Helicobacter
pylori cytotoxin-associated gene A activates the signal transducer and activator of transcription 3 pathway in vitro and in
vivo. Cancer Res 2009;69:632–9.
38 Bauer B, Bartfeld S, Meyer TF. H. pylori selectively blocks EGFR
endocytosis via the non-receptor kinase c-Abl and CagA. Cell
Microbiol 2009;11:156–69.
39 Nagy TA, Frey MR, Yan F, et al. Helicobacter pylori regulates cellular migration and apoptosis by activation of phosphatidylinositol 3-kinase signaling. J Infect Dis 2009;199:641–51.
40 Tabassam FH, Graham DY, Yamaoka Y. Helicobacter pylori activate epidermal growth factor receptor- and phosphatidylinositol
3-OH kinase-dependent Akt and glycogen synthase kinase
3beta phosphorylation. Cell Microbiol 2009;11:70–82.
41 Sokolova O, Bozko PM, Naumann M. Helicobacter pylori suppresses glycogen synthase kinase 3beta to promote beta-catenin
activity. J Biol Chem 2008;283:29367–74.
42 Yan F, Cao H, Chaturvedi R, et al. Epidermal growth factor
receptor activation protects gastric epithelial cells from Helicobacter pylori-induced apoptosis. Gastroenterology 2009;136:1297–
307. e1–3.
43 Nakayama M, Hisatsune J, Yamasaki E, et al. Helicobacter pylori
VacA-induced inhibition of GSK3 through the PI3K ⁄ Akt signaling pathway. J Biol Chem 2009;284:1612–9.
44 Suzuki M, Mimuro H, Kiga K, et al. Helicobacter pylori CagA
phosphorylation-independent function in epithelial proliferation and inflammation. Cell Host Microbe 2009;5:23–34.
45 Machado AM, Figueiredo C, Touati E, et al. Helicobacter pylori
infection induces genetic instability of nuclear and mitochondrial DNA in gastric cells. Clin Cancer Res 2009;15:2995–3002.
46 Bhattacharyya A, Chattopadhyay R, Burnette BR, et al. Acetylation of apurinic ⁄ apyrimidinic endonuclease-1 regulates
Helicobacter pylori-mediated gastric epithelial cell apoptosis.
Gastroenterology 2009;136:2258–69.
47 Hornsby MJ, Huff JL, Kays RJ, et al. Helicobacter pylori induces
an antimicrobial response in rhesus macaques in a cag pathogenicity island-dependent manner. Gastroenterology
2008;134:1049–57.
48 Otte JM, Neumann HM, Brand S, et al. Expression of betadefensin 4 is increased in human gastritis. Eur J Clin Invest
2009;39:126–38.
49 Dicksved J, Lindberg M, Rosenquist M, et al. Molecular characterization of the stomach microbiota in patients with gastric
cancer and in controls. J Med Microbiol 2009;58:509–16.
50 Lemke LB, Ge Z, Whary MT, et al. Concurrent Helicobacter bilis
infection in C57BL ⁄ 6 mice attenuates proinflammatory H.
pylori-induced gastric pathology. Infect Immun 2009;77:2147–58.
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl.1): 15–20
Helicobacter ISSN 1523-5378
Inflammation, Immunity, and Vaccines for Helicobacter pylori
Mario M. D’Elios*, and Leif P. Andersenà
*Department of Internal Medicine, University of Florence, Florence, Italy, Department of Biomedicine, Azienda Ospedaliera Universitaria Careggi,
Florence, Italy, àDepartment of Infection Control 9101, Copenhagen University Hospital, Righospitalet, Copenhagen, Denmark
Keywords
Mucosal immunity, Th1, Th2, Th17, cytokine,
regulatory lymphocyte, chemokine, VacA,
CagA, HP-NAP, vaccine.
Reprint requests to: Mario M. D’Elios,
Department of Internal Medicine, Viale
Morgagni 85, 50134 Florence, Italy.
E-mail: delios@unifi.it
Abstract
Helicobacter pylori infects almost half of the population worldwide and represents the major cause of gastroduodenal diseases, such as duodenal and gastric ulcer, gastric adenocarcinoma, autoimmune gastritis, and B-cell
lymphoma of mucosa-associated lymphoid tissue. Helicobacter pylori induces
the activation of a complex and fascinating cytokine and chemokine network in the gastric mucosa. Different bacterial and environmental factors,
other concomitant infections, and host genetics may influence the balance
between mucosal tolerance and inflammation in the course of H. pylori
infection. An inverse association between H. pylori prevalence and the frequencies of asthma and allergies was demonstrated, and the neutrophil activating protein of H. pylori was shown to inhibit the allergic inflammation of
bronchial asthma. During the last year, significant progress was made on the
road to the first efficient vaccine for H. pylori that will represent a novel and
very important bullet against both infection and gastric cancer.
Helicobacter pylori infects the stomach of more than 50%
of the human population and represents the major
cause of gastroduodenal pathologies, such as duodenal
and gastric ulcer, gastric adenocarcinoma, B-cell lymphoma of mucosa-associated lymphoid tissue (MALT),
and autoimmune gastritis. As in any infectious disease,
the type of innate and specific immunity elicited is of
crucial importance for protection, although an inappropriate response may contribute to the induction of
immunopathology. This article will focus on the major
findings on the host response and vaccines against H.
pylori published over the past year.
Natural Immunity
Helicobacter pylori activates a wide spectrum of innate
events resulting in a strong T helper (Th) 1 response.
Mucosal natural defense against H. pylori infection
depends on activation of both Toll-like receptors (TLR)
and Nod-like receptors (NLR), which lead to the generation of Th1 response specific for H. pylori. Different
components of H. pylori are able to activate innate
immune cells. The neutrophil activating protein of
H. pylori (HP-NAP) is a key factor in H. pylori TLR activation. HP-NAP induces interleukin (IL)-12 and IL-23
secretion in monocytes, dendritic cells, and neutrophils
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 21–28
via activation of TLR2 [1]. Helicobacter pylori factors
other than HP-NAP, such as the vacuolating cytotoxin
A (VacA), the cag pathogenicity island (PAI), and the
heat shock protein (HSP) 90 may contribute to the
expression of IL-12p40 and to Th1 polarized response
[2]. In particular H. pylori peptidoglycan, acting in concert with the bacterial type IV ‘‘syringe’’, encoded by
the cag PAI, plays an important role in activation of the
cytoplasmic nucleotide-binding oligomerization domain
(NOD) 1 in gastric epithelial cells and primes Th1
responses [3,4]. Another source of IL-12 might be natural killer cells, which can be elicited by H. pylori in
infected patients [5]. Following H. pylori infection,
gastric epithelial cells and monocytes produce other
Th1-inducing cytokines such as IL-18. IL-18 levels in
infected gastric mucosa correlated with the severity of
gastric inflammation both in adults and children [6,7].
Different bacterial virulence factors, such as cag PAI and
outer inflammatory protein (Oip) A, contribute to the
induction of IL-18 production in gastric epithelial cells.
In both gastric epithelial cells and monocytes ⁄ macrophages, H. pylori regulates the extracellular signalregulated kinase ⁄ c-Jun-N-terminal kinase (JNK)-AP-1
pathway. Upregulation of IL-18 mRNA in monocytes is
independent of cag PAI and OipA, whereas OipA and its
related p38 pathway regulate IL-18 protein induction at
21
Immunity and Vaccines for H. pylori
the post-transcriptional level in a cag-independent way,
and contribute to gastric injury [6]. Helicobacter pyloriinfected patients with IL-18-607C ⁄ C and -137G ⁄ G
genotypes have been shown to have higher IL-18 levels
and severe gastric inflammation [8]. In a very elegant
study in C57BL ⁄ 6 mice, Kaparakis et al. demonstrated
that transient elimination of macrophages during the
early period of H. pylori SS1 infection reduced the gastric pathology, suggesting that macrophages contribute
to the severity of gastric inflammation [9].
Neutrophil activation and mucosal IL-8 expression
are associated with persistent infection. A new triggering receptor expressed on myeloid cells-1 (TREM-1) has
been described on gastric epithelium and experimental
data suggest that TREM-1 expression on gastric epithelial cells amplifies inflammation of the underlying gastric mucosa by upregulation of IL-8 [10]. A novel
putative H. pylori outer membrane protein (HomB)
associated with peptic ulcer disease has been extensively investigated. HomB induces the secretion of IL-8
by gastric epithelial cells, and H. pylori homB knockout
mutant strains present reduced ability to bind to gastric
epithelial cells and to induce IL-8 secretion, implying
that HomB represents a novel virulence factor of H.
pylori actively involved in H. pylori-induced inflammation [11]. Individuals with lower neutrophil oxidative
burst activity might be more prone to H. pylori infection, due to reduced efficiency of neutrophil immune
functions [12]. Moreover, in a different experimental
setting, HP-NAP confirmed its ability to induce myeloperoxidase release from human neutrophils [13]. Furthermore, it has been shown that Helicobacter pullorum,
an entero-hepatic Helicobacter species of avian origin
detected in patients with acute diarrhea and inflammatory bowel disease, exerts a direct effect on human gastric (AGS) and intestinal (CaCo-2 and HT-29) cell lines,
by inducing IL-8 production. The H. pullorum-induced
IL-8 secretion requires bacterial adherence and lipopolysaccharides (LPS) and is mediated by nuclear factor
(NF)-jB signaling, suggesting that H. pullorum might
play a putative role in acute and chronic digestive diseases such as inflammatory bowel disease [14].
Helicobacter pylori LPS, another important bacterial
factor that modulates the innate immune response, has
been extensively studied for its pro-inflammatory activity. LPS has evolved differently in H. pylori communities
through genetic modifications in fucosyltransferases
that are involved in Lewis (Le) antigen expression.
Some of the LPS variants facilitate adaptation and survival in the individual gastric mucosa [15]. Furthermore, Le antigen expression and fucosylation can have
multiple biological effects, by affecting the development
of innate and acquired responses that develop after
22
D’Elios and Andersen
infection, implying that the fucosylated secretor ABH
antigens constitute a family of interactive members of
the mucosal human innate system that tightly regulates
host–bacterial interactions [16]. The host iron status
may affect the nature of LPS expressed by H. pylori, by
modifications in outer membrane vesicles [17]. Evidence suggests that long-term H. pylori infection can
induce antibodies that cross-react with the gastric
mucosa and that, in concert with H+K+-ATPase-specific
autoreactive and cross-reactive T cells, contribute to the
development of gastric autoimmunity and to mucosal
atrophy [18,19]. The LPS may decrease H. pylori elimination from the gastric mucosa and promote infection
persistence, by exerting an anti-phagocytic activity that
is reduced by LPS-binding protein [20]. Helicobacter
pylori proteins, such as VacA, may exert either inhibition or activation on different cell types. VacA exerts
immune suppression by inhibition of antigen processing
and presentation of antigen-presenting cells and by disruption of actin rearrangement and inhibition of calcium mobilization of T cells. VacA has different
receptors on different cell types, such as CD18 on T
cells [21], or sphyngomyelin on epithelial cells [22].
VacA can inhibit duodenal bicarbonate secretion via
prostaglandin E(2) inhibition by a histamine-dependent
mechanism in mice [23]. On the other side VacA
induces IL-8 production in U937 cells via activation of
p38 mitogen-activated protein kinase and intracellular
Ca2+ release, leading to the activation of the transcription factors ATF-2, CREB, and NF-jB [24].
The mechanisms of inflammation induced by CagA
have been further elucidated. Suzuki et al. demonstrated that nonphosphorylated CagA is able to promote
inflammation by sequential activation of PI3kinase ⁄ Akt
signaling that, in turn, leads to b-catenin and NF-jB
activation [25]. The CagA protein is also able to function both as a Grb2-associated binder protein (Gab)
adaptor and to activate the Src-homology 2 domain
containing tyrosine phosphatase (SHP-2) in a transgenic
Drosophila model [26]. Helicobacter pylori induces gastric
inflammation via a Cag-dependent mechanism both in
Rhesus macaques and in gerbils [27,28]. On the other
hand, Cag-independent signaling might lead to b1-integrin activation with JNK activation, which also promotes cell motility of gastric cancer cells [29].
Basu et al. demonstrated that the secreted peptidyl
prolyl cis-, trans-isomerase HP0175 protein was able to
bind to AGS cells by TLR4 and to transactivate EGFR
and vascular endothelial growth factor production [30].
Using the A ⁄ JCr mouse model, Helicobacter hepaticus
urease was shown to contribute to hepatic inflammation although it was not required for intestinal
colonization [31].
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 21–28
D’Elios and Andersen
Adaptive Immunity, Helicobacter, and
Cytokine Network
T-helper cells orchestrate host defense against pathogens via different types of cytokine secretion and effector functions; however, an inappropriate response
might lead to immunopathology. Current evidence suggests that in H. pylori infection, a predominant activation of Th1 cells with production of interferon (IFN)-c,
IL-12, IL-18, and tumor necrosis factor (TNF)-a occurs
in vivo in the gastric mucosa and contributes to tissue
damage [32,33]. Accordingly, Helicobacter infection of
lymphocyte-deficient mice fails to induce gastric inflammation. T-cell transfer into deficient animals then
results in severe gastritis, suggesting that host T-cell
responses to H. pylori play a key role in host damage
[34,35].
The fine balance between protection and pathology
in H. pylori infection is related not only to the major
Th1 cytokines, such as IFN-c, TNF-a, IL-12 [32], but
also to IL-23 (a powerful Th1 and IL-17-promoting factor), IL-17 and IL-21 [1,36,37]. IL-17A mRNA and protein are associated with H. pylori lesional sites from
human gastric biopsies [37,38]. When biopsies were
cultured in vitro and IL-17 activity was blocked, there
was a reduction in IL-8 gene expression implying that
IL-17 might be a relevant factor driving IL-8 production
and neutrophilic inflammation. In both humans and
mice, the upregulation of IL-23 was found in gastric
mucosa following H. pylori infection and was associated
not only with IL-17 but also with the upregulation of
many IFN signature transcripts [39]. IL-23 is present at
high levels in the lesional tissue compared with the surrounding tissue. Blocking IL-23 activity resulted in a
reduction of STAT3 and IL-17 expression [40]. Experimental evidence obtained in a mouse model of H. hepaticus infection suggests that the NF-jB subunit c-Rel
modulates the expression of IL-23 ⁄ IL-12 subunits and
plays an important role in the development of innate
and T-cell mediated inflammation [41].
The type of mucosal lymphocyte responses going on
in the duodenum and in the stomach of H. pyloriinfected patients were investigated in a highly endemic
area of H. pylori infection, i.e. Bangladesh, and compared to Sweden. Comparable amounts of T and B cells
were found in the stomach of Bangladeshi and Swedish
infected patients, but there was a lower systemic antibody response in Bangladeshi patients. However,
increased numbers of B cells and H. pylori-specific IgA
antibodies were detected in the duodenum of Bangladeshi patients, suggesting a more intense inflammation
going on in these patients frequently exposed to enteric
infections [42]. In Swedish infected patients, increased
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 21–28
Immunity and Vaccines for H. pylori
gastric levels of the CCL28 chemokine and CCL28 mediated recruitment of gastric IgA-secreting cells were
found, providing an explanation for the large influx of
IgA-secreting cells to the gastric mucosa in H. pyloriinfected individuals [43]. In a long-term follow-up of
north-eastern European H. pylori-infected patients,
Vorobjova et al. reported that different serological patterns were associated with histological manifestations of
gastritis in the progression towards atrophic gastritis, in
a long-term follow-up. Anti-CagA antibodies were a
sign of gastritis activity and corpus atrophy, the prevalence of anti-canalicular antibodies significantly
increased and paralleled the duration of H. pylori gastritis, whereas anti-HSP60 antibody levels indicated
chronic inflammation of the antrum [44].
Interactions Between H. pylori and
Asthma or Other Infections
Humans are colonized by a multitude of both beneficial
and pathogenic microbial organisms, including H. pylori.
Imbalances in the composition of bacterial microbiota
are postulated to be a major factor in many human disorders [45]. Human and microbial cells continuously
‘‘cross-talk’’ to each other and influence their respective
lives. Over the last century the incidence and severity
of bronchial asthma have drastically increased in developed countries and it has been proposed that infectious
agents can influence the development of allergic disorders, although the underlying reason has not been fully
elucidated. Bronchial asthma and allergic diseases are
sustained by Th2 inflammation and IL-4 production,
which is strongly inhibited by IL-12 and IFN-c, whereas
H. pylori infection elicits a powerful Th1 response [46].
Interestingly, large epidemiological studies recently
demonstrated a consistent negative association between
H. pylori infection and the presence of allergic disorders,
such as asthma and rhinitis, both in childhood and the
adult urban population [47–50]. In allergic asthmatic
patients, the typical Th2 response can be redirected in
vitro toward Th1 by HP-NAP [1]. To address whether
HP-NAP, a TLR2-ligand, could be beneficial in vivo for
the prevention and treatment of bronchial asthma, it
was administered via the intraperitoneal (systemic) or
the intranasal (mucosal) route using a mouse model of
allergic asthma. The in vivo (both mucosal and systemic) administration of HP-NAP prevents the classic
allergic Th2 bronchial inflammation, by a strong inhibition of IL-4, IL-5 and via the increase of IL-12 production. However, no suppression of bronchial Th2
cytokines was observed in TLR2 knockout mice following HP-NAP treatment [46,51]. Altogether these results
provide evidence that HP-NAP might be an important
23
Immunity and Vaccines for H. pylori
part of the molecular and cellular mechanisms underlying the negative association between H. pylori infection
and allergy.
In mouse Trichinella spiralis infection, another model
of Th2-mediated disease, HP-NAP was also able to
enhance an in vivo Th1 response and to exert a powerful anti-Th2 activity, targeting both the IL-5-induced
eosinophilia and the IL-4-mediated hyper-IgE responses
induced by parasitic infection [52]. Different microbial
factors and other concomitant infections may influence
the outcome of H. pylori infection. In a C57BL ⁄ 6 mouse
model of H. pylori infection, treatment with Lactobacillus
casei and Bifidobacterium lactis resulted in a suppressive
effect on Helicobacter-induced inflammation [53].
Accordingly,
Lactobacillus
plantarum,
Lactobacillus
rhamnosus, Lactobacillus lactis and bovine colostral preparation were able to reduce adherence and IL-8 production following H. pylori infection of AGS cells [54].
Regulatory Cells
CD25+ ⁄ Foxp3+ regulatory T cells (Treg) are a subset of
T cells that are physiologically devoted to the maintenance of self tolerance. Treg play a crucial role in regulating the effector immune responses in the different
districts of the organism by suppressing the activation
and proliferation of antigen-specific T cells, and an
abnormal Treg activation might lead to impaired tumor
immunity. Treg are able to suppress T-cell responses,
via both cell contact and by soluble factors, such as TGF
(transforming growth factor)-b and IL-10.
Helicobacter pylori-induced gastritis is associated with a
recruitment of Treg that correlates with the degree of
bacterial colonization and mucosal TGF-b expression
[55]. In a murine model CD4+ CD25+ Treg cells were
able to induce anergy of CD25) T cells in response to H.
pylori infection but were not required to maintain hyporesponsiveness [56].
Robinson et al. investigated the gastric Treg response
of infected patients and demonstrated that in subjects
with peptic ulcer disease, higher levels of IL-10-secreting Treg were present in the gastric mucosa, compared
with those without ulcers. IL-10 inhibited IL-8 expression and activation of NF-jB induced by H. pylori in
gastric epithelial cells, and enhanced H. pylori growth in
a bacterial-cell co-culture model [57]. Accordingly, a
significant increase of IL-10 serum levels was found in
a subset of Turkish infected patients [58].
Furthermore, H. hepaticus infection of mice
co-infected with diarrheagenic Escherichia coli resulted
in an accumulation of Treg cells at mucosal level [59]
resulting in exacerbated morbidity, with delayed recovery from weight loss and tissue damage. Thus, it can be
24
D’Elios and Andersen
speculated that Treg cells play a role in the lifelong persistence of H. pylori infection and that an inadequate
regulatory response may contribute to the immunopathology of H. pylori infection.
Gastric Cancer, Inflammation and Gastric
MALT Lymphoma
Low grade gastric MALT lymphoma represents the first
described neoplasia susceptible to regression following
antibiotic therapy eradicating H. pylori [60]. The neoplastic B-cell proliferation depends both on H. pylori
stimulation and exhaustive T-cell helper activity in conjunction with defective T-cell killing [61,62]. Ferrand
et al. showed that H. pylori strains can inhibit T-cell
proliferation, favoring chronic persistence of the infection and anarchical B-cell proliferation predisposing the
host to gastric MALT lymphoma [63]. Different factors
may affect the onset and progression of gastric MALT
lymphoma. The CXCR3 chemokine receptor is highly
expressed on both activated T and B cells of gastric
MALT lymphoma. Patients with CXCR3 expression
showed a significantly increased risk of nonresponsiveness to H. pylori eradication therapy, regardless of sex,
API2-MALT1 fusion or clinical stage [64]. The overexpression of B-cell-activating factor of the TNF family
(BAFF) was associated with H. pylori-independent
growth of gastric diffuse large B-cell lymphoma,
implying that the BAFF autocrine signal transduction
pathway may contribute to H. pylori independent
growth of gastric MALT lymphoma [65]. Furthermore,
the majority of MALT lymphomas were found to
express class-switched immunoglobulins and to develop
in an environment rich in Th2 cytokines [66].
Helicobacter pylori is a very important oncogenic factor
for gastric adenocarcinoma and many studies have
highlighted the role of chronic inflammation in the
development of gastric cancer [67]. Helicobacter pylori
may lead to gastric cancer via both a direct effect on
epithelial cells and by the induction of different cytokines, especially IL-1b and IL-1 receptor antagonist
(IL-1RN). Overexpression of even a single proinflammatory cytokine is sufficient to induce neoplasia by
eliciting inflammation. The European EPIC-EUROGAST
prospective study confirmed the association of IL-1RN
polymorphisms with the risk of noncardia gastric cancer
and indicated that IL-8-251T>A may modify the risk for
gastric cancer [68]. These results were confirmed by
many reports all over the world. A Turkish study
reported that the bacterial risk factor babA2 seemed to
be an important predictor of gastric malignancies, and
that the presence of the IL-1b-31TT genotype represented an important protective factor [69]. The
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 21–28
D’Elios and Andersen
upregulation of IL-1b, IL-8, and cyclooxygenase (COX)2 linked to gastric carcinogenesis was found in Brazilian
patients [70]. In a Costa Rica dyspeptic population
CagA status was found to be a risk factor for atrophic
antral but not body gastritis whereas the pro-inflammatory cytokine polymorphisms IL-1b +3945 and IL-1RB
were not associated with the atrophic lesions of dyspeptic populations [71]. In a Korean survey study, the
genetic polymorphisms of IL-8, IL-6, and IL-10 were
associated with the development of H. pylori induced
gastroduodenal diseases [72]. TNF-a inducing protein
has been shown to be a novel H. pylori factor able to
induce TNF-a secretion, to enter the nucleus of gastric
epithelial cells and to induce carcinogenesis in a cagindependent way [73]. During H. pylori exposure, the
production of MIF and IL-8 by gastric epithelial cells
leads to the expression and activation of epidermal
growth factor receptor (EGFR) in a cag PAI – independent way [74]. The p53 protein family, including p73
protein, by acting in concert play an important role in
the epithelial and inflammatory response to H. pylori
related to gastric malignancy via induction of apoptosis
and promoting alterations of cell differentiation [75].
Experimental evidence obtained by studying the eosinophil infiltration in gastric infected tissues of patients
originated from areas with different rates of infection
suggested that eosinophils and mast cells might have a
dual role in H. pylori infection: they can downmodulate
gastric inflammation and cancer development in low
risk areas whereas they might promote inflammation
and progression to malignancy of precancerous lesions
in high risk areas [76].
Vaccines
Despite almost 20 years of efforts, no efficacious vaccine
against H. pylori is currently available for humans.
Immunization with different vaccine formulations,
based on the use of selected antigens known to be
involved in the pathogenesis of infection, such as those
containing VacA, CagA, and HP-NAP or urease, have
been shown to prevent experimental infections in animals [77]. BabA and SabA adhesins have also been proposed for an anti-H. pylori vaccine [78]. Although the
efficacy of a vaccine against gastric H. pylori infection
has been shown, little is known about the mechanisms
of bacterial clearance. Not only a specific antibody
response but a concerted action of cellular, molecular,
and humoral responses are needed to give full protection against H. pylori. A vaccine based on H. pylori Sydney strain 1 lysate and cholera toxin (CT) adjuvant has
been used to intranasally immunize mice and the protection achieved was high. The immunization resulted
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 21–28
Immunity and Vaccines for H. pylori
in a strong IFN-c producing T-cell response associated
with an increase in chemokines, such as MIP-2, KC and
LIX, which attract neutrophils to the stomach and are
important for H. pylori eradication [79]. An interesting
study pointed out that dendritic cells play a critical role
in supporting the effector cellular response needed for
the development of a successful H. pylori vaccine [80].
Using a Th1 vaccine consisting of an H. pylori sonicate
plus CpG oligonucleotides and a Th2 vaccine consisting
of an LPS-depleted sonicate combined with CT, Taylor
et al. demonstrated in a mouse model that, although
the CpG sonicate vaccine induced stronger systemic and
local immune responses, only the LPS-depleted sonicate
CT toxin-conjugated vaccine resulted in effective protection [81]. A further mechanism of vaccine-induced
protection is the effector response elicited by the leptin
receptor signaling, that has been elegantly proposed by
Wehzens et al. [82].
In two prospective, randomized, double-blind controlled studies, Salmonella enterica serovar Typhi Ty21abased, oral live vaccines containing H. pylori urease or
HP0231 protein were tested in H. pylori-negative volunteers. Both these vaccine preparations were well tolerated but did not confer satisfactory protection [83].
Over the last year, a very promising study entered
the scene and will presumably lead to the launch of the
first vaccine against H. pylori in humans. Malfertheiner
et al. investigated the safety and immunogenicity of a
vaccine consisting of recombinant VacA, CagA, and
HP-NAP given intramuscularly with an aluminium
hydroxide adjuvant to H. pylori-negative healthy subjects. This very important randomized single-blind
Phase I study involved 57 H. pylori-negative volunteers
and explored three different schedules (0, 1, 2 weeks;
0, 1, 2 months; and 0, 1, 4 months) and two dosages of
each antigen (10 and 25 lg) versus alum controls. All
of the subjects were followed for 5 months and 36 of
them received a booster vaccination 18–24 months after
the end of the first set of vaccination. In both vaccine
and placebo recipients, only very mild adverse reactions
were present on monthly schedule. All of the vaccinees
mounted specific IgG and cellular responses to one or
two antigens and 86% of vaccinated subjects responded
to all three antigens. Both antibody and cellular memory responses could be elicited by vaccination between
18 and 24 months later. The safety and the immunogenicity results obtained in this study suggested that the
intramuscular vaccine formulation consisting of VacA,
CagA and HP-NAP plus aluminium hydroxide adjuvant
represents a very promising candidate vaccine for the
prevention of H. pylori infection [84].
Collectively these findings suggest that achieving a
successful vaccine against H. pylori will have a great
25
Immunity and Vaccines for H. pylori
impact on global health because it will be beneficial not
only for preventing H. pylori infection (a class I oncogenic
factor) but also for the prevention of gastric cancer.
Conflicts of Interest
M.M.D.E. is inventor and applicant of patent
EU05425666.4, WO2007039451 for potential use of
HP-NAP as therapy of cancer, allergic, and infectious
diseases.
Acknowledgements
We thank Copenhagen University Hospital, Ente Cassa
di Risparmio di Firenze, and the Italian Ministry of University and Research, for their support of our studies.
References
1 Amedei A, Cappon A, Codolo G, et al. The neutrophil-activating protein of Helicobacter pylori promotes Th1 immune
responses. J Clin Invest 2006;116:1092–101.
2 Takeshima E, Tomimori K, Teruya H, et al. Helicobacter pyloriinduced interleukin-12 p40 expression. Infect Immun
2009;77:1337–48.
3 Kaparakis M, Philpott DJ, Ferrero RL. Mammalian NLR proteins; discriminating foe from friend. Immunol Cell Biol
2007;85:495–502.
4 Fritz JH, Le Bourhis L, Sellge G, et al. Nod1-mediated innate
immune recognition of peptidoglycan contributes to the onset
of adaptive immunity. Immunity 2007;26:445–59.
5 O’Keefe J, Gately CM, O’Donoghue Y, Zulquernain SA,
Stevens FM, Moran AP. Natural killer cell receptor T-lymphocytes in normal and Helicobacter pylori-infected human gastric
mucosa. Helicobacter 2008;13:500–5.
6 Yamauchi K, Choi IJ, Lu H, Ogiwara H, Graham DY, Yamaoka Y.
Regulation of IL-18 in Helicobacter pylori infection. J Immunol
2008;180:1207–16.
7 Dzierzanowska-Fangrat K, Michalkiewicz J, Cielecka-Kuszyk J,
Nowak M, Celinska-Cedro D, Rozynck E, Dzierzanowska D,
Crabtree JE. Enhanced gastric IL-18 mRNA expression in Helicobacter pylori-infected children is associated with macrophage
infiltration, IL-8, and IL-1 beta mRNA expression. Eur J Gastroenterol Hepatol 2008;20:314–9.
8 Sakai K, Kita M, Sawai N, Shiomi S, Sumida Y, Kanemasa K,
Mitsufuji S, Imanishi J, Yamaoka Y. Levels of interleukin-18
are markedly increased in Helicobacter pylori-infected gastric
mucosa among patients with specific IL18 genotypes. J Infect
Dis 2008;197:1752–61.
9 Kaparakis M, Walduck AK, Price JD, Pedersen JS, van Rooijen
N, Pearse MJ, Wijburg OL, Strugnell RA. Macrophages are
mediators of gastritis in acute Helicobacter pylori infection in
C57BL ⁄ 6 mice. Infect Immun 2008;76:2235–9.
10 Schmausser B, Endrich S, Beier D, Moran AP, Burek CJ,
Rosenwald A, Rieckmann P, Muller-Hermelink HK, Eck M.
Triggering receptor expressed on myeloid cells-1 (TREM-1)
expression on gastric epithelium: implication for a role of
TREM-1 in Helicobacter pylori infection. Clin Exp Immunol
2008;152:88–94.
26
D’Elios and Andersen
11 Oleastro M, Cordeiro R, Ferrand J, et al. Evaluation of the clinical significance of homB, a novel candidate marker of Helicobacter pylori strains associated with peptic ulcer disease. J Infect
Dis 2008;198:1379–87.
12 Matsuzaka M, Fukuda S, Yamai K, et al. Are individuals with
lower neutrophil oxidative burst activity more prone to Helicobacter pylori infection? Luminescence 2008;23:132–8.
13 Wang CA, Liu YC, Du SY, Lin CW, Fu HW. Helicobacter pylori
neutrophil-activating protein promotes myeloperoxidase release
from human neutrophils. Biochem Biophys Res Commun
2008;377:52–6.
14 Varon C, Duriez A, Lehours P, Menard A, Layè S, Zerbib F,
Megraud F, Laharie D. Study of Helicobacter pullorum proinflammatory properties on human epithelial cells in vitro. Gut
2009;58:629–35.
15 Nilsson C, Skoglund A, Moran AP, Annuk H, Engstrand L,
Normark S. Lipopolysaccharide diversity evolving in Helicobacter
pylori communities through genetic modifications in fucosyltransferases. PLoS ONE 2008;3:3811–24.
16 Linden S, Mahdavi J, Semino-Mora C, Olsen C, Carlstedt I,
Boren T, Dubois A. Role of ABO secretor status in mucosal
innate immunity and H. pylori infection. PLoS Pathog
2008;4:e2–9.
17 Keenan JI, Davis KA, Beaugie CR, McGovern JJ, Moran AP.
Alterations in Helicobacter pylori outer membrane and outer
membrane vesicle-associated lipopolysaccharides under
iron-limiting growth conditions. Innate Immun 2008;14:279–90.
18 Moran AP. Relevance of fucosylation and Lewis antigen expression in the bacterial gastroduodenal pathogen Helicobacter pylori.
Carbohydr Res 2008;343:1952–65.
19 D’Elios MM, Appelmelk BJ, Amedei A, Bergman MP, Del Prete G.
Gastric autoimmunity: the role of Helicobacter pylori and molecular
mimicry. Trends Mol Med 2004;10:316–23.
20 Grebowska A, Moran AP, Matusiak A, et al. Anti-phagocytic
activity of Helicobacter pylori lipopolysacchardies (LPS)-possible
modulation of the innate immune response to these bacteria.
Pol J Microbiol 2008;57:185–92.
21 Sewald X, Gebert-Vogl B, Prassl S, et al. Integrin subunit CD18
is the T-lymphocyte receptor for the Helicobacter pylori vacuolating cytotoxin. Cell Host Microbe 2008;3:20–9.
22 Gupta VR, Patel HK, Kostolanasky SS, Ballivian RA, Eichberg J,
Blankel SR. Sphingomyelin functions as a novel receptor for
Helicobacter pylori VacA. PLoS Pathog 2008;5:1–12.
23 Tuo B, Song P, Wen G, Sewald X, Gebert-Vogl B, Haas R,
Manns M, Seidler U. Helicobacter pylori vacuolating cytotoxin
inhibits duodenal bicarbonate secretion by a histamine-dependent mechanism in mice. J Infect Dis 2009;159:505–12.
24 Hisatsune J, Nakayama M, Isomoto H, et al. Molecular characterization of Helicobacter pylori VacA induction of IL-8 in U937
cells reveals a prominent role for p38MAPK in activating transcription factor-2, cAMP response element binding protein, and
NF-B activation. J Immunol 2008;180:5017–27.
25 Suzuki M, Mimuto H, Kiga K, et al. Helicobacter pylori CagA
phosphorylation-independent function in epithelial proliferation and inflammation. Cell Host Microbe 2009;5:23–34.
26 Botham CM, Wandler AM, Guillemin K. A transgenic Drosophila model demonstrates that the Helicobacter pylori CagA protein
functions as a eukaryotic Gab adaptor. PLoS Pathog 2008;4:
64–71.
27 Hornsby MJ, Huff JL, Kays RJ, Canfield DR, Bevins CL, Solnick
JV. Helicobacter pylori induces an antimicrobial response in rhesus macaques in a cag pathogenicity island-dependent manner.
Gastroenterology 2008;134:1049–57.
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 21–28
D’Elios and Andersen
28 Wiedemann T, Loell E, Mueller S, Stoeckehuber M, Stolte M,
Haas R, Rieder G. Helicobacter pylori cag-pathogenicity islanddependent early immunological response triggers later precancerous gastric changes in Mongolian gerbils. PLoS ONE
2009;4:e4754–66.
29 Snider JL, Allison C, Bellaire BH, Ferrero RL, Cardelli JA. The
beta1 integrin activates JNK independent of CagA, and JNK
activation is required for Helicobacter pylori CagA+ induced
motility of gastric cancer cells. J Biol Chem 2008;283:13952–63.
30 Basu S, Pathak SK, Chatterjee G, Pathak S, Basu J, Kundu M.
Helicobacter protein HP0175 transactivates epidermal growth factor receptor through TLR4 in gastric epithelial cells. J Biol Chem
2008;283:32369–76.
31 Ge Z, Lee A, Whary MT, Rogers AB, Maurer KJ, Taylor NS,
Schauer DB, Fox JG. Helicobacter hepaticus urease is not required
for intestinal colonization but promotes hepatic inflammation
in male A ⁄ JCr mice. Microb Pathog 2008;45:18–24.
32 D’Elios MM, Manghetti M, De Carli M, Costa F, Baldari CT, Burroni D, Telford JL, Romagnani S, Del Prete G. T helper 1 effector
cells specific for Helicobacter pylori in the gastric antrum of
patients with peptic ulcer disease. J Immunol 1997;158:962–7.
33 Ernst P, Gold BD. The disease spectrum of Helicobacter pylori:
the immunopathogenesis of gastroduodenal ulcer and gastric
cancer. Annu Rev Microbiol 2000;54:615–40.
34 Eaton KA, Ringler SR, Danon SJ. Murine splenocytes induce
severe gastritis and delayed-type hypersensitivity and suppress
bacterial colonization in Helicobacter pylori-infected SCID mice.
Infect Immun 1999;67:4594–602.
35 Smythies LE, Waites KE, Lindsey JR, Harris PR, Ghiara P,
Smith PD. Helicobacter pylori-induced mucosal inflammation is
Th1 mediated and exacerbated in IL-4, but not IFN-c genedeficient mice. J Immunol 2000;165:1022–9.
36 Cooper AM. IL-17 and anti-bacterial immunity: protection
versus tissue damage. Eur J Immunol 2009;39:649–52.
37 Luzza F, Parrello T, Monteleone G, Sebkova L, Romano M,
Zarrilli R, Imeneo M, Pallone F. Up-regulation of IL-17 is associated with bioactive IL-8 expression in Helicobacter pyloriinfected human gastric mucosa. J Immunol 2000;165:5332–7.
38 Shiomi S, Toriie A, Imamura S, et al. IL-17 is involved in Helicobacter pylori-induced gastric inflammatory responses in a
mouse model. Helicobacter 2008;13:518–24.
39 Vivas JR, Regnault B, Michel V, Bussière FI, Avé P, Huerre M,
Labigne A, D’Elios MM, Touati E. Interferon gamma-signature
transcript profiling and IL-23 upregulation in response to Helicobacter pylori infection. Int J Immunopathol Pharmacol
2008;21:515–26.
40 Caruso R, Fina D, Paoluzi OA, et al. IL-23-mediated regulation
of IL-17 production in Helicobacter pylori-infected gastric
mucosa. Eur J Immunol 2008;38:470–8.
41 Wang Y, Rickman BH, Poutahidis T, Schlieper K, Jackson EA,
Erdman SE, Fox JG, Horwitz BH. c-Rel is essential for the
development of innate and T cell-induced-colitis. J Immunol
2008;180:8118–25.
42 Bhuiyan TR, Qadri F, Bardhan PK, Ahmad MM, Kindlund B,
Svennerholm AM, Lundgren A. Comparison of mucosal B- and
T-cell responses in Helicobacter pylori-infected subjects in a
developing and a developed country. FEMS Immunol Med Microbiol 2008;54:70–9.
43 Hansson M, Hermansson M, Svensson H, Elfvin A, Hansson LE,
Johnsson E, Sjöling A, Quiding-Järbrink M. CCL28 is increased
in human Helicobacter pylori-induced gastritis and mediates
recruitment of gastric immunoglobulin-A-secreting cells. Infect
Immun 2008;76:3304–11.
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 21–28
Immunity and Vaccines for H. pylori
44 Vorobjova T, Maaros HI, Uibo R. Immune responses to Helicobacter pylori and its association with dynamics of chronic gastritis
in the antrum and in the corpus. APMIS 2008;116:465–76.
45 Mazmanian SK, Round JL, Kasper DL. A microbial symbiosis
factor prevents intestinal inflammatory disease. Nature
2008;453:620–5.
46 D’Elios MM, Codolo G, Amedei A, Mazzi P, Berton G, Zanotti G,
Del Prete G, de Bernard M. Helicobacter pylori, asthma and allergy.
FEMS Immunol Med Microbiol 2009;56:1–8.
47 Chen Y, Blaser MJ. Inverse associations of Helicobacter pylori
with asthma and allergy. Arch Intern Med 2007;167:821–7.
48 Chen Y, Blaser MJ. Helicobacter pylori colonization is inversely
associated with childhood asthma. J Infect Dis 2008;198:553–60.
49 Blaser MJ, Chen Y, Reibman J. Does Helicobacter pylori protect
against asthma and allergy? Gut 2008;57:561–7.
50 Reibman J, Marmor M, Filner J, Fernandez-Beros ME, Rogers L,
Perez-Perez GI, Blaser MJ. Asthma is inversely associated with
Helicobacter pylori status in an urban population. PLoS ONE
2008;3:e4060–5.
51 Codolo G, Mazzi P, Amedei A, Del Prete G, Berton G, D’Elios MM,
de Bernard M. The neutrophil-activating protein of Helicobacter
pylori down-modulates Th2 inflammation in ovalbumin-induced
allergic asthma. Cell Microbiol 2008;10:2355–63.
52 Del Prete G, Chiumiento L, Amedei A, Piazza M, D’Elios MM,
Codolo G, de Bernard M, Masetti M, Bruschi F. Immunosuppression of T(H)2 responses in Trichinella spiralis infection by
Helicobacter pylori neutrophil-activating protein. J Allergy Clin
Immun 2008;58:908–13.
53 Zhang L, Su P, Henriksson A, O’Rourke J, Mitchell H. Investigation of the immunomodulatory effects of Lactobacillus casei
and Bifidobacterium lactis on Helicobacter pylori infection. Helicobacter 2008;13:183–90.
54 Rokka S, Myllylykangas S, Joutsjoki V. Effect of specific colostral antibodies and selected lactobacilli on the adhesion of Helicobacter pylori on AGS cells and the Helicobacter-induced IL-8
production. Scand J Immunol 2008;68:280–6.
55 Kandulski A, Wex T, Kuester D, Peitz U, Gebert I, Roessner A,
Malfertheiner P. Naturally occurring regulatory T cells
(CD4+,CD25high,FOXP3+) in the antrum and cardia are associated with higher H. pylori colonization and increased gene
expression of TGF-beta1. Helicobacter 2008;13:295–303.
56 Stuller KA, Dingh H, Redline RW, Czinn SJ, Blanchard TG.
CD25+ T cells induce Helicobacter pylori-specific CD25-T cell
anergy but are not required to maintain persistent hyporesponsiveness. Eur J Immunol 2008;38:3426–35.
57 Robinson K, Kenefeck R, Pidgeon EL, Shakib S, Patel S, Polson RJ,
Zaitoun AM, Atherton JC. Helicobacter pylori-induced peptic ulcer
disease is associated with inadequate regulatory T cell responses.
Gut 2008;57:1375–85.
58 Kayhan B, Arasli M, Eren H, Aydemir S, Kayhan B, Aktas E,
Tekin I. Analysis of peripheral blood lymphocyte phenotypes
and Th1 ⁄ Th2 cytokines profile in the systemic immune
responses of Helicobacter pylori infected individuals. Microbiol
Immunol 2008;52:531–8.
59 McBee ME, Zheng PZ, Rogers AB, Fox JG, Schauer DB. Modulation of acute diarrheal illness by persistent bacterial infection.
Infect Immun 2008;76:4851–8.
60 Wotherspoon AC, Doglioni C, Diss TC, Pan L, Moschini A,
De Boni M, Isaacson PG. Regression of primary low-grade B
cell gastric lymphoma of mucosa-associated lymphoid tissue
after eradication of Helicobacter pylori. Lancet 1993;342:575–7.
61 Hussell T, Isaacson PG, Crabtree JE, Spencer J. Helicobacter
pylori-specific tumour-infiltrating T cells provide contact
27
Immunity and Vaccines for H. pylori
62
63
64
65
66
67
68
69
70
71
28
dependent help for the growth of malignant B cells in low
grade gastric lymphoma of mucosa-associated lymphoid tissue.
J Pathol 1996;178:122–7.
D’Elios MM, Amedei A, Manghetti M, Costa F, Baldari CT,
Quazi AS, Telford JL, Romagnani S, Del Prete G. Impaired
T-cell regulation of B-cell growth in Helicobacter pylori-related
gastric low grade MALT lymphoma. Gastroenterology
1999;117:1105–12.
Ferrand JJ, Roumanes D, Pitard V, Moreau JF, Mégraud F,
Lehours P. Modulation of lymphocyte proliferation induced by
gastric MALT lymphoma-associated Helicobacter pylori strains.
Helicobacter 2008;13:167–73.
Yamamoto H, Nakamura T, Matsuo K, Tajika M, Kawai H,
Ohmiya N, Niwa Y, Goto H, Nakamura S. Significance of
CXCR3 expression in gastric low-grade-B-cell lymphoma of
mucosa-associated lymphoid tissue type for predicting responsiveness to Helicobacter pylori eradication. Cancer Sci
2008;99:1769–73.
Kuo SH, Yeh PY, Chen LT, et al. Overexpression of B cell-activating factor of TNF family (BAFF) is associated with Helicobacter
pylori-independent growth of gastric diffuse large B-cell lymphoma with histologic evidence of MALT lymphoma. Blood
2008;112:2927–34.
van Maldegem F, van Dijk R, Wormhoudt TA, Kluin PM, Willemze R, Cerroni L, van Noesel CJ, Bende RJ. The majority of
cutaneous marginal zone B-cell lymphomas expresses classswitched immunoglobulins and develops in a T-helper type 2
inflammatory environment. Blood 2008;112:3355–61.
El-Omar EM, Carrington M, Chow WH, et al. Interleukin-1
polymorphisms associated with increased risk of gastric cancer.
Nature 2000;404:398–402.
Crusius JB, Canzian F, Capellá G, et al. Cytokine gene polymorphisms and the risk of adenocarcinoma of the stomach
in the European prospective investigation into cancer and
nutrition (EPIC-EURGAST). Ann Oncol 2008;19:1894–902.
Erzin Y, Koksal V, Altun S, Dobrucali A, Aslan M, Erdamar S,
Goksel S, Dirican A, Kocazeybek B. Role of host interleukin
1beta gene (IL-1B) and interleukin 1 receptor antagonist gene
(IL-1RN) polymorphisms in clinical outcomes in Helicobacter
pylori-positive Turkish patients with dyspepsia. J Gastroenterol
2008;43:705–10.
Bartchewsky W, Martini MR, Masiero M, Squassoni AC, Alvarez MC, Ladeira MS, Salvatore D, Trevisan M, Pedrazzoli J Jr,
Ribeiro ML. Effect of Helicobacter pylori infection on IL-8, IL1beta and COX-2 expression in patients with chronic gastritis
and gastric cancer. Scand J Gastroenterol 2009;44:153–61.
Sierra R, Une C, Ramirez V, Alpizar-Alpizar W, Gonzalez MI,
Ramirez JA, De Mascarel A, Cuenca P, Perez-Perez G, Megraud
F. Relation of atrophic gastritis with Helicobacter pylori-CagA(+)
and interleukin-1 gene polymorphisms. World J Gastroenterol
2008;14:6481–7.
D’Elios and Andersen
72 Kang JM, Kim N, Lee DH, Park JH, Lee MK, Kim JS, Jung HC,
Song IS. The effects of genetic polymorphisms of IL-6, IL-8,
and IL-10 on Helicobacter pylori-induced gastroduodenal
diseases in Korea. J Clin Gastroenterol 2005;43: 420–8.
19077731.
73 Suganuma M, Yamaguchi K, Ono Y, Matsumoto H, Hayashi T,
Ogawa T, Imai K, Kuzuhara T, Nishizono A, Fujiki H. TNFalpha-inducing protein, a carcinogenic factor secreted from
H. pylori, enters gastric cancer cells. Int J Cancer
2008;123:117–22.
74 Beswick EJ, Reyes VE. Macrophage migration inhibitory factor
and interleukin-8 produced by gastric epithelial cells during
Helicobacter pylori exposure induce expression and activation of
the epidermal growth factor receptor. Infect Immun
2008;76:3233–40.
75 Wei J, O’Brien D, Vilgelm A, Piazuelo MB, Correa P, Washington MK, El-Rifai W, Peek RM, Zaika A. Interaction of Helicobacter pylori with gastric epithelial cells is mediated by the p53
protein family. Gastroenterology 2008;134:1412–23.
76 Piazuelo MB, Camargo MC, Mera RM, et al. Eosinophils and
mast cells in chronic gastritis: possible implications in carcinogenesis. Hum Pathol 2008;39:1360–9.
77 Del Giudice G, Covacci A, Telford J, Montecucco C, Rappuoli R.
The design of vaccines against Helicobacter pylori and their development. Annu Rev Immunol 2001;19:523–63.
78 Ilver D, Arnqvist A, Ogren J, Frick IM, Kersulyte D, Incecik ET,
Berg DE, Covacci A, Engstrand L, Borén T. Helicobacter pylori
adhesin binding fucosylated histo-blood group antigens
revealed by retagging. Science 1998;279:373–7.
79 DeLyria ES, Redline RW, Blanchard TG. Vaccination of mice
against H. pylori induces a strong Th-17 response and immunity
that is neutrophil dependent. Gastroenterology 2009;136:247–56.
80 Zhang M, Berndt BE, Eaton KA, Rathinavelu S, Pierzchala A,
Kao JY. Helicobacter pylori-pulsed dendritic cells induce H. pylorispecific immunity in mice. Helicobacter 2008;13:200–8.
81 Taylor JM, Ziman ME, Canfield DR, Vajdy M, Solnick JV. 1:
Effects of a Th1- versus a Th2-biased immune response in protection against Helicobacter pylori challenge in mice. Microb
Pathog 2008;44:20–7.
82 Wehrens A, Aebischer T, Meyer TF, Walduck AK. Leptin receptor signaling is required for vaccine-induced protection against
Helicobacter pylori. Helicobacter 2008;13:94–102.
83 Aebischer T, Bumann D, Epple HJ, et al. Correlation of T cell
response and bacterial clearance in human volunteers challenged with Helicobacter pylori revealed by randomised controlled vaccination with Ty21a-based Salmonella vaccines. Gut
2008;57:1065–72.
84 Malfertheiner P, Schultze V, Rosenkranz B, et al. Safety and
immunogenicity of an intramuscular Helicobacter pylori vaccine
in noninfected volunteers: a phase I study. Gastroenterology
2008;135:787–95.
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 21–28
Helicobacter ISSN 1523-5378
Helicobacter pylori and Non-malignant Diseases
Takahisa Furuta* and Jean-Charles Delchier
*Center for Clinical Research, Hamamatsu University School of Medicine, Hamamatsu, Japan, Department of Gastroenterology, Créteil University
Hospital Henri Mondor, Créteil, France
Keywords
Gastritis, peptic ulcer, GERD, NSAID, aspirin,
dyspepsia, polymorphism.
Reprint requests to: Takahisa Furuta, Center
for Clinical Research, Hamamatsu University
School of Medicine, 1-20-1, Handayama, Higashi-Ku, Hamamatsu, 431-3192, Japan. E-mail:
furuta@hama-med.ac.jp or Jean Charles Delchier, Service d’Hépatogastroentérologie,
AP-HP Hôpital Henri Mondor, 51 Avenue du
Maréchal de Lattre de Tassigny, 94000 Créteil,
France. E-mail: jean-charles.delchier@hmn.
aphp.fr
Abstract
It is well known that Helicobacter pylori infection is associated with many
nonmalignant disorders such as gastritis, peptic ulcer, gastroesophageal
reflux disease (GERD), gastric polyp, nonsteroidal anti-inflammatory drug
(NSAID) ⁄ aspirin-induced gastric injury, and functional dyspepsia. In 2008,
interesting articles on the association of H. pylori infection with these disorders were presented, some of which intended to reveal the mechanisms of
inter-individual differences in response to H. pylori infection, and have demonstrated that genetic differences in host and bacterial factors as well as
environmental factors account for these differences. A decline in the occurrence of peptic ulcer related to H. pylori was confirmed. An inverse relationship between H. pylori infection and GERD was also confirmed but the
impact of gastric atrophy on the prevention of GERD remained debatable.
For NSAID-induced gastric injury, eradication of H. pylori infection has been
recommended. During this year, eradication of H. pylori infection was recommended for patients treated with antiplatelet therapy as well as aspirin
and NSAID. It was also reported that for patients with functional dyspepsia,
eradication of H. pylori offers a modest but significant benefit.
Helicobacter pylori-positive peptic ulcer (PU) is one of the
most important indications for H. pylori eradication.
However, it has been made clear that H. pylori infection
is also associated with nonmalignant disorders other
than peptic ulcer diseases (PUD) and that eradication of
H. pylori is sometimes effective for the treatment of
these disorders. There are inter-individual differences in
response to H. pylori infection. One of the reasons for
the inter-individual differences is genetics. Environmental factors are also associated with such differences.
In 2008, several new polymorphisms associated with
H. pylori-related disorders were reported. However, the
main factors associated with the clinical outcome of
H. pylori infection in each individual have not been
fully elucidated. In this review, some interesting articles
on the association of H. pylori infection with nonmalignant disorders published between April 2008 and
March 2009 will be discussed.
Gastritis and H. pylori Infection
It is well known that H. pylori infection causes histologic gastritis. There are inter-individual differences in
the severity or patterns of gastritis which are then associated with the further development of different kinds
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 29–35
of disorders, such as duodenal ulcer (DU), gastric ulcer
(GU), and gastric cancer. Genetic differences in host
and bacterial factors have been considered to be one of
the reasons for the inter-individual differences.
For the explanation of these inter-individual differences in response to H. pylori infection, polymorphisms
of cytokines, such as interleukins (ILs) and tumor
necrosis factor (TNF)-a, have been studied intensively
since the year 2000. These cytokine polymorphisms are
associated with different patterns of gastritis among different individuals. In 2008, several new polymorphisms
associated with H. pylori-induced gastritis were reported
(Table 1).
Tahara et al. studied the effects of Toll-like receptors
(TLRs) on gastritis and found that TLR2-196 to -174ins
alleles were associated with more severe intestinal
metaplasia in patients older than 60 years and were
correlated with severity of gastric mucosal atrophy and
intestinal metaplasia in female subjects [1]. They also
studied the polymorphisms of Regulated upon activation, normal T-cell expressed, and secreted (RANTES)
and found that RANTES-28G carrier was associated with
a reduced risk of developing more severe intestinal
metaplasia in H. pylori-positive subjects aged 60 years
and older and in female subjects [2]. Trejo-de la OA,
29
Furuta and Delchier
H. pylori and Non-malignant Diseases
Table 1 Representative studies on genetics associated with pathogenesis of Helicobacter pylori-related gastritis published in 2008
Authors
Summary
Reference
Tahara et al.
Tahara et al.
Trejo-de la et al.
Achyut et al.
TLR2-196 to -174ins alleles are associated with severity of gastritis and intestinal metaplasia.
RANTES-28G allele decreases the risk of intestinal metaplasia.
TLR4 polymorphisms are associated with cytokine secretion.
Tumor necrosis factor-alpha (-308G ⁄ A) and interleukin-10 (-819C ⁄ T) are associated with
gastritis, especially follicular gastritis.
Polymorphisms of cagA and vacA (S1 ⁄ 2, m1 ⁄ 2) are not associated with the clinical outcome
of H. pylori infection.
Polymorphisms of virulence factors (vacA, cagA, cagE, iceA, and babA2) are not associated
with the clinical outcome of H. pylori infection.
cagA EPIYA-C segment is associated with the development of intestinal metaplasia.
Environmental factors are important than the genetics of host and bacteria.
[1]
[2]
[3]
[4]
Jafari et al.
Chomvarin et al.
Basso et al.
Kim et al.
et al. also studied the influence of TLR polymorphism
and observed that single-nucleotide polymorphisms
(SNPs) in the TLR4 gene were associated with severe H.
pylori-associated diseases and with a modified pattern of
inflammatory cytokines and chemokines in the gastric
mucosa infected with H. pylori [3].
H. pylori is also associated with lymphoid follicle gastritis, which is known to sometimes evolve into monoclonal mucosa-associated lymphoid tissue (MALT)
lymphoma. Achyut et al. studied the association of
TNF-a and IL-10 gene polymorphisms with gastritis and
lymphoid follicle formation and found that IL-10-819T
and TNF-a-308A alleles may increase the risk of gastritis
and lymphoid follicle formation [4].
There have been several important reports on the polymorphism of bacterial factors. H. pylori strains have been
classified into two groups: strains with high virulence and
those with low virulence. The differences between the
two groups are partly explained by the status of cagA and
vacA, which are well known to be polymorphic. For vacA,
strains with an s1 ⁄ m1 genotype have been thought to be
more virulent than those with s2 ⁄ m2. However, Jafari
et al. evaluated the effects of vacA genotypes on gastric
inflammation and injury as well as clinical presentation
in Iranian populations and found that the vacA genotypes
and cagA status were not useful markers for gastroduodenal diseases in their country [5]. Chomvarin et al. from
Thailand attempted to determine whether any correlation exists between genotypes of vacA, cagA, cagE, iceA,
and babA2 and clinical manifestations in dyspeptic
patients infected with H. pylori and concluded that neither a single gene nor a combination of vacA, cagA, cagE,
iceA, and babA2 genes was significantly helpful in predicting the clinical outcome of H. pylori infection in their
country [6]. However, Basso et al. studied cagA and vacA
polymorphisms as well as the number of type C Glu-ProIle-Tyr-Ala motif (EPIYA) (EPIYA-C) segments, which
increase phosphorylation-dependent cagA activity in
30
[5]
[6]
[7]
[8]
H. pylori-positive Italian patients with different disorders
and they confirmed the association of cagA and vacA
s1 ⁄ m1 polymorphisms with PUD and cancers and noted
that the most important factors in western countries were
the number of cagA EPIYA-C segment for cancer risk and
the intermediate region type of vacA for PUD risk [7].
Because the EPIYA-C segment is the Src homology 2
domain-containing
protein
tyrosine
phosphatase
(SHP-2)-binding site of cagA is clearly associated with
RAS ⁄ MAP kinase, EPIYA-C will be the key factor for
elucidating the bacterial types and their corresponding
clinical outcomes, including gastric cancer.
As stated before, a variety of polymorphisms from
both bacterial and host sides were reported to be associated with the severity and ⁄ or the type of gastritis. In
contrast, Kim et al. evaluated risk factors of atrophic
gastritis and intestinal metaplasia with respect to
H. pylori virulence factors (i.e., cagA, vacA m1, and oipA),
and environmental factors (i.e., smoking and alcohol)
and host polymorphisms (i.e., IL-1b-511, IL-1RN, TNFA-308, IL-10-592, IL-10-819, IL-10-1082, IL-8-251,
IL-6-572, GSTP1, p53 codon 72, and ALDH2) and found
that the bacterial factors were important risk factors for
atrophic gastritis but that environmental and host factors were more important for intestinal metaplasia [8].
The conclusion from this article is that to understand
the inter-individual differences in response to H. pylori
infection among different subjects, not only genetics of
hosts and bacteria, but also environmental factors have
to be studied. Therefore, the useful marker that predicts
the individual response to H. pylori infection remains to
be elucidated in relation to environmental factors.
Gastroduodenal Ulcer and H. pylori
Infection
It is common knowledge that H. pylori infection is,
along with nonsteroidal anti-inflammatory drugs
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 29–35
Furuta and Delchier
H. pylori and Non-malignant Diseases
(NSAIDs) ⁄ aspirin, a major factor of PUD. Some interesting reports on PUD and H. pylori infection were published in 2008, mainly dealing with epidemiology and
pathogenesis (Table 2).
Sung et al. performed a systematic review of the published literature concerning the prevalence and incidence of PUD [9]. The analyzed articles came from
western countries. The main conclusion was that PUD
remains a common condition despite decreasing incidence and prevalence owing to a decrease in H. pylori
infection. In contrast, Wu et al. from Taiwan reported
that a dramatic decrease in the incidence of admissions
for complicated or uncomplicated PUD from 1997 to
2006 correlated with a significant increase in eradication therapy and use of proton-pump inhibitor (PPI)
[10].
Eradication of H. pylori infection is known to be effective in the prevention of bleeding ulcers. van Leerdam
et al. examined epidemiological surveys on gastrointestinal bleeding cases and observed that H. pylori infection
is found in about 50% of bleeding PU patients [11].
Therefore, they concluded that all ulcer patients should
be tested for H. pylori infection and eradication treatment should be given to those who are positive.
Cytokine polymorphisms have previously been
shown to be able to modulate host response to H. pylori
infection and to determine the occurrence of PUD. Vascular factors could play a role in the pathogenesis of
PUD regardless of the main ulcerogenic agent involved,
H. pylori or NSAIDs. Kim et al. evaluated whether the
vascular endothelial growth factor (VEGF) polymorphism could predict susceptibility to PUD through modified angiogenic activities and found that the VEGF
polymorphism -1780T ⁄ C could significantly predict the
predisposition to PUD after exposure to etiologic risks
[12]. To understand the importance of this polymorphism, previously reported SNPs, such as IL-1b and
TNF-a, are needed for a comparative study.
Recently, endoscopic submucosal dissection (ESD)
and endoscopic mucosal resection (EMR) were proposed for the treatment of early gastric cancer. The timing of H. pylori eradication on the process of ulcer
healing after EMR or ESD has been controversial,
because eradication of H. pylori restores gastric acid
secretion, which sometimes induces the ulcers to bleed
just after EMR or ESD. Cheon et al. prospectively evaluated the effect of H. pylori eradication on the healing
of gastric ulcer after EMR and stated that H. pylori eradication might improve the ulcer’s healing rate after
EMR [13]. Even if a supplementary examination is necessary, there seem to be cases in which eradication of
H. pylori immediately after EMR is beneficial.
Gastroesophageal Reflux Disease (GERD)
and H. pylori Infection
Studies have shown that the prevalence of H. pylori
infection is lower in GERD patients than in non-GERD
subjects. Therefore, H. pylori infection has been considered to be possibly protective against the development
of GERD. The fact that the eradication of H. pylori
favors GERD and ⁄ or exacerbates symptoms in patients
with GERD remains controversial. Several studies published in 2008 ⁄ 2009 dealt with this subject and again
reported controversial results (Table 3).
Corley et al. performed a case-control study on a
large population from California by matching patients
with a new diagnosis of Barrett’s esophagus with
patients with GERD and control subjects randomly
selected from the base population [14]. The control
group was original in comparison with the previous
studies in which patients requiring gastroscopy for
digestive symptoms other than GERD were included in
the control group, with a possibility of overestimating
the H. pylori rate. They found that H. pylori infection
and cagA+ status were inversely associated with a new
diagnosis of Barrett’s esophagus and that the association
might be at least partly mediated through GERD. Somi
et al. studied a more limited number of patients and
found a similar inverse association between H. pylori
infection and cagA status and reflux esophagitis [15].
However, Fass et al. studying the factors associated with
refractory GERD found that the status of H. pylori infection played a very limited role in refractory GERD [16].
Table 2 Representative studies on the association of Helicobacter pylori infection and gastroduodenal ulcers published in 2008
Author
Summary
Reference
Wu et al.
Increases in H. pylori eradication therapy and proton-pump inhibitor use decrease the
incidence of gastric and duodenal ulcer diseases.
Around half of the bleeding ulcer patients are infected with H. pylori. Eradication therapy
is recommended.
VEGF-1780T ⁄ C polymorphism is associated with peptic ulcer risk.
Eradication of H. pylori facilitates the ulcer after endoscopic mucosal resection.
[10]
Van Leerdam et al.
Kim et al.
Chen et al.
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 29–35
[11]
[12]
[13]
31
Furuta and Delchier
H. pylori and Non-malignant Diseases
Table 3 Representative studies on the association of Helicobacter pylori infection with gastroesophageal reflux diseases (GERD)
Authors
Summary
Reference
Corley et al.
Prevalence of H. pylori seropositivity is negatively correlated with the risk of Barrett’s
esophagus.
cagA-positive H. pylori strains decrease the risk of GERD.
H. pylori infection has no association with refractory GERD.
There is no association between H. pylori infection and GERD.
GERD often occurs after eradication of H. pylori, but NERD does not.
H. pylori infection and gastric atrophy are associated with a reduced risk of esophageal
adenocarcinoma, Barrett’s esophagus, and reflux esophagitis, although gastric atrophy
may not fully explain the inverse associations observed with H. pylori infection.
Reflux esophagitis is inversely associated with gastric atrophy.
Serum gastrin and pepsinogen I and II do not correlate with the different grades of
severity of GERD.
GERD patients infected with H. pylori should undergo eradication therapy for the prevention
of gastric cancer.
[14]
Somi et al.
Fass et al.
Grande et al.
Kim et al.
Anderson et al.
Kwon et al.
Monkemuller et al.
Wu et al.
Similarly, Grande et al. did not find any difference in
the main characteristics of a group of 146 GERD
patients according to their H. pylori status [17]. These
findings suggest that H. pylori status plays no important
role in the development of GERD and erosive esophagitis. Kim et al. compared risk factors for erosive esophagitis and nonerosive reflux disease (NERD) and found
that the history of H. pylori eradication could be related
to the risk of erosive gastritis, but not of NERD [18].
Several studies were performed to clarify the relationship between H. pylori status, gastric atrophy, and
GERD. Anderson et al. performed a case-control study
including a large number of patients with esophageal
adenocarcinoma, Barrett’s esophagus, reflux esophagitis, and controls [19]. They found an inverse association
of H. pylori seropositivity and also atrophy determined
by the pepsinogen I ⁄ II ratio with esophageal adenocarcinoma, Barrrett’s esophagus, and reflux esophagitis.
However, although gastric atrophy was involved, it
might not fully explain the inverse association with
H. pylori infection. Similarly, Kwon et al., who compared a group of 45 patients having erosive esophagitis
with a group of 66 control patients, found that the rate
of infection of H. pylori was lower in the esophagitis
group and the pepsinogen I ⁄ II ratio was higher than
that in the control group, suggesting an inverse association between GERD and H. pylori-related gastric atrophy
[20]. In contrast, Monkemuller et al. did not find any
correlation between serum gastrin and pepsinogen I
and II with the severity of GERD [21].
Because continuous administration of PPI for GERD
patients carries the risk of exacerbating the gastritis in
the event of an H. pylori infection, the preventive eradication of H. pylori is recommended for patients with
GERD who are in need of maintenance doses of a PPI,
32
[15]
[16]
[17]
[18]
[19]
[20]
[21]
[22]
although eradication of H. pylori increases the risk of
rendering the GERD ‘obstinate’. Wu et al. stated that,
although H. pylori eradication may lead to more resilient GERD in a subset of patients, the benefits of
H. pylori eradication outweighed the risks from the
point of view of prevention of gastric cancer, especially
in Asian populations with a high incidence of gastric
cancer [22].
In conclusion, most of the articles published in 2008
confirm that H. pylori infection is inversely related to
GERD, erosive esophagitis, Barrettt’s esophagus, and
esophageal carcinoma. Whether reduction of GERD is
only mediated through H. pylori-induced corpus atrophy
is still being debated. The concept that eradication of H.
pylori is needed in GERD patients treated with PPI has
not changed.
Gastric Polyps and H. pylori Infection
Several interesting papers on H. pylori infection and gastric polyps were published in 2008. Since some gastric
polyps may disappear after eradication of H. pylori, the
pathophysiological role of H. pylori infection in the
development of gastric hyperplastic polyps has been
suggested. Ohnishi et al. studied the pathophysiologic
role of cagA using cagA transgenic mice and found
that wild-type cagA transgenic mice developed gastric
epithelial hyperplasia and some of the mice developed
gastric polyps and adenocarcinomas of the stomach and
small intestine, suggesting that cagA is an oncogenic
protein [23]. Interestingly, such pathologic abnormalities were not observed in transgenic mice expressing
phosphorylation-resistant cagA, indicating the importance of cagA tyrosine phosphorylation in the development of H. pylori-associated neoplasms.
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 29–35
Furuta and Delchier
H. pylori and Non-malignant Diseases
Cronkhite-Canada syndrome (CCS) is a rare syndrome characterized by multiple polyps of the digestive
tract with symptoms that include loss of taste, hair loss,
and nail growth problems. Chronic diarrhea and protein-losing enteropathy are often observed. The cause
of the disease is unknown. Okamoto et al. prescribed
H. pylori eradication therapy for an H. pylori-positive
patient with CCS in Japan and noted a regression of
polyps and resolution of clinical findings such as edema
with the normalization of serum total protein and albumin levels [24]. This case report suggests the possible
role of H. pylori infection in the pathogenesis of CCS.
Whether this particular strain was cagA-positive is
unclear, but most H. pylori strains in Japan are cagApositive. Therefore, cagA status is assumed to be associated with the development of gastric polyps.
prevention of GI complications in NSAID users need to
be examined case by case. Eradication of H. pylori is
important in preventing gastroduodenal injury as a
result of antiplatelet and ⁄ or NSAID therapy.
Epidemiologic studies have revealed that the incidence of gastric cancer is lower in subjects receiving
NSAID and ⁄ or aspirin compared with nonusers of
NSAID and ⁄ or aspirin. In 2008, a supportive study was
reported. Li et al. studied the effects of aspirin on the
development of heterotopic proliferative glands in
H. pylori-infected Mongolian gerbils and found that
aspirin alleviated H. pylori-induced hyperplasia and the
development of heterotopic proliferative glands and also
increased H. pylori-induced apoptosis [30]. They concluded that aspirin was responsible for the antineoplastic activities in H. pylori-related gastric carcinogenesis.
NSAIDs ⁄ Aspirin-Induced Gastric Injury
and H. pylori Infection
Functional Dyspepsia (FD) and H. pylori
Infection
No major original contribution to this subject was published in 2008. However, a consensus of the American
College of Cardiology on antiplatelet therapy and
NSAID use and the guidelines of the American College
of Gastroenterology for prevention of NSAID-related
ulcer complications have been recently published
[25–28] (Table 4). Kiltz et al. reviewed the literature
from a rheumatological point of view [29]. Similar recommendations were given. For antiplatelet therapy, the
recommendation is to examine H. pylori infection in
patients with a history of PUD and to eradicate H. pylori
infection when present. However, PPI were recommended to prevent recurrence of complications. For
NSAIDs, Kiltz et al. concluded from the review of the
literature that it was well demonstrated that NSAIDnaive users benefited from testing for H. pylori infection
and subsequent H. pylori eradication therapy prior to
the initiation of NSAID, but that H. pylori eradication
alone did not offer protection from gastroduodenal
injuries in chronic NSAID users [29]. To relieve patients
with recent ulcer complications from further gastrointestinal (GI) events, eradication of H. pylori alone is
insufficient and long-term acid inhibition is required.
The management of H. pylori infection and the
The role of H. pylori infection in FD has not been fully
elucidated and the effect of H. pylori eradication is still
controversial. In 2008, several reports on the effect of
H. pylori infection on FD were presented (Table 5).
Selgrad et al. stated in a review that population-based
studies have demonstrated that H. pylori is detected
more frequently in dyspeptic patients than in controls
and that H. pylori eradication therapy gives a modest
but significant benefit in nonulcer dyspepsia cases and
leads to long-term symptom improvement [31]. Consequently the ‘‘test and treat’’ strategy should remain the
first option in patients with unexplored dyspepsia without alarm features in areas where H. pylori prevalence
is greater than 20%. In western countries with a low
prevalence of H. pylori, migrant communities may constitute a target group for the ‘‘test and treat’’ strategy
[32]. An important study from Denmark evaluated the
long-term effects of H. pylori screening and treatment of
dyspepsia by determining the dyspepsia health-care
consumption and quality of life in a large randomized
community-based trial [33]. The prevalence of H. pylori
in screened subjects was low (17.5%). The effect of
eradication on the rate of dyspepsia was modest and
was not statistically significant contrary to the
Table 4 Representative studies on the association of Helicobacter pylori infection with nonsteroidal anti-inflammatory drug (NSAID) ⁄ aspirin-related
disorders published in 2008
Author
Summary
Reference
Bhatt et al.
Kiltz et al.
Li et al.
Eradication of H. pylori is recommended in NSAID ⁄ aspirin users with a history of peptic ulcer.
Eradication of H. pylori is effective in patients who have never used NSAID ⁄ aspirin.
Aspirin inhibits the development of heterotopic proliferative gland in Mongolian gerbils infected with H. pylori.
[25–27]
[29]
[30]
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 29–35
33
Furuta and Delchier
H. pylori and Non-malignant Diseases
Table 5 Representative studies on the association of Helicobacter pylori infection with functional dyspepsia published in 2008
Author
Summary
Reference
Selgrad et al.
Hansen et al.
‘‘Test and treat’’ is one of the treatment strategies for dyspeptic patients.
H. pylori treatment has a modest but significant effect on the consultation rate and the
number of sick leave days for dyspepsia.
Patients with functional dyspepsia in Asia would benefit from treatment for H. pylori
infection.
Eradication of H. pylori improves dyspeptic symptoms.
The symptomatic benefit of H. pylori eradication therapy is greatest among duodenal
ulcer patients.
The COMT genotype seems to influence the susceptibility to dyspepsia.
[31]
[33]
Gwee et al.
de Artaza Varasa et al.
Koivisto et al.
Tahara et al.
consultation and sick leave rates which were significant; the incidence of ulcers also decreased significantly.
A randomized placebo-controlled trial from Singapore
showed that, in an Asian population with FD, eradication of H. pylori had a major beneficial effect when
compared with a placebo, with a symptom resolution
rate of 39% versus 3%, respectively, after 1 year [34].
Differences between eastern and western patients with
FD could be related to the lower prevalence of reflux
symptoms in the Asian patients.
de Artaza Varasa et al. studied whether antral gastritis,
commonly associated with PUD, may predict a greater
symptomatic response to H. pylori eradication in FD and
found that there was a tendency of symptomatic benefit
with H. pylori eradication in patients with antral gastritis
[35]. Similarly, Koivisto et al. showed that DU patients
(from 50 to 59 years of age) with antral neutrophil
inflammation, were significantly predictive of symptomatic improvement after H. pylori eradication [36].
Tahara et al. attempted to clarify the association
between 5HTR2A C102T polymorphism, CD14 gene C159T polymorphism, and polymorphism in codon 158
of the COMT gene, and dyspeptic symptoms [37–39].
They found that neither 5HTR2A polymorphism nor
CD14 gene C-159T polymorphism was likely to be associated with dyspeptic symptoms, but that the COMT
genotype seemed to influence the susceptibility of dyspepsia. The role of genetics in the development of dyspepsia needs further evaluation.
The impact of H. pylori on symptom control in patients
with long-term PPI treatment was studied by Raghunath
et al. [40]. They found that H. pylori infection was associated with lower reflux symptom scores only in
patients with GERD and uninvestigated dyspepsia.
Conclusion
H. pylori infection is associated with many nonmalignant disorders as described before. Genetics of hosts
and bacteria as well as environmental factors are
34
[34]
[35]
[36]
[37–39]
responsible for the inter-individual differences in
response to H. pylori infection in different individuals.
Unfortunately, the impact of newly discovered polymorphisms is still unclear. Therefore, comparative studies are needed to clarify the important SNPs associated
with a response to H. pylori infection. Although the
pathophysiologic role of H. pylori in nonmalignant diseases has not been fully elucidated, eradication of the
bacteria is sometimes effective for the treatment of
these disorders. Eradication of H. pylori infection has
also been recommended for patients treated with
NSAID ⁄ aspirin and ⁄ or antiplatelet agents. Indeed, there
are no disorders for which eradication of H. pylori infection is contraindicated; therefore, the ‘‘test and treat
strategy’’ appears to be useful in H. pylori-positive
patients with certain symptoms, such as dyspepsia.
However, further studies are needed to clarify more
precisely the association of H. pylori infection with these
nonmalignant disorders, which will contribute to higher
quality of clinical practice in the treatment of digestive
diseases.
Conflict of Interest
None of the authors had any conflict of interest related
to this manuscript.
References
1 Tahara T, Arisawa T, Wang F, et al. Toll-like receptor 2 (TLR)
-196 to 174del polymorphism in gastro-duodenal diseases in
Japanese population. Dig Dis Sci 2008;53:919–24.
2 Tahara T, Arisawa T, Shibata T, et al. Effect of RANTES
promoter genotype on the severity of intestinal metaplasia in
Helicobacter pylori-infected Japanese subjects. Dig Dis Sci
2009;54:1247–52.
3 Trejo-de la OA, Torres J, Perez-Rodriguez M, et al. TLR4 singlenucleotide polymorphisms alter mucosal cytokine and chemokine
patterns in Mexican patients with Helicobacter pylori-associated
gastroduodenal diseases. Clin Immunol 2008;129:333–40.
4 Achyut BR, Tripathi P, Ghoshal UC, Moorchung N, Mittal B.
Interleukin-10 (-819C ⁄ T) and tumor necrosis factor-alpha
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 29–35
Furuta and Delchier
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
(-308G ⁄ A) gene variants influence gastritis and lymphoid
follicle development. Dig Dis Sci 2008;53:622–9.
Jafari F, Shokrzadeh L, Dabiri H, et al. vacA genotypes of Helicobacter pylori in relation to cagA status and clinical outcomes in
Iranian populations. Jpn J Infect Dis 2008;61:290–3.
Chomvarin C, Namwat W, Chaicumpar K, et al. Prevalence of
Helicobacter pylori vacA, cagA, cagE, iceA and babA2 genotypes in
Thai dyspeptic patients. Int J Infect Dis 2008;12:30–6.
Basso D, Zambon CF, Letley DP, et al. Clinical relevance of
Helicobacter pylori cagA and vacA gene polymorphisms. Gastroenterology 2008;135:91–9.
Kim N, Park YS, Cho SI, et al. Prevalence and risk factors of
atrophic gastritis and intestinal metaplasia in a Korean population without significant gastroduodenal disease. Helicobacter
2008;13:245–55.
Sung JJ, Kuipers EJ, El-Serag HB. Systematic review: the global
incidence and prevalence of peptic ulcer disease. Aliment Pharmacol Ther 2009;29:938–46.
Wu CY, Wu CH, Wu MS, et al. A nationwide population-based
cohort study shows reduced hospitalization for peptic ulcer disease associated with H. pylori eradication and proton pump
inhibitor use. Clin Gastroenterol Hepatol 2009;7:427–31.
van Leerdam ME. Epidemiology of acute upper gastrointestinal
bleeding. Best Pract Res Clin Gastroenterol 2008;22:209–24.
Kim YS, Park SW, Kim MH, et al. Novel single nucleotide polymorphism of the VEGF gene as a risk predictor for gastroduodenal ulcers. J Gastroenterol Hepatol 2008;23(Suppl. 2):S131–9.
Cheon JH, Kim JH, Lee SK, Kim TI, Kim WH, Lee YC. Helicobacter pylori eradication therapy may facilitate gastric ulcer healing after endoscopic mucosal resection: a prospective
randomized study. Helicobacter 2008;13:564–71.
Corley DA, Kubo A, Levin TR, et al. Helicobacter pylori and gastroesophageal reflux disease: a case-control study. Helicobacter
2008;13:352–60.
Somi MH, Fattahi E, Fouladi RF, Karimi M, Bonyadi R, Baballou
Z. An inverse relation between CagA+ strains of Helicobacter pylori
infection and risk of erosive GERD. Saudi Med J 2008;29:393–6.
Fass R, Gasiorowska A. Refractory GERD: what is it? Curr
Gastroenterol Rep 2008;10:252–7.
Grande M, Cadeddu F, Villa M, et al. Helicobacter pylori and gastroesophageal reflux disease. World J Surg Oncol 2008;6:74.
Kim N, Lee SW, Cho SI, et al. The prevalence of and risk factors for erosive oesophagitis and non-erosive reflux disease: a
nationwide multicentre prospective study in Korea. Aliment
Pharmacol Ther 2008;27:173–85.
Anderson LA, Murphy SJ, Johnston BT, et al. Relationship
between Helicobacter pylori infection and gastric atrophy and the
stages of the oesophageal inflammation, metaplasia, adenocarcinoma sequence: results from the FINBAR case-control study.
Gut 2008;57:734–9.
Kwon JH, Chung IS, Son HS, et al. The relationship of gastrin,
pepsinogen, and Helicobacter pylori in erosive reflux esophagitis.
Korean J Gastroenterol 2008;51:159–66.
Monkemuller K, Neumann H, Nocon M, et al. Serum gastrin
and pepsinogens do not correlate with the different grades of
severity of gastro-oesophageal reflux disease: a matched casecontrol study. Aliment Pharmacol Ther 2008;28:491–6.
Wu JC. Gastroesophageal reflux disease: an Asian perspective.
J Gastroenterol Hepatol 2008;23:1785–93.
Ohnishi N, Yuasa H, Tanaka S, et al. Transgenic expression of
Helicobacter pylori CagA induces gastrointestinal and hematopoietic neoplasms in mouse. Proc Natl Acad Sci USA 2008;105:
1003–8.
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 29–35
H. pylori and Non-malignant Diseases
24 Okamoto K, Isomoto H, Shikuwa S, Nishiyama H, Ito M, Kohno S.
A case of Cronkhite–Canada syndrome: remission after treatment
with anti-Helicobacter pylori regimen. Digestion 2008;78:82–7.
25 Bhatt DL, Scheiman J, Abraham NS, et al. ACCF ⁄ ACG ⁄ AHA
2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: a report of the
American College of Cardiology Foundation Task Force on
Clinical Expert Consensus Documents. J Am Coll Cardiol
2008;52:1502–17.
26 Bhatt DL, Scheiman J, Abraham NS, et al. ACCF ⁄ ACG ⁄ AHA
2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use. Am J Gastroenterol 2008;103:2890–907.
27 Bhatt DL, Scheiman J, Abraham NS, et al. ACCF ⁄ ACG ⁄ AHA
2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: a report of the
American College of Cardiology Foundation Task Force on
Clinical Expert Consensus Documents. Circulation
2008;118:1894–909.
28 Lanza FL, Chan FK, Quigley EM. Guidelines for prevention of
NSAID-related ulcer complications. Am J Gastroenterol
2009;104:728–38.
29 Kiltz U, Zochling J, Schmidt WE, Braun J. Use of NSAIDs and
infection with Helicobacter pylori – what does the rheumatologist
need to know? Rheumatology (Oxford) 2008;47:1342–7.
30 Li GQ, Xia HH, Chen MH, et al. Effects of aspirin on the
development of Helicobacter pylori-induced gastric inflammation
and heterotopic proliferative glands in Mongolian gerbils.
Helicobacter 2008;1:20–9.
31 Selgrad M, Kandulski A, Malfertheiner P. Dyspepsia and
Helicobacter pylori. Dig Dis 2008;26:210–4.
32 de Vries AC, Van Driel HF, Richardus JH, et al. Migrant
communities constitute a possible target population for primary
prevention of Helicobacter pylori-related complications in low
incidence countries. Scand J Gastroenterol 2008;43:403–9.
33 Hansen JM, Wildner-Christensen M, Hallas J, Schaffalitzky de
Muckadell OB. Effect of a community screening for Helicobacter
pylori: a 5-yr follow-up study. Am J Gastroenterol
2008;103:1106–13.
34 Gwee KA, Teng L, Wong RK, Ho KY, Sutedja DS, Yeoh KG.
The response of Asian patients with functional dyspepsia to
eradication of Helicobacter pylori infection. Eur J Gastroenterol
Hepatol 2009;21:417–24.
35 de Artaza Varasa T, Valle Munoz J, Perez-Grueso MJ, et al.
Effect of Helicobacter pylori eradication on patients with
functional dyspepsia. Rev Esp Enferm Dig 2008;100:532–9.
36 Koivisto TT, Voutilainen ME, Farkkila MA. Symptoms, endoscopic findings and histology predicting symptomatic benefit
of Helicobacter pylori eradication. Scand J Gastroenterol 2008;43:
810–6.
37 Tahara T, Arisawa T, Shibata T, et al. Serotonin-2A receptor
gene T102C polymorphism in patients with dyspeptic symptoms. Hepatogastroenterology 2008;55:1921–4.
38 Tahara T, Arisawa T, Shibata T, Nakamura M, Wang F, Hirata I.
COMT gene val158met polymorphism in patients with
dyspeptic symptoms. Hepatogastroenterology 2008;55:979–82.
39 Tahara T, Arisawa T, Shibata T, et al. A genetic variant
of the CD14 C-159T in patients with functional dyspepsia
(FD) in Japanese subjects. J Clin Biochem Nutr 2008;42:
104–10.
40 Raghunath AS, Hungin AP, Mason J, Jackson W. Symptoms
in patients on long-term proton pump inhibitors: prevalence
and predictors. Aliment Pharmacol Ther 2009;29:431–9.
35
Helicobacter ISSN 1523-5378
Basic Aspects of Gastric Cancer
Marta Correia,* José Carlos Machado*, and Ari Ristimäkià§
*IPATIMUP – Institute of Molecular Pathology and Immunology of the University of Porto, Porto, Portugal, Faculty of Medicine, University of
Porto, Porto, Portugal, àDepartment of Pathology, Institute of Diagnostics, University of Oulu and Oulu University Hospital, Oulu, Finland,
§
Genome-Scale Biology Research Program, Biomedicum Helsinki, Department of Pathology, Haartman Institute, University of Helsinki, Helsinki, Finland
Keywords
Gastric cancer, H. pylori, polymorphism,
inflammation, dysplasia, stem cell.
Reprint requests to: José Carlos Machado,
IPATIMUP, Rua Dr. Roberto Frias, s ⁄ n,
4200-465 Porto, Portugal.
E-mail: josem@ipatimup.pt
Abstract
Gastric cancer is a worldwide health burden, which is still the second most
common cause of cancer related deaths with little improvement of longterm survival during the past decades. Understanding the molecular nature
of this disease and its precursor lesions has been under intense investigation
and our review attempts to highlight recent progress in this field of cancer
research. First, host-related genetic susceptibility is dealt with genes involved
in inflammation and carcinogen metabolism. Next, role of overexpression of
a proinflammatory cytokine (interleukin-1beta) and deletion of a cell-cell
adhesion molecule (E-cadherin) are described in experimental mouse models of gastric carcinogenesis. Finally, the role of stem cells in gastric cancer is
covered.
Gastric cancer (GC) remains a considerable public
health problem worldwide, and although its incidence
and mortality rates have gradually decreased, GC is second only to lung cancer as the leading cause of cancer
death [1]. The great majority of gastric malignancies are
adenocarcinomas that can be divided into two histologic entities, intestinal and diffuse types, which exhibit
distinct epidemiological and genetic patterns. Curative
treatment of GC requires complete surgical removal of
the neoplastic tissue, but even with curative intent the
5-year survival is only about 20–30%. The high mortality is mostly because of late diagnosis of the disease,
creating an urgent need for new diagnostic markers
and treatment modalities.
A widely accepted model for the development of GC
is that the disease arises from Helicobacter pylori infection
in a susceptible human host [2]. This gram-negative
bacterium is acquired in childhood and persists in the
stomach over decades. Case–control studies have shown
that H. pylori seropositivity is associated with a significantly increased risk of GC (2.1–16.7 times greater than
seronegative persons) [3–5], being considered a causative pathogen for gastric carcinogenesis. Inflammation
may be the key promoting factor in the process of carcinogenesis induced by H. pylori. This bacterium possesses
a unique array of features that makes it highly adapted
to this ecological niche and persistent as a long-term
infection of the gastric mucosa. The infection first
induces chronic superficial (nonatrophic) gastritis,
which can progress through chronic atrophic gastritis,
36
intestinal metaplasia, and dysplasia toward GC. However, only a small number of infected patients will
eventually develop GC (<1%) [6]. Besides family history, which is a risk factor independent of H. pylori
infection, host genetic factors such as genes associated
with inflammatory response probably participate in
stomach carcinogenesis.
Genetic Susceptibility to GC
Susceptibility without evident familial clustering is,
despite presenting the weakest genetic effects, the main
category of inherited susceptibility to cancer. High penetrance of cancer-related genes accounts for a very low
proportion of overall cancer incidence, while cancersusceptible alleles, as a result of their high frequency,
may account for a significant fraction of the overall
cancer incidence. In recent years it has been shown
that polymorphisms in several genes considered to be
critical for gastric carcinogenesis, such as those involved
in the inflammatory response to H. pylori infection
[7–11], in the mucosal protection towards H. pylori
infection [12–15], in the protection of DNA to oxidative
damage [16], and in detoxification enhancement
[17,18], may influence the risk of progression to GC.
The first published epidemiologic evidence indicating
the association between an increased risk of GC and
proinflammatory polymorphisms came from a study of
the interleukin-1-beta (IL-1b) and IL-1 receptor antagonist genes (IL-1RN) [19]. Recently, the EPIC 2008 study
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 36–40
Correia et al.
confirmed that proinflammatory IL-1RN genotypes are
significantly associated with an increased risk of noncardia adenocarcinoma in H. pylori-positive cases [7].
In addition to polymorphisms in interleukin genes,
the polymorphisms in the promoter region of tumor
necrosis factor-alpha (TNF-a) gene have been extensively studied in relation to GC. TNF-a is a pleiotropic
cytokine mostly produced by activated monocytes and
macrophages, which play a key role in the inflammatory response. Although several promoter polymorphisms have already been identified, most studies have
focused on the TNF-a -308G>A single nucleotide polymorphism (SNP). Canedo et al. performed a case-control study for the TNF-a -308G>A polymorphism to
determine the association with the risk of development
of GC [8]. Their results indicate that the detected association between the proinflammatory TNF-308*A allele
and the increased risk of GC is at least partially influenced by linkage disequilibrium (with an as yet unidentified locus) [8]. This study emphasizes the importance
of extending single SNP association studies to haplotype-based approaches.
IL-16 is known for promoting the secretion of tumorassociated inflammatory cytokines by monocytes. Gao
et al. [9] was the first to examine the association
between SNPs of the IL-16 gene and GC. The authors
demonstrated that the rs11556218 T ⁄ G polymorphism
of the IL-16 gene was significantly associated with susceptibility to GC [9]. Interferon gamma (IFNc) is one of
the most important Th1-related cytokines which have
been shown to promote gastritis. Individuals homozygous for the IFNGR1-56*T allele were shown to have a
fourfold increased risk of developing early-onset GC
when compared with those homozygous for the
IFNGR1-56*C allele [10].
Carcinogens and toxins are metabolized via the xenobiotic pathway which is an important defense mechanism against carcinogenesis. Hence, polymorphisms on
enzymes involved in the protection of oxidation and
enhancement of detoxification of carcinogens may
therefore participate in GC. Selenoprotein S (SEPS1) is
a novel selenoprotein located in the endoplasmic reticulum (ER) and plasma membrane. It is involved in the
control of the inflammatory response of ER. SEPS1 protects cells from oxidative damage and apoptosis, and is
widely expressed in a variety of tissues. Recently, the
-105G>A promoter polymorphism of SEPS1 was shown
to be associated with plasma levels of proinflammatory
cytokines, such as IL-1b, IL-6, and TNF-a. It is known
that the substitution of the allele A for G at position 105 reduces the promoter activity in HepG2 cells, and
therefore also the IL-1b levels which are associated
with GC. In a Japanese study comprising 574
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 36–40
Basic Aspects of Gastric Cancer
individuals, it was demonstrated for the first time that
the -105G>A polymorphism of the SEPS1 gene was
associated with an increased risk of intestinal-type GC
[17].
Glutathione-S-transferase (GST) is another important
enzyme catalyzing conjugation of potentially mutagenic
electrophilic compounds, with nucleophilic glutathione
yielding less toxic and more water-soluble compounds,
readily excreted via urine or bile. Both GSTT1 and
GSTM1 genes of the GST super gene family exhibit
either null or deletion polymorphism. Individuals
homozygous for the null allele lack GST enzyme activity and thus have an increased risk for cancer. GSTP1
exhibits a polymorphism within its coding region (A to
G transition at nucleotide +313), which leads to
reduced enzyme activity. Tripathi et al. reported that
the frequency of GSTT1*0 was higher in GC patients
(diffuse-type) than in the controls. Analysis of combined GSTM1*0 and GSTP1*0 frequencies revealed that
simultaneous deletion of both genes was associated
with a 2–5 times higher risk of GC in comparison with
the presence of both the genes [18].
Intestinal-Type GC
Intestinal-type GC is believed to develop by a multistep
process also known as Correa sequence, in which invasive cancer is preceded by atrophic gastritis and metaplastic and dysplastic lesions. Usually this sequence of
events is initiated and promoted by persistent H. pylori
infection. However, only a fraction of infected persons
develop cancer. Therefore, knowledge of cancer risk in
relation to premalignant lesions in the stomach is an
important basis for making decisions on surveillance
and treatment of these patients. Previously reported
progression rates to GC vary considerably and even for
dysplasia the range is as high as from 0% to over 70%
per year. Understandably, surveillance strategies of
patients with such lesions are highly controversial. De
Vries et al. analyzed the GC risk and surveillance practice among Dutch patients (n = 92,250) who were diagnosed with a premalignant lesion in the stomach
between 1991 and 2004 using the Dutch Nationwide
Histopathology Registry [20]. Follow-up data were collected and evaluated until December 2005, and they
show that the distribution of histologic findings were
67% for intestinal metaplasia, 24% for atrophic gastritis, 8% for mild-to-moderate dysplasia, and 0.6% for
severe dysplasia. The annual incidence of GC was 0.1%
for atrophic gastritis, 0.25% for intestinal metaplasia,
0.6% for mild-to-moderate dysplasia, and 6% for severe
dysplasia within 5 years after initial diagnosis. Importantly, only 61% of the patients with severe dysplasia
37
Correia et al.
Basic Aspects of Gastric Cancer
and 26–38% for the other lesions were re-evaluated by
endoscopy. These figures seem alarmingly low, considering that the relative risk for GC in this study was estimated to be about 40-fold for severe dysplasia when
compared with patients having atrophic gastritis. It is
also noted that patients with mild-to-moderate gastric
dysplasia have a similar or even higher risk of cancer
than patients with Barrett’s esophagus. One of the
major conclusions is that endoscopic surveillance at
short intervals is warranted in patients with gastric
dysplasia.
Knowledge of individual risk of progression of premalignant gastric lesions to GC would be useful information in planning surveillance strategies, especially for
low-risk lesions such as atrophic gastritis and intestinal
metaplasia. In addition to environmental factors, distribution and extent of histologic lesions in the stomach,
and H. pylori virulence factors, host genetics play a role
in gastric carcinogenesis. One of the most consistent
and strongest association with GC and polymorphisms
is the IL-1b gene, as recently reviewed by McNamara
and El-Omar [21]). IL-1b is a proinflammatory cytokine
that also inhibits acid secretion in the stomach, and certain polymorphisms in this gene lead to an increased
risk of noncardia GC in the presence of H. pylori infection. Tu et al. have now published a transgenic mouse
model that enlightens the role and possible mechanisms
of the procarcinogenic effects of IL-1b [22]. In this
paper, it is shown that stomach-specific expression of
IL-1b leads to gastric inflammation and eventually to
neoplastic changes, including intramucosal adenocarcinoma, that were more severe when mice were infected
with Helicobacter felis. Furthermore, in this mouse model
myeloid-derived suppressor cells seemed to contribute
to the carcinogenic cascade while T and B cells were
not needed for this phenomenon. Interestingly, IL-1bactivated Nuclear factor-kappaB (NF-jB) in these cells
led to an increase in IL-6 and TNF-a production. It has
been hypothesized that myeloid-derived suppressor cells
could contribute to immunoresponse, angiogenesis, and
tumor invasion. However, since these cells were not
specifically deleted in this study, a role of other cells
(such as neutrophils, macrophages, dendritic cells, myofibroblasts and endothelial cells) cannot be excluded.
This study thus shows that IL-1b is sufficient in promoting inflammation and carcinogenesis in the
stomach.
Tumor suppressor gene p53 is a marker of poor prognosis in many malignant diseases, and inactivating
mutations of the p53 gene can be found in 38–71% of
GC [reviewed in Ref. 23]. In addition, p53 mutations
have already been found in intestinal metaplasia and
in dysplastic lesions, suggesting that the gene’s
38
inactivation may be an early event in gastric carcinogenesis. Indeed, Szoke et al. published that the RR
genotype of codon 72 was found to be associated with
a reduced incidence of intestinal metaplasia among H.
pylori-infected patients [24]. The p53 gene contains several polymorphic sites of which the polymorphism of
codon 72 has been most extensively studied in GC.
However, the results are conflicting, and a recent metaanalysis concluded that the p53 codon 72 polymorphism may be associated with GC but only in Asian
cohorts [25]. One possible explanation for these conflicting results is owing to the fact that the p53 family
also includes other proteins, namely p63 and p73. Both
of these proteins share structural similarity with p53,
activate p53 target genes and are involved in regulation
of apoptosis. The scenario is somewhat complex, since
certain subforms of p63 and p73 proteins can act in a
dominant-negative manner towards p53. Wei et al.
recently demonstrated that H. pylori infection of gastric
epithelial cells in vitro and in vivo in mice lead to
upregulation of p73 protein [26]. These results suggest
that p73 may play an important role in the pathogenesis
associated with H. pylori infection, and that alterations
in p73 gene may play a role in gastric carcinogenesis.
Diffuse-Type GC
Intestinal-type GC predominates in high-risk geographic
areas and shows a correlation with the prevalence of H.
pylori infection. Diffuse-type GC, in contrast, is more
uniformly distributed and is apparently unrelated to H.
pylori prevalence. Owing to its development underneath
the gastric mucosal surface, diffuse GC is usually
diagnosed at an advanced stage and is consequently
associated with a poorer outcome. It can be further subdivided into poorly differentiated carcinoma, and
signet-ring cell carcinoma (SRCC). It is suggested that
the latter is an initial, differentiated form of diffuse GC
that may evolve into poorly differentiated carcinoma
[27]. Moreover, and despite the decreasing incidence of
GC worldwide, the incidence of diffuse GC in the form
of SRCC is increasing. At the molecular level, diffusetype GC can be distinguished from intestinal-type GC
on the basis of the cell–cell adhesion molecule, E-cadherin. This molecule is the key component of the epithelial adherens junction and as such is required for
functional intercellular adhesion within epithelial
sheets. E-cadherin is downregulated very early during
diffuse GC development, suggesting a role in the
initiation of this disease. In fact, a causal relationship
between E-cadherin deficiency and the initiation of
diffuse GC has been established. In a N-methyl-N-nitrosourea-treated mice model homizygous for the
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 36–40
Correia et al.
E-cadherin gene (cdh1+ ⁄ )), the presence of a second
CDH1 hit is the earliest observable stage of human diffuse GC, also providing evidence for epigenetic downregulation of E-cadherin as an initiator of malignancy
[28].
An alternative mechanism to explain loss of function
of E-cadherin in diffuse-type gastric transformation may
involve the epithelial–mesenchymal transition (EMT)
regulator TWIST through crosstalk with Hedgehog (Hh)
signaling. The Hh signal activation selectively occurs in
diffuse-type GC and blocking of Hh signaling inhibits
the growth of GC cells [29]. Transforming growth factor-b (TGF-b), which is a multifunctional cytokine, is a
potent inhibitor of epithelial cell proliferation. Moreover, TGF-b may promote tumor growth by inducing
the epithelial cells to undergo EMT. Inhibition of TGF-b
signaling has also been reported to prevent progression
and metastasis onset in diffuse GC, mainly because of
its ability to enhance angiogenesis [30].
Role of Stem Cells in GC
In the last years several lines of evidence have suggested that stem cells play an important role in gastric
carcinogenesis. Houghton et al. showed that H. pyloriinduced inflammation can cause migration of bone
marrow-derived stem cells to the gastric mucosa, where
they may subsequently transform into GC lineages
[31]. McDonald et al. demonstrated that mitochondrial
DNA (mtDNA) mutations establish themselves in stem
cells within normal human gastric body units, and are
passed on to all their differentiated progeny [32].
Mutated units can divide by fission to form patches,
with each unit sharing an identical, mutant mtDNA
genotype. These data show that human gastric body
units are clonal, contain multiple multipotential stem
cells, and provide definitive evidence for how mutations spread within the human stomach, and show how
field cancerization develops [32].
Apart from its role in embryonic development and
tissue regeneration, Hh signaling is involved in adult
stem cell maintenance. Hh signaling is activated in GC
tumors, and appears to be crucial for the differentiation of gastric progenitor cells into mucus and parietal
cells [33]. The proposed model is that cancer develops
from tissue progenitor cells after chronic stimulation
from various injuries (e.g. H. pylori-persistent infection), and that during the repair process, developmental signaling pathways activate tissue progenitor cells.
Chronic stimulation may ultimately result in irreversible activation of the signaling pathways which leads
to cancer formation. Mesenchymal stem cells (MSCs),
a subtype of stem cells with great capacity of self-
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 36–40
Basic Aspects of Gastric Cancer
renewal and differentiation, have been isolated from
several tumors. The question of whether a group of
MSCs exists in GC has arisen and, for the first time,
MSCs have been isolated from tumors of GC patients
[34]. Altogether, the expanding field of gastric cancer
stem cell biology may offer novel avenues of research
with impacts on the diagnosis and treatment of
cancer.
Conflicts of Interest
The authors have declared no conflicts of interest.
References
1 Parkin DM, Bray F, Ferlay J, Pisani P. Global cancer statistics.
CA Cancer J Clin 2002;55:74–108.
2 Suerbaum S, Michetti P. Helicobacter pylori infection. N Engl J
Med 2002;347:1175–86.
3 Forman D, Newell DG, Fullerton F, Yarnell JW, Stacey AR,
Wald N, Sitas F. Association between infection with Helicobacter
pylori and risk of gastric cancer: evidence from a prospective
investigation. BMJ 1991;302:1302–5.
4 Nomura A, Stemmermann GN, Chyou PH, Kato I, Perez-Perez
GI, Blaser MJ. Helicobacter pylori infection and gastric carcinoma
among Japanese Americans in Hawaii. N Engl J Med
1991;325:1132–6.
5 Parsonnet JH, Orentreich N, Sibley RK. Helicobacter pylori infection and the risk of gastric carcinoma. N Engl J Med
1991;325:1127–31.
6 Parsonnet J, Friedman GD, Orentreih N, Vogelman H. Risk for
gastric cancer in people with CagA positive or CagA negative
Helicobacter pylori infection. Gut 1997;40:297–301.
7 Crucius JBA, Canzian F, Capellá G, et al. Cytokine gene
polymorphisms and the risk of adenocarcinoma of the stomach
in the European prospective investigation into cancer
and Nutrition (EPIC-EURGAST). Ann Oncol 2008;19:
1894–902.
8 Canedo P, Duraes C, Pereira F, Regalo G, Lunet N, Barros H,
Carneiro F, Seruca R, Rocha J, Machado JC. Tumor necrosis
factor alpha extended haplotypes and risk of gastric carcinoma.
Cancer Epidemiol Biomarkers Prev 2008;17:2416–20.
9 Gao LB, Rao L, Wang YY, et al. The association of interleukin-16
polymorphisms with IL16 serum levels and risk of colorectal and
gastric cancer. Carcinogenesis 2009;30:295–9.
10 Canedo P, Corso G, Pereira F, et al. The interferon gamma
receptor 1(IFNGR1) 56C ⁄ T gene polymorphism is associated
with increased risk of early gastric carcinoma. Gut
2009;57:1504–8.
11 Lo S, Chen J, Wu C, Lui W. Functional polymorphism of
NFKB1 promoter may correlate to the susceptibility of gastric
cancer in aged patients. Surgery 2009;145:280–5.
12 Hishida A, Matsuo K, Goto Y, Mitsuda Y, Hiraki A, Naito M,
Wakai K, Tajima K, Hamajima N. Toll-like receptor 4+ 3275 G ⁄ C
polymorphism, Helicobacter pylori seropositivity, and the risk of
gastric atrophy and gastric cancer in Japanese. Helicobacter
2009;14:47–53.
13 Shibata T, Arisawa T, Tahara T, et al. Protective role of genetic
polymorphism of heat shock protein 70-2 for gastric cancer
risk. Dig Dis Sci 2009;54:70–4.
39
Basic Aspects of Gastric Cancer
14 Zhang Y, Jin M, Liu B, Ma X, Kaiyan Y, Li Q, Chen K. Association between H-RAS T81C genetic polymorphism and gastrointestinal cancer risk: a population based case-control study in
China. BMC Cancer 2008;8:256–63.
15 Sawa T, Mounawar M, Tatemichi M, Gilibert I, Katoh T, Ohshima H.
Increased risk of gastric cancer in Japanese subjects is associated
with microsatellite polymorphisms in the heme oxygenase- and
the inducible nitric oxide synthase gene promoters. Cancer Lett
2008;269:78–84.
16 Capella G, Pera G, Sala N, et al. DNA repair polymorphisms
and the risk of stomach adenocarcinoma and severe chronic
gastritis in the EPIC–EURGAST study. Int J Epidemiol
2008;37:1316–25.
17 Shibata T, Arisawa T, Tahara T, et al. Selenoprotein S (SEPS1)
gene -105G>A promoter polymorphism influences the susceptibility to gastric cancer in the Japanese population. BMC Gastroenterol 2009;9:2.
18 Tripathi S, Ghoshal U, Ghoshal U, Mittal B, Krishnani N,
Chourasia D, Agasrwal A, Singh K. Gastric carcinogenesis: possible role of polymorphisms of GSTM1, GSTT1, and GSTP1
genes. Scand J Gastroenterol 2008;43:431–9.
19 El-Omar EM, Carrington M, Chow WH, et al. Interleukin-1
polymorphisms associated with increased risk of gastric cancer.
Nature 2000;404:398–402.
20 de Vries AC, van Grieken NC, Looman CW, Casparie MK,
de Vries E, Meijer GA, Kuipers EJ. Gastric cancer risk in
patients with premalignant gastric lesions: a nationwide cohort
study in the Netherlands. Gastroenterology 2008;134:945–52.
21 McNamara D, El-Omar E. Helicobacter pylori infection and the
pathogenesis of gastric cancer: a paradigm for host–bacterial
interactions. Dig Liver Dis 2008;40:504–9.
22 Tu S, Bhagat G, Cui G, et al. Overexpression of interleukin1beta induces gastric inflammation and cancer and mobilizes
myeloid-derived suppressor cells in mice. Cancer Cell
2008;14:408–19.
23 Kountouras J, Zavos C, Chatzopoulos D, Katsinelos P. New
aspects of Helicobacter pylori infection involvement in gastric
oncogenesis. J Surg Res 2008;146:149–58.
40
Correia et al.
24 Szoke D, Molnár B, Solymosi N, Sipos F, Galamb O, Gyorffy A,
Tulassay Z. The RR genotype of codon 72 of p53 gene reduces
the development of intestinal metaplasia. Dig Liver Dis
2009;41:179–84.
25 Zhou Y, Li N, Zhuang W, Liu GJ, Wu TX, Yao X, Du L, Wei
ML, Wu XT. P53 codon 72 polymorphism and gastric cancer: a
meta-analysis of the literature. Int J Cancer 2007;121:1481–6.
26 Wei J, O’Brien D, Vilgelm A, Piazuelo MB, Correa P, Washington MK, El-Rifai W, Peek RM, Zaika A. Interaction of Helicobacter pylori with gastric epithelial cells is mediated by the p53
protein family. Gastroenterology 2008;134:1412–23.
27 Humar B, Fukuzawa R, Blair V, et al. Destabilized adhesion in
the gastric proliferative zone and Src kinase activation mark
the development of early diffuse gastric cancer. Cancer Res
2007;67:2480–9.
28 Humar B, Blair V, Charlton A, More H, Martin I, Guildford P.
E-cadherin deficiency initiates gastric signet-ring cell carcinoma
in mice and man. Cancer Res 2009;69:2050–6.
29 Ohta H, Aoyagi K, Fukaya M, et al. Cross talk between Hedgehog and epithelial-mesenchymal transition pathways in gastric
pit cells and in diffuse-type gastric cancers. BJC 2009;100:
389–98.
30 Komuro A, Yashiro M, Iwata C, et al. Diffuse-type gastric
carcinoma: progression, angiogenesis, and transforming growth
factor b signaling. J Natl Cancer Inst 2009;101:592–604.
31 Houghton JM, Stoicov C, Nomura S, et al. Gastric cancer
originating from bone marrow derived cells. Science 2004;306:
1568–71.
32 McDonald S, Greaves L, Gutierrez-Gonzalez L, et al. Mechanisms
of field cancerization in the human stomach: the expansion
and spread of mutated gastric stem cells. Gastroenterology
2008;134:500–10.
33 Kang D, Han M, Song M, et al. The role of Hedgehog signaling
during gastric regenaration. J Gastroenterol 2009;44:372–9.
34 Cao H, Xu W, Qian H, et al. Mesenchymal stem cell-like cells
derived from human gastric cancer tissues. Cancer Lett
2009;274:61–71.
ª 2009 The Authors
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Helicobacter ISSN 1523-5378
Helicobacter pylori and Clinical Aspects of Gastric Cancer
Jan Bornschein,* Theodore Rokkas, Michael Selgrad* and Peter Malfertheiner*
*Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke-University of Magdeburg, Magdeburg, Germany,
Gastroenterology Clinic, Henry Dunant Hospital, Athens, Greece
Keywords
Gastric cancer, H. pylori, eradication therapy,
screening, cost-effectiveness, intestinal
metaplasia, glandular atrophy, endoscopic
resection, D2 lymphadenectomy, prevention
strategies
Reprint requests to: P20 ⁄ D2 Peter Malfertheiner,
Department of Gastroenterology, Hepatology
and Infectious Diseases, Otto-von-GuerickeUniversity of Magdeburg, Leipziger Str. 44,
D-39120 Magdeburg, Germany. Tel.: 0049 391
6713100; Fax: 0049 391 6713105;
E-mail: peter.malfertheiner@med.ovgu.de
Abstract
In spite of important new insights into the basic mechanisms of gastric carcinogenesis, progress in the management of gastric cancer has been modest.
Some modifications in the chemotherapies used for palliation and strategies
for downstaging of the disease prior to surgical intervention are noteworthy.
The positive experience with endoscopic mucosal resection (EMR) and
submucosal dissection (ESD) for treatment of early gastric cancer has been
confirmed and extended. The procedure-related morbidity and post-interventional quality of life is clearly favorable compared to open surgical
resection in well-selected patients. New data on Helicobacter pylori revealed
that eradication after endoscopic resection of early gastric cancer significantly reduces the incidence of recurrent and metachronous gastric neoplasias. It can further improve healing rates of treatment induced gastric ulcers.
Eradication therapy therefore remains the best target for prevention of the
disease. Critical is the ‘‘point of no return’’ when mucosal alterations (i.e.
intestinal metaplasia, glandular atrophy) are no longer reversible. A population-based screen-and-eradicate strategy for H. pylori infection can at present
only be recommended in high incidence regions.
Early diagnosis and efficient therapy for gastric cancer
(GC) remain an ongoing challenge for health systems
worldwide [1]. Approximately 80% of patients are diagnosed in an advanced stage with no curative treatment
options. Surgical treatment with curative intent has a
general 5-year survival rate of approximately 24% [2].
Currently, the major task is to define a general applicable stage-adjusted algorithm that not only respects the
outcome of each treatment modality concerning mortality and morbidity, but also the post-interventional
quality of life.
Development of adequate regimes for adjuvant as
well as neoadjuvant or peri-operative systemic chemotherapy will have a significant role in the future [3,4].
For palliative chemotherapy taxan- and platinum-based
combination-therapies are the standard of care. Modified regimens are under evaluation to lower treatmentrelated toxicities and to improve the quality of life
[5–10].
This review gives a brief overview of articles published between March 2008 and April 2009 on the
achievements in prevention, diagnosis and management
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 41–45
of GC with an emphasis on H. pylori eradication as a
means for successful prevention.
Primary Staging
Park et al. evaluated the diagnostic potential of EUS
compared with multidetector-CT for restaging of patients after neoadjuvant systemic therapy (Docetaxel in
combination with Cisplatin) in 40 Korean patients [11].
Both modalities revealed comparable results, but in a
multivariate analysis EUS-documented downstaging
was an independent prognostic factor for overall survival. In conclusion, EUS should be standard for evaluation of local tumor response after neoadjuvant
treatment [11].
Nitti et al. evaluated the prognostic value of subclassification of T2-stage disease into T2a (muscularis propria) and T2b (subserosa) and related treatment
algorithms [12]. In a retrospective analysis of 373
patients treated for GC with curative intention, the
tumor-related mortality risk for the T2a stage was comparable to the T1 stage whereas for the T2b stage it was
41
Treatment and Prevention of Gastric Cancer 2009
similar to the T3 stage disease. Thus, subclassification of
T2-tumors is recommended for planning the therapeutic strategy [12].
Curative Gastric Resection
Laparoscopic resection has been shown to be a safe and
adequate curative treatment in early gastric cancer
(EGC), including stage I and II tumors [13]. This
approach results in favorable outcome not only concerning treatment-related aspects (e.g. intraoperative
blood loss, total amount of analgetics used, post-operative hospitalization period) but also concerning physical, emotional, social and general symptom scales
compared to open gastrectomy [14].
In a Korean study open partial gastrectomy was compared with total gastrectomy Although overall survival
was comparable in both groups (99.2% vs 98.5%,
respectively, at final follow-up), post-operative complications occurred significantly more often in patients
that had only proximal gastrectomy (61.8% vs 12.6%)
[15]. Therefore, total gastrectomy and Roux-en-Y anatomical reconstruction is superior to limited proximal
resection concerning post-operative complications.
There is still ongoing debate about the required
extent of lymphadenectomy for adequate curative treatment of localized GC. In Asian countries, D2 lymph
node dissection represents the standard of care whereas
in several Western countries D1 dissection is still
performed.
Sasako et al. evaluated the efficacy and safety profile
of additional dissection of the paraaortic lymph nodes
(PAND) in comparison to regular D2 lymphadenectomy
in patients with preoperative tumor stage of T2b, T3 or
T4 [16]. Major surgical complications (e.g. anastomotic
leakage, pancreatic fistula, abdominal abcess) were not
statistically different between the groups. There was no
difference in 5-year overall survival between patients
with D2 or D2 + PAND dissection (69.2% vs 70.3%,
respectively; HR 1.03; 95% CI 0.77–1.37). In conclusion, more extended lymphnode dissection than D2
cannot be recommended for standard GC treatment
[16].
Bornschein et al.
[17]. Generally this approach was only legitimate for
mucosal defined tumors, whereas by the recently introduced technique of endoscopic submucosal dissection
(ESD), tumors involving the upper submucosal layers
can also be treated using an insulation-tipped diathermy knife (alternatively a hook knife). A further
advantage of this method is the ‘‘en bloc’’ resection of
the specimen that allows a more precise pathological
assessment concerning gross and microscopically complete tumor resection.
In a feasibility study in Japan, 551 consecutive
patients with 589 EGCs were treated with ESD and
received a median follow-up of 30 months (6–89) [18].
Inclusion criteria were (1) mucosal cancer with ulcer
findings and largest diameter £3 cm, and (2) minute
submucosal invasive cancer with largest diameter
£3 cm (<500 lm distance from the muscularis mucosa).
Curative resection was achieved, when vertical and lateral tumor margins were free of malignant tissue, no
submucosal invasion deeper than 500 lm from the
muscularis mucosa was detected, and lymphatic or vascular involvement was absent.
‘‘En bloc’’ resection was achieved in 94.4% with
94.7% defined as curative resection. There were no
treatment related deaths; minor complications were
bleeding (1.8%) or perforation (4.5%), both being
endoscopically manageable in all cases. During followup, local recurrence was documented in three cases
only with non-curative resection and in one case after
piece-meal resection (all of these cases underwent gastrectomy with D2 lymph node dissection). Metachronous GC occurred in 13 patients after curative
resection, and in one after non-curative resection
within 12–42 months. The 3-year and 5-year survival
rates were 98.4 and 97.1%, respectively, with death
occurring due to other tumors or heart disease [18].
Long-term follow-up data are needed for an adequate
comparison with related outcome of surgical
procedures.
Rescue treatment after non-curative resection should
be surgical. However, for well-selected patients
re-endoscopic treatment could be considered [19,20].
Endoscopic Versus Surgical Treatment
Helicobacter pylori Eradication in the
Prevention of Recurrence
Endoscopic treatment of EGC is an established method
for a curative attempt because of a significant improvement in quality of life in comparison to more radical
surgical techniques. Standard procedure represents the
endoscopic mucosal resection (EMR) for elevated EGC
<2 cm in diameter and small (<1 cm) depressed tumors
without ulceration according to the Japanese guidelines
The efficacy of primary prevention of GC by eradication
of H. pylori has been confirmed in several studies [21].
An important issue was that once preneoplastic changes
(gastric atrophy and intestinal metaplasia) are established, prevention of further progression to invasive
cancer is more unlikely to occur [22]. The so-called
‘‘point of no return’’ has been identified to be critical
42
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 41–45
Bornschein et al.
for an effective prevention of GC incidence or recurrence. Watari et al. examined the effect of H. pylori
eradication on the histology and cellular phenotype of
gastric intestinal metaplasia. They showed that H. pylori
eradication changes the cellular phenotype of gastric
intestinal metaplasia, which might be an important factor in the reduction of gastric cancer incidence after
successful eradication [23].
Unexpectedly and with more question marks on the
‘‘point of no return’’ theory, Fukase et al. demonstrated
that even after endoscopic resection of early GC, recurrence of metachronous GC is significantly reduced by
H. pylori eradication [24].
In a multicenter, open-label randomized trial, 544
patients who underwent EMR of EGC received either
eradication treatment against H. pylori (lansoprazole
30 mg, amoxicillin 750 mg and clarithromycin 200 mg,
each twice daily) or a placebo regimen. Follow-up
endoscopy was performed at 6, 12, 24 and 36 months.
Primary endpoint of the intention-to-treat analysis was
occurrence of GC at a site other than the primary treated site of the stomach (metachronous GC). At the
3-year-follow-up, metachronous GC developed in 9 of
272 patients who received eradication treatment (3.3%)
and in 24 of the 272 placebo patients (8.8%) resulting
in an odds ratio (OR) of 0.353 (95% CI 0.161–0.775,
p = 0.009). In the modified intention-to-treat analysis
adjusted for loss to follow-up and respecting the patient
population that had received at least one posttreatment assessment of tumor status, an HR for metachronous GC of 0.339 was documented (95% CI 0.157–
0.729; p = 0.003). From these findings, it can be stated
that eradication of H. pylori is an effective method for
prevention of metachronous GC after endoscopic treatment of EGC and should be routinely applied. These
data confirm previous observations which have been
published by other authors [25,26].
A further beneficial effect of post-interventional eradication of H. pylori was demonstrated by Cheon et al.
[27]. Of 47 patients who had undergone EMR for EGC,
in 21 H. pylori infection was cured whereas 26 patients
were either treated with a proton-pump inhibitor (PPI)
alone or the eradication therapy failed. At 4 weeks
post-treatment, there was a significant difference concerning healing of the treatment-induced ulcers, with
the group with successful H. pylori eradication showing
superior ulcer reduction rates [27].
Precancerous Lesions
For adequate individualized risk assessment in planning
prevention strategies, the question of whether gastric
atrophy and intestinal metaplasia (IM) are premalignant
ª 2009 The Authors
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Treatment and Prevention of Gastric Cancer 2009
rather than paramalignant lesions is still under debate.
Most data point to an increased risk of gastric carcinogenesis if glandular atrophy, IM and even more so if
dysplastic changes are detected [28].
In a large retrospective analysis, de Vries et al. evaluated data of 92,250 patients who were filed in the
Dutch Nationwide Histopathology Registry for the period from 1991 until 2004. Follow-up of the registered
patients was analyzed until 2005 [29]. Among these
patients 22,365 (24%) were diagnosed with atrophic
gastritis, 61,707 (67%) with IM, 7616 (8%) with
mild ⁄ moderate dysplasia and 562 (0.6%) with severe
dysplasia. Endoscopic and histopathologic follow-up
was performed in 26% of patients with atrophic gastritis, 28% with IM, and 38% with mild ⁄ moderate dysplasia compared to 61% with severe dysplasia (p < 0.001).
In the follow-up group, the annual incidence of GC
increased according to the severity of the mucosal alteration present in 0.1% for patients with atrophic gastritis, 0.25% with IM, 0.6% with mild ⁄ moderate dysplasia
and 6% with severe dysplasia. The resulting HR for
severe dysplasia was 40.14 (95% CI 32.2–50.1). Further
independent risk factors in the multivariate analysis
were male gender (HR 1.5; 95% CI 1.3–1.7) and age
(HR for 75–84 years 3.75; 95% CI 2.8–5.1) [29].
The cancer risk in patients with mild ⁄ moderate dysplasia was comparable to the risk for the development
of colorectal cancer after removal of colonic adenomas.
However, no recommendation for surveillance has been
proposed. So far, the best estimate for the regression in
histopathology scores can be calculated as a function of
the square of the time the patient is H. pylori negative
after eradication therapy [30]. There is an important
need for guidelines to determine at what intervals
patients will require endoscopic control.
Population-based Screening
Population-based screening and treatment of H. pylori
infection most likely represents the current best option
for primary prevention of GC, but several aspects need
to be considered, such as timing, methods and costeffectiveness in various regions of the world. Certain
populations, such as those in East Asia, have a high
incidence of GC compared to populations in Africa,
South Asia or Europe and this is probably linked with
certain H. pylori strains. In high risk populations, mainly
H. pylori with East Asian type CagA are present [31].
In a recent calculation for a high risk region in
China, an empirically calibrated model of GC was used
to estimate the reduction of lifetime cancer risk, lifeexpectancy and screening, as well as treatment-related
costs [32]. Three options were considered: (i) single
43
Bornschein et al.
Treatment and Prevention of Gastric Cancer 2009
lifetime screening at age 20, 30 or 40; (ii) single lifetime
screening followed by rescreening individuals with negative results, and (iii) universal treatment for H. pylori
infection at age 20, 30 or 40.
Screening and treatment in individuals at the age of
20 resulted in adequate reduction of the lifetime risk
for GC (males: 14.5%; females 26.6%) with costs below
US$1500 per life year saved. By application of universal
treatment, the risk reduction was even increased by
1.5% and 2.3%, respectively, but the incremental costeffectiveness rates exceeded US$2500 per life ⁄ year
saved. Assessing persons at an older age or rescreening
of negative individuals was not cost-effective. Results of
prospective trials on a global scale are needed to support these theoretical estimations.
7
8
9
10
11
Conclusion
The development of EMR ⁄ ESD enables a better curative
access with preservation of a good quality of life in
EGC. Palliative therapies for GC have still not achieved
an important breakthrough. In the development of
cost-effective primary prevention strategies the detection and treatment of H. pylori infection is the best
available option [33]. Treatment of the infection is
never too late as it also has the potential to prevent
recurrence of GC as well as development of metachronous GC after endoscopic resection in some patients.
Conflict of Interest
P. Malfertheiner is involved in advisory boards and lectures with Astra Zeneca, Nycomed, Abbott and Novartis.
All other authors have declared no conflicts of interest.
References
1 Parkin DM, Bray F, Ferlay J, Pisani P. Global cancer statistics,
2002. CA Cancer J Clin 2005;55:74–108.
2 Coleman MP, Gatta G, Verdecchia A, Esteve J, Sant M, Storm H,
Allemani C, Ciccolallo L, Santaquinali M, Berrino F. EUROCARE-3 summary: cancer survival in Europe at the end of the
20th century. Ann Oncol 2003;5(Suppl. 14):v128–49.
3 Cunningham D, Allum WH, Stenning SP, Thompson JN, Van d V,
Nicolson M, et al. Perioperative chemotherapy versus surgery
alone for resectable gastroesophageal cancer. N Engl J Med
2006;355:11–20.
4 Sun P, Xiang JB, Chen ZY. Meta-analysis of adjuvant chemotherapy after radical surgery for advanced gastric cancer. Br J
Surg 2009;96:26–33.
5 Schonnemann KR, Jensen HA, Yilmaz M, Jensen BY, Larsen
O, Pfeiffer P. Phase II study of short-time oxaliplatin, capecitabine and epirubicin (EXE) as first-line therapy in patients with
non-resectable gastric cancer. Br J Cancer 2008;99:858–61.
6 Jung JY, Kwon JH, Kim JH, Song HH, Kim I, Lee KS, et al.
Phase II study of the paclitaxel, cisplatin, 5-fluorouracil and
44
12
13
14
15
16
17
18
19
20
21
22
23
leucovorin (TPFL) regimen in the treatment of advanced or
metastatic gastric cancer. Oncol Rep 2009;21:523–9.
Lin RB, Fan NF, Guo ZQ, Wang XJ, Liu J, Chen L. A phase II
study of 5-fluorouracil ⁄ leucovorin in combination with paclitaxel and oxaliplatin as first-line treatment for patients with
advanced gastric cancer. J Chemother 2008;20:744–8.
Nagata N, Kimura M, Hirabayashi N, Tuburaya A, Murata T,
Kondo K, et al. Phase II study of weekly paclitaxel and cisplatin
combination therapy for advanced or recurrent gastric cancer.
Hepatogastroenterology 2008;55:1846–50.
Emi Y, Yamamoto M, Takahashi I, Orita H, Kakeji Y, Kohnoe
S, et al. Phase II study of weekly paclitaxel by one-hour infusion for advanced gastric cancer. Surg Today 2008;38:1013–20.
Lee JJ, Kim SY, Chung HC, Lee KH, Song HS, Kang WK, et al.
A multi-center phase II study of S-1 plus paclitaxel as first-line
therapy for patients with advanced or recurrent unresectable
gastric cancer. Cancer Chemother Pharmacol 2009;63:1083–90.
Park SR, Lee JS, Kim CG, Kim HK, Kook MC, Kim YW, et al.
Endoscopic ultrasound and computed tomography in restaging
and predicting prognosis after neoadjuvant chemotherapy in
patients with locally advanced gastric cancer. Cancer
2008;112:2368–76.
Nitti D, Marchet A, Mocellin S, Rossi GM, Ambrosi A, Mencarelli R. Prognostic value of subclassification of T2 tumours in
patients with gastric cancer. Br J Surg 2009;96:398–404.
Zhang X, Tanigawa N, Nomura E, Lee SW. Curability of laparoscopic gastrectomy for gastric cancer: an analysis of 10 years’
experience. Gastric Cancer 2008;11:175–80.
Kim W, Song KY, Lee HJ, Han SU, Hyung WJ, Cho GS. The
impact of comorbidity on surgical outcomes in laparoscopyassisted distal gastrectomy: a retrospective analysis of multicenter results. Ann Surg 2008;248:793–9.
An JY, Youn HG, Choi MG, Noh JH, Sohn TS, Kim S. The difficult choice between total and proximal gastrectomy in proximal early gastric cancer. Am J Surg 2008;196:587–91.
Sasako M, Sano T, Yamamoto S, Kurokawa Y, Nashimoto A,
Kurita A, et al. D2 lymphadenectomy alone or with para-aortic
nodal dissection for gastric cancer. N Engl J Med 2008;359:
453–62.
Japanese Gastric Cancer Association. Japanese Classification of
Gastric Carcinoma - 2nd English Edition. Gastric Cancer
1998;1:10–24.
Isomoto H, Shikuwa S, Yamaguchi N, Fukuda E, Ikeda K,
Nishiyama H, et al. Endoscopic submucosal dissection for early
gastric cancer: a large-scale feasibility study. Gut 2009;58:331–6.
Song KY, Park SM, Kim SN, Park CH. The role of surgery in
the treatment of recurrent gastric cancer. Am J Surg 2008;
196:19–22.
Oda I, Gotoda T, Sasako M, Sano T, Katai H, Fukagawa T, et al.
Treatment strategy after non-curative endoscopic resection of
early gastric cancer. Br J Surg 2008;95:1495–500.
Fuccio L, Zagari RM, Minardi ME, Bazzoli F. Systematic review:
Helicobacter pylori eradication for the prevention of gastric
cancer. Aliment Pharmacol Ther 2007;25:133–41.
Wong BC, Lam SK, Wong WM, Chen JS, Zheng TT, Feng RE,
et al. Helicobacter pylori eradication to prevent gastric cancer in a
high-risk region of China: a randomized controlled trial. JAMA
2004;291:187–94.
Watari J, Das KK, Amenta PS, Tanabe H, Tanaka A, Geng X,
et al. Effect of eradication of Helicobacter pylori on the histology
and cellular phenotype of gastric intestinal metaplasia. Clin
Gastroenterol Hepatol 2008;6:409–17.
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 41–45
Bornschein et al.
24 Fukase K, Kato M, Kikuchi S, Inoue K, Uemura N, Okamoto S,
et al. Effect of eradication of Helicobacter pylori on incidence of
metachronous gastric carcinoma after endoscopic resection of
early gastric cancer: an open-label, randomised controlled trial.
Lancet 2008;372:392–7.
25 Uemura N, Mukai T, Okamoto S, Yamaguchi S, Mashiba H,
Taniyama K, et al. Effect of Helicobacter pylori eradication on subsequent development of cancer after endoscopic resection of early
gastric cancer. Cancer Epidemiol Biomarkers Prev 1997;6:639–42.
26 Nakagawa S, Asaka M, Kato M, Nakamura T, Kato C, Fujioka T,
et al. Helicobacter pylori eradication and metachronous gastric
cancer after endoscopic mucosal resection of early gastric cancer. Aliment Pharmacol Ther 2006;24(Suppl. 4):214–8.
27 Cheon JH, Kim JH, Lee SK, Kim TI, Kim WH, Lee YC. Helicobacter pylori eradication therapy may facilitate gastric ulcer healing after endoscopic mucosal resection: a prospective
randomized study. Helicobacter 2008;13:564–71.
28 Ohata H, Kitauchi S, Yoshimura N, Mugitani K, Iwane M,
Nakamura H, et al. Progression of chronic atrophic gastritis
associated with Helicobacter pylori infection increases risk of
gastric cancer. Int J Cancer 2004;109:138–43.
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 41–45
Treatment and Prevention of Gastric Cancer 2009
29 de Vries AC, van Grieken NC, Looman CW, Casparie MK,
de VE, Meijer GA, et al. Gastric cancer risk in patients with
premalignant gastric lesions: a nationwide cohort study in the
Netherlands. Gastroenterology 2008;134:945–52.
30 Mera R, Fontham ET, Bravo LE, Bravo JC, Piazuelo MB,
Camargo MC, et al. Long term follow up of patients treated for
Helicobacter pylori infection. Gut 2005;54:1536–40.
31 Yamaoka Y, Kato M, Asaka M. Geographic differences in gastric
cancer incidence can be explained by differences between
Helicobacter pylori strains. Intern Med 2008;47:1077–83.
32 Yeh JM, Kuntz KM, Ezzati M, Goldie SJ. Exploring the costeffectiveness of Helicobacter pylori screening to prevent gastric
cancer in China in anticipation of clinical trial results. Int J
Cancer 2009;124:157–66.
33 Talley NJ, Fock KM, Moayyedi P. Gastric Cancer Consensus
conference recommends Helicobacter pylori screening and
treatment in asymptomatic persons from high-risk
populations to prevent gastric cancer. Am J Gastroenterol
2008;103:510–4.
45
Helicobacter ISSN 1523-5378
Treatment of Helicobacter pylori Infection
Anthony O’Connor, Javier Gisbert* and Colm O’Morain
Department of Gastroenterology, Adelaide and Meath Hospital incorporating the National Children’s Hospital Tallaght, Trinity College Dublin,
Dublin, Ireland, *Gastroenterology Unit, La Princesa University Hospital, and Centre de Investigación Biomédica en Red de Enfermedades Hepáticas
y Digestivas (CiBEREHD), Madrid, Spain
Keywords
Helicobacter, triple therapy, second-line
therapy, rescue therapy, susceptibility testing,
sequential therapy, compliance.
Reprint requests to: Colm O’Morain, Department of Gastroenterology, Adelaide and Meath Hospital incorporating the National
Children’s Hospital Tallaght, Trinity College
Dublin, Dublin, Ireland.
E-mail: gastroenterology@amnch.ie
Abstract
This article aims to examine current best practice in the field reference to
first-line, second-line, rescue and emerging treatment regimens for Helicobater pylori eradication. The recommended first-line treatment in published
guidelines in Europe and North American is proton pump inhibitor combined with amoxicillin and clarithromycin being the favoured regimen.
Rates of eradication with this regimen however are falling alarmingly due to
a combination of antibiotic resistance and poor compliance with therapy.
Bismuth based quadruple therapies and levofloxacin based regimes have
been shown to be effective second line regimens. Third-line options include
regimes based on rifabutin or furazolidone, but susceptibility testing is the
most rational option here, but is currently not used widely enough. Sequential therapy is promising but needs further study and validation outside of
Italy. Although the success of first line treatments is falling, if compliance is
good and a clear treatment paradigm adhered to, almost universal eradication rates can still be achieved. If compliance is not achievable, the problem
of antibiotic resistance will continue to beset any combination of drugs used
for H. pylori eradication.
The treatment of Helicobacter pylori infection has posed
conundrums for clinicians since the bacterium was first
discovered in the early 1980s. The challenges go
beyond finding the correct combination of antibiotics
and manipulation of gastric pH to ensure eradication
and include avoiding the development of antimicrobial
resistance and ensuring compliance with prescribed
treatment. The Maastricht-III consensus stated that for
an eradication treatment regime to be considered effective, it would need to achieve an intention-to-treat
eradication rate in excess of 80% [1]. However, in
recent times, eradication rates in practice for many of
the most common regimens have fallen well below
these levels, generally due to the interwoven factors of
poor compliance with medication and antibiotic resistance [2].
First-Line Therapy (Standard Triple
Therapy)
The combination of a proton pump inhibitor (PPI) with
two antibiotics has been accepted as the first-line
therapy of choice for H. pylori eradication since a
randomized control trial in 1996 [3]. The recommended
first-line treatment in published guidelines in Europe
46
and North America reflect this with PPI combined with
amoxicillin and clarithromycin being the favored regimen [1,4]. However, some caveats have been applied to
these guidelines in recent years to take into account falling eradication rates. As recently as 2000, studies had
suggested eradication rates for standard triple therapy
were in excess of 90% [5]. However, more recent publications have suggested that this level has fallen alarmingly to be around 70% in many areas and even as low
as 60% in some [6,7]. For instance, the most recent Maastricht guidelines recommend substituting metronidazole for clarithromycin where resistance to that
antibiotic exceeds 15–20% [3]. Eradication rates with
this regime are 87.8% when strains are clarithromycin
sensitive and 18.3% when strains are clarithromycin
resistant [8]. The rate of clarithromycin resistance is
increasing, probably due to greater use of clarithromycin
in the community for respiratory tract infections [9,10].
An Italian study noted that rates of clarithromycin resistance increased twofold in that country from 1990 to
2005 [11]. A similar phenomenon was noted in England
with resistance rates rising by 57% between 2002 and
2006 [12]. A study in the United States estimated clarithromycin resistance at 10.1% [13]. There has also been
debate as to the ideal duration of therapy. In recent
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 46–51
O’Connor et al.
years, longer regimes have supplanted the previous 7day triple therapy. A meta-analysis in 2000 suggested a
14-day course of therapy showed 7–9% better cure regimens than 7-day regimes [14]. However, another metaanalysis differed, stating no clinical benefit from longer
courses of treatment, although the quality of some of
the studies included in this second meta-analysis has
been questioned [15]. The published guidelines are also
beginning to reflect this with the 2007 American College of Gastroenterology guidelines recommending 10day treatment courses [4]. In addition, the most recent
Maastricht consensus stated that 14 days of treatment
had an advantage over 7 days in terms of eradication
[1].
Second-line Therapy
As first-line therapy has been noted to fail in approximately 20% of patients, the need for effective secondline therapy is clear [16]. Many putative second-line
therapies are currently in use but the most common
are bismuth-based and levofloxacin-based therapies
[17]. Bismuth-based quadruple therapy consisting of a
PPI, bismuth, tetracycline, and metronidazole is
reported to have an efficacy of 76% in patients who
failed first-line therapy [18]. This is generally given for
10 days and taken four times daily, although a study of
a 14-day twice daily regimen reported 95% efficacy in
a mix of first-line and second-line patients which might
improve compliance and tolerability [19]. Bismuthbased therapy has proved quite safe. A meta-analysis in
2008 showed no serious adverse event in 4763 patients
who received it. No statistically significant increase in
any side effect other than dark stools was illustrated
[20]. Levofloxacin-based therapy has grown in popularity in recent years. A very recent Spanish multicenter
study of 300 patients who had failed first-line eradication therapy revealed 81% per-protocol and 77% intention-to-treat analysis when a 10-day levofloxacin-based
regimen was used, with good tolerability and a low side
effect rate of 22% [21]. Concerns have been expressed
regarding the development of fluoroquinolone resistance when levofloxacin is used for Helicobacter eradication. A rapidly increasing rate of quinolone resistance
was reported in several countries: 15% in 2004 in
Japan, 16.8% in 2006 in Belgium, from 11.2% in 2003
to 22.1% in 2005 in Germany, from 3% in 1999 to
15% in 2004 in France and from 2.8% to 11.8%
between 1998 and 2003 in Taiwan [22–28]. The apparently rapid rate at which fluoroquinolone resistant
seems to develop may limit the use of levofloxacin in
H. pylori eradication to second-line therapy. Another
concern exists regarding the side effects of the
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 46–51
Treatment of H. pylori Infection
fluoroquinolones. Tendonitis was reported in 704 of
46,000 patients receiving levofloxacin in one study
[29]. Other case reports have noted hepatotoxicity [30].
Third-line Therapy
Patients who fail both initial- and second-line therapy
for H. pylori pose an interesting and challenging question [31]. Compliance must, of course, be questioned.
The options are to use further empiric regimes or to
employ treatments tailored to individual antibiotic sensitivities. Two of the more common empiric rescue antibiotics used are rifabutin [32] and furizoladone [33].
Rifabutin is an antituberculous agent. For the eradication of H. pylori, it can be administered as PPI, rifabutin
(150 mg), amoxicillin (1 g), all twice daily for 14 days.
One study on rifabutin used for treatment failures
achieved 95% eradication rates as second-line therapy
and 68% eradication for third- or subsequent line therapy [34]. Another study limited to patients who did not
achieve eradication with standard first-line or bismuthbased second-line therapy revealed 79% eradication
rates based on intention-to-treat analysis [35]. These
results, however, have been contradicted somewhat by
the largest study to date on rifabutin as a third-line
treatment which estimated eradication rates as being
61% [36]. Rifabutin is limited as a treatment option by
a number of factors. Stocks are low in Europe. Also, rifabutin is a useful tool in the treatment of the increasingly problematic multi-drug resistant tuberculosis
infection. Greater use of rifabutin in the treatment of
H. pylori would likely result in the development of more
resistant strains of Mycobacterium tuberculosis. Also serious myelotoxicity and ocular adverse events have been
reported with this treatment [37,38]. Furazolidone is
also useful in treatment failures [39,40]. A study of 10
patients, in whom first-line, second-line and rifabutinbased therapy had failed revealed 60% eradication
when it was used along with amoxicillin and PPI [41].
When this data was incorporated into a systematic
review of furazolidone-based treatments for third- and
subsequent line eradication therapy, they were shown
to be effective 65% of the time [42]. The other principal strategy for salvage therapy in H. pylori involves culture and antibiotic testing. This is a very logical
approach as H. pylori is a latent infection and therefore
has more in common with other latent conditions such
as tuberculosis and syphilis, where susceptibility testing
is routinely employed, than with conditions, such as a
urinary or a respiratory tract infection where empiric
antibiotic regimes are used. Susceptibility testing is
limited by the fact that in vivo resistance may not accurately reflect in vitro resistance, notably with respect to
47
O’Connor et al.
Treatment of H. pylori Infection
metronidazole [43]. Currently such an approach is
mainly carried out in specialist centers with research
interest and expertise in the treatment of H. pylori [44];
however, greater interest in the pathogen and its effects
and the development of newer technologies in the field
of susceptibility testing will encourage this practice to
become more widespread. This will undoubtedly have
benefits and lead to more accurate prescribing and
lower rates of resistance [45].
Sequential Therapy
Sequential therapy has been proposed as an alternative
to standard triple therapy for the eradication of H. pylori
[46,47]. The primary goal of this regimen is to overcome clarithromycin resistance. Hypothetically, during
the first part of therapy, amoxicillin weakens the bacterial cell wall, which prevents the formation of the
channels that block clarithromycin from binding to the
bacterium and hence causes resistance to the antibiotic.
A meta-analysis published last year demonstrated that
eradication rates with sequential therapy are 93.4%
compared with 76.9% for standard triple therapy [48].
Sequential therapy is not affected by bacterial factors
(CagA status, bacterial load) and host factors (underlying disease, smoking) which, until now, have predicted
the outcome of conventional eradication treatments.
Even when strains were clarithromycin resistant, the
eradication rate with sequential therapy was 82.2%
compared with 40.6% for triple therapy. So far, almost
all of the studies analyzing sequential therapy have
been performed in Italy and the sequential regimen has
been given equivalent status to standard 7–14 day triple
therapies as first-line treatment in the updated Italian
guidelines on H. pylori management, where it has been
stated that: ‘‘The Working Group advised the use of 7–
14 day triple therapies or a sequential therapy as firstline treatment’’ [49]. The main drawback to sequential
therapy may lie in its complexity and how this may
affect compliance. Although the meta-analysis quoted
showed that compliance was superior amongst patients
receiving sequential therapy compared to standard triple therapy, it is counter-intuitive that a regimen which
lasts longer and involves a change in the medications
consumed in mid-course could enhance compliance
[50]. The advantages of sequential treatment over
triple-therapy need to be confirmed in randomized controlled trials in different countries and settings before a
generalized change is recommended in first-line
H. pylori treatment. Accordingly, the American College of
Gastroenterology Guideline on the Management of Helicobacter pylori Infection states that ‘‘Sequential therapy
may provide an alternative to clarithromycin-based
48
triple therapy but requires validation within the United
States before it can be recommended as a first-line therapy’’ [4], and the European Maastricht III Consensus
Report points out that ‘‘Sequential treatment deserves
further evaluation in different regions’’ [1]. The main
disadvantage of the sequential therapy regime is that it
is more complex for the patient, requiring a change of
medication in the middle of the treatment period.
Although it was not shown in the meta-analysis, it is
felt that this would likely have a negative impact on
compliance. Whether it is necessary to provide the
drugs sequentially or whether the four constituent
components of sequential therapy can be given concurrently is unclear. A meta-analysis published in 2009 on
this showed a per-protocol eradication level of 92.9%
and intention-to-treat eradication of 89.7% [51]. This
quadruple therapy appears to be an effective, safe and
well-tolerated alternative to triple therapy and is less
complex than sequential therapy, emphasizing that
studies comparing both alternatives are urgently
needed. It must be noted that although it is designed to
overcome clarithromycin resistance, clarithromycin is
central to both sequential and quadruple therapy and
would still be at the mercy of changes in patterns of
clarithromycin resistance which are probably primarily
contingent on the rates of prescription of clarithromycin
in the community for nongastrointestinal infections
[52]. In addition, there exists a body of opinion that
clarithromycin and metronidazole ought not be used
together for H. pylori eradication as those who fail to
have eradication will subsequently have at least single
and often double resistance [53]. Sequential therapy
undoubtedly shows promise but must be further evaluated before it can supplant triple therapy in the existing
guidelines.
Adjuncts
Adjunctive therapies may offer some promise in H. pylori
eradication. Probiotics have been proposed as a useful
adjunct [54]. In one study undertaken in 2008, prescribing probiotics with H. pylori eradication therapy had no
effect on the side effect profile but did increase the rates
of eradication [55]. However, another study on concurrent probiotic administration suggested the inverse with
better side effect profiles but no increase in eradication
or rates of compliance with therapy [56]. Vaccination
has also been proposed as a means of controlling
H. pylori and the morbidity associated with it. The challenge model was first established in human volunteers
in 2004 [57] and subsequent to this, a vaccine is in
Phase I trials and its manufacturers claim it has been
shown to be safe and immunogenic in early trials [58].
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 46–51
O’Connor et al.
Treatment of H. pylori Infection
Conclusion
Establishing efficacious and acceptable treatment regimens for patients infected with H. pylori continues to
pose problems for physician and patient alike. The
decrease in eradication rates needs to be firmly
addressed with evidence-based clinical practice. It is
probably the case, however, that the tools to successfully eradicate H. pylori are already present and that
they simply need to be properly utilized. It has been
repeatedly illustrated that, if compliance is good and a
clear treatment paradigm adhered to, very high eradication rates can be achieved. For example, a study published in 2008 in a Finnish tertiary referral centre
revealed 100% eradication in 644 consecutive patients
where compliance was ensured and patients were treated with standard first- and second-line therapies as per
the Maastricht guidelines and third-line rescue therapy
was tailored to antibiotic susceptibility [59]. Another
study in Greece published earlier this year found 98.1%
eradication rates when the Maastricht-III guidelines
were implemented with empiric therapy used for thirdline patients [60]. Another 2008 study evaluated the efficacy of different ‘rescue’ therapies empirically prescribed
during 10 years to 500 patients in whom at least one
eradication regimen had failed to cure H. pylori infection.
The authors concluded that it is possible to construct an
overall treatment strategy to maximize H. pylori eradication, on the basis of administration of four consecutive
empirical regimens [61]. The key factors in these studies
were an awareness of the importance of compliance and
the provision of structured aftercare and follow-up programs to ensure eradication. It has been proven that
such measures can improve compliance [62]. It is very
likely the case that empowering patients to achieve high
levels of compliance is what accounts for the impressive
eradication rates in centers where patient follow-up is
structured and comprehensive [63]. While it is important to develop new regimes to overcome the problems
of resistance, a need also exists to work as efficiently as
possible with our current regimes and facilitate patient
compliance. If compliance is not achievable, the problem of antibiotic resistance will continue to beset any
combination of drugs used for H. pylori eradication.
Conflicts of Interest
The authors have delcared no conflicts of interest.
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References
1 Malfertheiner P, Megraud F, O’Morain C, Bazzoli F, El-Omar
E, Graham D, Hunt R, Rokkas T, Vakil N, Kuipers EJ. Current
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 46–51
20
concepts in the management of Helicobacter pylori infection: the
Maastricht III Consensus Report. Gut 2007;56:772–81.
Vakil NH. pylori treatment: new wine in old bottles? Am J Gastroenterol 2009;104:26–30.
Lind T, Veldhuyzen van Zanten S, Unge P, et al. Eradication
of Helicobacter pylori using one-week triple therapies combining
omeprazole with two antimicrobials: the MACH I Study. Helicobacter 1996;1:138–44G.
Chey WD, Wong BC. American College of Gastroenterology
guideline on the management of Helicobacter pylori infection.
Am J Gastroenterol 2007;102:1808–25.
Kearney DJ, Brousal A. Treatment of Helicobacter pylori infection
in clinical practice in the United States. Dig Dis Sci
2000;45:265–71.
Saad RJ, Chey WD. Treatment of Helicobacter pylori infection in
2006. Gastroenterol Hepatol Annu Rev 2006;1:30–5.
Kadayifci A, Buyukhatipoglu H, Cemil Savas M, Simsek I. Eradication of Helicobacter pylori with triple therapy: an epidemiologic analysis of trends in Turkey over 10 years. Clin Ther
2006;28:1960–6.
Mégraud FH. pylori antibiotic resistance: prevalence, importance, and advances in testing. Gut 2004;53:1374–84.
Romano M, Iovene MR, Russo MI, Rocco A, Salerno R, Cozzolino D, Pilloni AP, Tufano MA, Vaira D, Nardone G. Failure of
first-line eradication treatment significantly increases prevalence of antimicrobial-resistant Helicobacter pylori clinical isolates. J Clin Pathol 2008;61:1112–5.
Boyanova L Prevlance of multidrug-resistant Helicobacter pylori
in Bulgaria. J Med Microbiol 2009;58(Pt 7):930–5.
De Francesco V, Margiotta M, Zullo A, Hassan C, Giorgio F,
Burattini O, et al. Prevalence of primary clarithromycin resistance in Helicobacter pylori strains over a 15 year period in Italy.
J Antimicrob Chemother 2007;59:783–5.
Chisholm SA, Teare EL, Davies K, Owen RJ. Surveillance of
primary antibiotic resistance of Helicobacter pylori at centres in
England and Wales over a six-year period (2000–2005). Euro
Surveill 2007;12:E3–4.
Osato MS, Reddy R, Reddy SG, et al. Pattern of primary resistance of Helicobacter pylori to metronidazole or clarithromycin in
the United States. Arch Intern Med 2001;161:1217.
Calvet X, Garcı́a N, López T, Gisbert JP, Gené E, Roque M. A
meta-analysis of short versus long therapy with a proton pump
inhibitor, clarithromycin and either metronidazole or amoxycillin for treating Helicobacter pylori infection. Aliment Pharmacol
Ther 2000;14:603–9.
Fuccio L, Minardi ME, Zagari RM, Grilli D, Magrin Ni, Bazzoli
F. Meta-analysis: duration of first-line proton-pump inhibitor
based triple therapy for Helicobacter pylori eradication. Ann Int
Med 2007;147:553–62.
Gisbert JP. Rescue’’ regimens after Helicobacter pylori treatment
failure. World J Gastroenterol 2008;21:14.
Gisbert JP, Javares JM. Review article: Helicobacter pylori ‘‘rescue’’ regimen when proton pump inhibitor based-triple therapies fail. Aliment Pharmacol Ther 2002;16:1047–57.
Hojo M, Miwa H, Nagahara A, et al. Pooled analysis on the efficacy of the second-line treatment regimens for Helicobacter
pylori infection. Scand J Gastroenterol 2001;36:690–700.
Dore MP, Graham DY, Mele R, Marras L, Nieddu S, Manca A,
Realdi G. Colloidal bismuth subcitrate-based twice-a-day quadruple therapy as primary or salvage therapy for Helicobacter
pylori infection. Am J Gastroenterol 2002;97:857–60.
Ford AC, Malfertheiner P, Giguere M, Santana J, Khan M,
Moayyedi P. Adverse events with bismuth salts for Helicobacter
49
O’Connor et al.
Treatment of H. pylori Infection
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
50
pylori eradication: systematic review and meta-analysis. World J
Gastroenterol 2008;14:7361–70.
Gisbert JP, Bermejo F, Castro-Fernández M, Pérez-Aisa A,
Fernández-Bermejo M, Tomas A, et al. Second-line rescue therapy with levofloxacin after H. pylori treatment failure: a Spanish multicenter study of 300 patients. Am J Gastroenterol
2008;103:71–6.
Miyachi H, Miki I, Aoyama N, Shirasaka D, Matsumoto Y, Toyoda M, et al. Primary levofloxacin resistance and gyrA ⁄ B mutations among Helicobacter pylori in Japan. Helicobacter
2006;11:243–9.
Bogaerts P, Berhin C, Nizet H, Glupczynski Y. Prevalence and
mechanisms of resistance to fluoroquinolones in Helicobacter
pylori strains from patients living in Belgium. Helicobacter
2006;11:441–5.
Glocker E, Stueger HP, Kist M. Quinolone resistance in Helicobacter pylori isolates in Germany. Antimicrob Agents Chemother
2007;51:346–9.
Tankovic J, Lascols C, Sculo Q, Petit JC, Soussy CJ. Single and
double mutations in gyrA but not in gyrB are associated with
low- and high-level fluoroquinolone resistance in Helicobacter
pylori. Antimicrob Agents Chemother 2003;47:3942–4.
Cattoir V, Nectoux J, Lascols C, Deforges L, Delchier JC, Megraud F, et al. Update on fluoroquinolone resistance in Helicobacter pylori: new mutations leading to resistance and first
description of a gyrA polymorphism associated with hypersusceptibility. Int J Antimicrob Agents 2007;29:389–96.
Hung KH, Sheu BS, Chang WL, Wu HM, Liu CC, Wu JJ. Prevalence of primary fluoroquinolone resistance among clinical
isolates of Helicobacter pylori at a University Hospital in Southern
Taiwan. Helicobacter 2009;14:61–5.
Chang WL, Sheu BS, Cheng HC, Yang YJ, Yang HB, Wu JJ
Resistance to metronidazole, clarithromycin and levofloxacin of
Helicobacter pylori before and after clarithromycin-based therapy
in Taiwan. J Gastroenterol Hepatol 2009;May 20. Epub ahead of
print.
van der Linden PD, Sturkenboom MC, Herings RM, Leufkens
HG, Stricker BH. Fluoroquinolones and risk of Achilles tendon
disorders. BMJ 2002;324:1306–7.
Spahr L, Rubbia-Brandt L, Marinescu O, Armenian B, Hadengue A. Acute fatal hepatitis related to levofloxacin. J Hepatol
2001;35:308–9.
Gisbert JP, Pajares JM. Helicobacter pylori ‘‘rescue’’ therapy after
failure of two eradication treatments. Helicobacter 2005;10:
363–72.
Suzuki S, Suzuki H, Nishizawa T, Kaneko F, Ootani S, Muraoka
H, Saito Y, Kobayashi I, Hibi T. Past rifampicin dosing determines rifabutin resistance of Helicobacter pylori. Digestion
2009;79:1–4.
De Francesco V, Ierardi E, Hassan C, Zullo A. Furazolidone
therapy for Helicobacter pylori: is it effective and safe? World J
Gastroenterol 2009;21:15.
Van der Poorten D, Katelaris PH. The effectiveness of rifabutin
triple therapy for patients with difficult-to-eradicate Helicobacter
pylori in clinical practice. Aliment Pharmacol Ther 2007;26:
1537–42.
Gisbert JP, Calvet X, Bujanda L, Marcos S, Gisbert JL, Pajares
JM. ‘Rescue’ therapy with rifabutin after multiple Helicobacter
pylori treatment failures. Helicobacter 2003;8:90–94.
Gonzalez Carro P, Perez Roldan F, De Pedro Esteban A, Legaz
Huidobro ML, Soto Fernandez S, Roncero Garcia Escribano O,
Esteban Lopez-Jamar JM, Pedraza Martin C, Ruiz Carrillo F.
Efficacy of rifabutin-based triple therapy in Helicobacter pylori
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
infected patients after two standard treatments. J Gastroenterol
Hepatol 2007;22:60–63.
Apseloff G. Severe neutropenia among healthy volunteers
given rifabutin in clinical trials. Clin Pharmacol Ther
2003;74:591–2.
Bhagat N, Read RW, Rao NA, et al. Rifabutin-associated
hypopyon uveitis in human immunodeficiency virusnegative
immunocompetent individuals. Ophthalmology 2001;108:
750–2.
Cheng H, Hu FL. Furazolidone, amoxicillin, bismuth and rabeprazole quadruple rescue therapy for the eradication of Helicobacter pylori. World J Gastroenterol 2009;15:860–4.
Abbas Z, Yakoob J, Abid S, Jafri W, Islam M, Azam Z, Hilal I.
Furazolidone, co-amoxiclav, colloidal bismuth subcitrate, and
esomeprazole for patients who failed to eradicate Helicobacter
pylori with triple therapy. Dig Dis Sci 2008;Dec 5. [Epub ahead
of print].
Qasim A, Sebastian S, Thornton O, Dobson M, McLoughlin R,
Buckley M, O’Connor H, O’Morain C. Rifabutin- and furazolidone-based Helicobacter pylori eradication therapies after failure
of standard first- and second-line eradication attempts in dyspepsia patients. Aliment Pharmacol Ther 2005;21:91–6.
Buzas GM, Jozan J. Nitrofuran-based regimens for the eradication of Helicobacter pylori infection. J Gastroenterol Hepatol
2007;22:1571–81.
Graham DY. Antibiotic resistance in Helicobacter pylori: implications for therapy. Gastroenterology 1998;115:1272–7.
Megraud F, Lamouliatte H. Review article: the treatment of
refractory Helicobacter pylori infection. Aliment Pharmacol Ther
2003;17:1333–43.
Graham DY. Efficient identification and evaluation of effective
Helicobacter pylori therapies. Clin Gastroenterol Hepatol
2009;7:145–8.
Vakil N, Vaira D. Sequential therapy for Helicobacter pylori: time
to consider making the switch? JAMA 2008;17:300.
Tong JL, Ran ZH, Shen J, Xiao SD. Sequential therapy vs. standard triple therapies for Helicobacter pylori infection: a metaanalysis. J Clin Pharm Ther 2009;34:41–53.
Jafri NS, Hornung CA, Howden CW. Meta-analysis: sequential
therapy appears superior to standard therapy for Helicobacter
pylori infection in patients naive to treatment. Ann Intern Med
2008;148:923–31.
Caselli M, Zullo A, Maconi G, Parente F, Alvisi V, Casetti T,
et al. ‘‘Cervia II Working Group Report 2006: guidelines on
diagnosis and treatment of Helicobacter pylori infection in Italy.
Dig Liver Dis 2007;39:782–9.
O’Morain CA, O’Connor JP. Is sequential therapy superior to
standard triple therapy for the treatment of Helicobacter
pylori infection? Nat Clin Pract Gastroenterol Hepatol 2009;6:
8–9.
Essa AS, Kramer JR, Graham DY, Treiber G. Meta-analysis:
four-drug, three-antibiotic, non-bismuth-containing ‘‘concomitant therapy’’ versus triple therapy for Helicobacter pylori eradication. Helicobacter 2009;14:109–18.
Megraud F. Epidemiology and mechanism of antibiotic
resistance in Helicobacter pylori. Gastroenterology 1998;
115:1278–82.
Axon AT. Treatment of Helicobacter pylori: an overview. Aliment
Pharmacol Ther 2000;14(Suppl. 3):1–6.
Scaccianoce G, Zullo A, Hassan C, Gentili F, Cristofari F, Cardinale V, Gigliotti F, Piglionica D, Morini S. Triple therapies plus
different probiotics for Helicobacter pylori eradication. Eur Rev
Med Pharmacol Sci 2008;12:251–6.
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 46–51
O’Connor et al.
55 Kim MN, Kim N, Lee SH, et al. The effects of probiotics on PPItriple therapy for Helicobacter pylori eradication. Helicobacter
2008;13:261–8.
56 Cremonini F, Di Caro S, Covino M, Armuzzi A, Gabrielli M,
Santarelli L, Nista EC, Cammarota G, Gasbarrini G, Gasbarrini
A. Effect of different probiotic preparations on anti-Helicobacter
pylori therapy-related side effects: a parallel group, triple
blind, placebo-controlled study. Am J Gastroenterol
2002;97:2744–9.
57 Graham DY, Opekun AR, Osato MS, El-Zimaity HM, Lee CK,
Yamaoka Y, Qureshi WA, Cadoz M, Monath TP. Challenge
model for Helicobacter pylori infection in human volunteers. Gut
2004;53:1235–43.
58 Malfertheiner P, Schultze V, Rosenkranz B, et al. Safety and
immunogenicity of an intramuscular Helicobacter pylori vaccine
in noninfected volunteers: a phase I study. Gastroenterology
2008;135:787–95.
59 Seppälä K, Kosunen TU, Veijola L, Sipponen P, Arkkila PE,
Rautelin H, Tilvis R. Cure of Helicobacter pylori infection in all
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 46–51
Treatment of H. pylori Infection
60
61
62
63
compliant patients: report on 644 subjects. Scand J Gastroenterol
2008;43:1149–50.
Rokkas T, Sechopoulos P, Robotis I, Margantis G, Pistiolas D.
Cumulative H. pylori eradication rates in clinical practice by
adopting first and second line regimens proposed by the Maastricht III consensus and a third line empirical regimen. Am J
Gastroenterol 2009;104:21–5.
Gisbert JP, Gisbert JL, Marcos S, Jimenez-Alonso I, MorenoOtero R, Pajares JM. Empirical rescue therapy after Helicobacter
pylori treatment failure: a 10-year single-centre study of 500
patients. Aliment Pharmacol Ther 2008;27:346–54.
Al-Eidan FA, McElnay JC, Scott MG, McConnell JB. Management of Helicobacter pylori eradication – the influence of structured counselling and follow-up. Br J Clin Pharmacol
2002;53:163–71.
Stenström B, Mendis A, Marshall B. Helicobacter pylori – the latest in diagnosis and treatment. Aust Fam Physician 2008;37:
608–12.
51
Helicobacter ISSN 1523-5378
Helicobacter pylori Infection in Pediatrics
Angelika Kindermann* and Ana I. Lopes
*Department of Pediatric Gastroenterology, Emma’s Children’s Hospital, University of Amsterdam, Amsterdam, The Netherlands, Gastroenterology
Unit, Department of Pediatrics, University Hospital Santa Maria, Lisbon, Portugal
Keywords
Children, prevalence, recurrent abdominal
pain, anemia, stool antigen test, treatment.
Reprint requests to: Ana I. Lopes, MD, PhD,
Gastroenterology Unit, Department of Pediatrics, University Hospital Santa Maria, Avenida
Professor Egas Moniz, 1649-035 Lisbon,
Portugal. E-mail: anaisalopes@sapo.pt
Abstract
This review summarizes the articles published on Helicobacter pylori infection
in children between April 2008 and March 2009. Recent evidence highlights
the decreasing prevalence trend of H. pylori infection and supports both intrafamilial and extrafamilial transmission. The association with various symptoms is still being debated. Interestingly, H. pylori infection seems inversely
associated with allergic diseases. Monoclonal stool antigen tests are widely
used and accurate for the diagnosis of H. pylori infection, but less accurate in
young children. The new biprobe real-time PCR assay applied to stools
showed a poor sensitivity in children. Using the urea hydrolysis rate next to
the delta over baseline values, the 13C-urea breath test provides excellent
results for all age children, even for young children. Treatment of H. pylori
infection remains a challenge, considering suboptimal efficacy of current
therapy. Among emerging alternatives, sequential treatment appears promising. The adjunction of probiotics to conventional regimens, although eliciting great interest, has shown limited therapeutic benefit.
Pathogenesis
Whereas there is evidence for a role of genetic markers
on disease severity in adults, in children this association
is not clear. Ko et al. found no association between
cagA, vacA, and iceA with gastritis severity in Korea [1].
On the other hand, Oleastro et al. suggested the homB
gene as a new putative virulence marker highly associated with peptic ulcer disease (PUD) in children and
adults. HomB also correlated with the presence of cagA,
babA2, vacAs1, hopQI, and oipA and seemed involved in
Helicobacter pylori adherence and in inflammatory
response [2].
To determine whether host gene polymorphisms coding for Toll-like receptors (TLR) influence the immune
response to the infection, Moura et al. studied TLR2,
TLR4, and TLR5 polymorphisms in a large cohort of
children. None of them were associated with H. pylori
infection or duodenal ulcer disease. Otherwise, the
presence of TLR4 was associated with infection by cagApositive strains and with increased levels of interleukin
(IL)-8 and -10 [3]. This might contribute to more
severe consequences of the infection in adulthood. A
Polish group found significantly higher IL-18, IL-8, and
IL-1b transcript levels and macrophage number in the
antral mucosa of H. pylori-infected children than in
52
H. pylori-negative children. They also observed a significant correlation between macrophage number and histological parameters of gastritis [4]. Another group from
Turkey found that expression of a-defensin was significantly higher in H. pylori-infected children and associated with higher grades of inflammation and neutrophil
density [5]. Leach et al. from Canada showed a high
expression of the inflammatory S100 calgranulin proteins in H. pylori-infected mucosa, correlating with the
severity of gastritis, and its absence in normal gastric
mucosa [6].
Czaja et al. found that the mean fasting serum gastrin
level was higher in children with H. pylori-associated
gastritis compared to H. pylori-negative cases, with or
without gastritis. In contrast to earlier studies suggesting that a decrease in the number of somatostatinproducing D cells with an unchanged number of
gastrin-producing G cells may lead to PUD, these
authors found no difference in G-cell density and D-cell
density, regardless of the presence or absence of gastritis
or H. pylori infection [7].
Prevalence
A cross-sectional population-based study of H. pylori
infection prevalence was conducted on 2480 Chinese
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 52–57
Kindermann and Lopes
children (age 6–19 years) by using 13C-urea breath test
(UBT) [8]. A surprisingly low prevalence rate was
found, with an overall positivity of 13.1%, related to a
low educational level of the child’s mother (OR =
2.43), family history of gastric cancer (OR = 2.19), and
household member number >5 (OR = 1.57).
Siai et al. reported a 51.4% seroprevalence rate
(ELISA IgG) in Tunisian school children, 6 years old,
significantly related to household crowding, late bottleweaning, and bed-sharing [9].
Two studies evaluated H. pylori infection prevalence
by using a stool antigen test. Kori et al. observed a
prevalence rate of 24.7% in daycare children from
Israel with higher rates in the 13- to 60-month-old
group (32.5%) compared to the 3- to 12-month-old
group (7.1%), suggesting infection acquisition most
probably after the first year of life [10]. Yucel et al.
showed a 30.9% prevalence rate in asymptomatic Turkish children (mean age 6.8 ± 3.0 years), related to a
low education level of child’s mother, adverse living
conditions, and a high number of siblings [11].
In India, Mishra et al. confirmed an increasing detection rate of H. pylori with age, by documenting positivity in saliva ⁄ stool samples by nested PCR in
2.1% ⁄ 4.25% (<5 years), 22.7% ⁄ 13.6% (6–10 years),
55.9% ⁄ 50% (11–16 years) of cases, respectively [12].
Three retrospective observational studies assessed
H. pylori infection prevalence in children submitted to
endoscopy. Elitsur et al. observed an overall infection
rate of 12.1% and a significant decrease in mean
annual infection rate in the last 6 years of the study
period in 1743 North American children over a 13-year
study period [13]. A decreasing prevalence from 60.4%
to 30.4% (first and last years of the study, respectively),
was reported by Kawakami et al. in Brazilian children
over a 10-year period [14]. In Canada, Segal et al. documented a very low overall infection rate (7.1%) [15].
Transmission
The transmission of H. pylori remains poorly understood. New data including fingerprinting analysis studies, supports both intrafamilial (mostly mother-to-child)
and extrafamilial transmission. In a systematic review
which included a birth cohort study enrolling 1066
healthy newborns, Weyerman et al., using a monoclonal stool antigen test, identified maternal infection as
the single significant risk factor (OR 13.0) for acquisition of infection in childhood [16]. Konno et al., using
DNA fingerprinting analysis of cultured H. pylori from
42 children and their infected family members, identified fingerprint patterns identical to those of at least
one family member in 76% of the children, with a
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 52–57
H. pylori in Pediatrics
significantly higher rate of identity in the mothers’
patterns, compared to those of fathers (p < .01).
Mother-to-child transmission was thus suggested as the
most probable route of transmission of H. pylori [17].
Herrera et al. compared H. pylori genotypes (cultures
and ⁄ or DNAs obtained by the string test) from members
of low income families in Peru [18]. Interestingly, in
70% of the cases, mother–child strain pairs did not
match, nor did most strains from siblings or other family members, thus further suggesting the possibility of
community acquisition of H. pylori infection.
Symptoms
The association with many symptoms is still a subject of
great debate.
Recurrent Abdominal Pain
During the last year, there was just one study concerning this topic. In agreement with most previous studies,
Masoodpoor et al. found no relationship between recurrent abdominal pain and H. pylori infection in children.
The prevalence of H. pylori infection in children with
RAP and in healthy children in the age range of
12–15 years was similar [19].
Peptic Ulcer and Reflux Disease
Houben et al. analyzed retrospectively 76 patients who
were admitted to the hospital with signs of acute upper
gastrointestinal bleeding. Helicobacter pylori was identified in 55% of these patients and in 90% a duodenal
ulcer was found. This shows a strong relation between
gastrointestinal bleeding because of duodenal ulcer disease and H. pylori infection in childhood [20].
There were no new studies regarding gastroesophageal reflux disease nor nonulcer dyspepsia during this
period.
Extra-gastrointestinal Manifestations
During this period many studies continued to investigate the relationship between H. pylori infection and
extraintestinal manifestations such as iron deficiency
anemia (IDA), growth failure, asthma, atopy and various other conditions.
Iron Deficiency Anemia
Fagan et al. concluded that H. pylori plays a casual role
in hematological outcomes of children. They followed
children after H. pylori eradication treatment for a
53
Kindermann and Lopes
H. pylori in Pediatrics
period of 40 months. They found a lower prevalence of
iron deficiency and IDA in H. pylori-negative children
compared with H. pylori-positive children [21]. On the
other hand, no association between H. pylori infection
and IDA was seen in three other studies [22–24]. It is
indeed difficult to distinguish between anemia due to
infection with H. pylori and to other confounding factors, such as poor nutritional status or another underlying disease.
Growth Failure
There is ongoing discussion about the association
between H. pylori and growth retardation. In the past,
possible mechanisms such as malabsorption and
decreased appetite were mentioned as a possible cause
of growth failure. During the last year, two studies
were added on this subject. Both papers did not support
a role of H. pylori on growth failure in children [25,26].
Allergy
In developed countries, allergies have become more
prevalent in recent decades, whereas the prevalence of
H. pylori has been decreasing in these countries. This
gives rise to search about the association between this
micro-organism and allergies.
Chen & Blaser carried out a cross-sectional analysis on
the data from 7412 pediatric participants in the National
Health and Nutrition Examination Survey (NHANES) in
the U.S., to assess the association between H. pylori
infection and childhood asthma. They found that
H. pylori seropositivity was inversely associated with
asthma, recent wheezing, allergic rhinitis, dermatitis,
eczema, and rash [27]. A second study confirmed a low
rate of H. pylori antibodies in children with bronchial
asthma [28]. These findings are intriguing and incite
thought about research in this field, including asthma
prevention. Cam et al. investigated immune responses
(T-helper cell function) in H. pylori infected children and
compared the cytokine responses in the atopic and
nonatopic group. The frequency of atopy was lower in
the H. pylori-infected group (31.9 vs 48.1%), whereas
atopic symptoms were similar between infected and
noninfected children. Their results demonstrated a
counteractive cytokine interaction between H. pylori
infection and atopy, but it did not protect against atopy
[29].
Atherosclerosis
Helicobacter pylori infection has been proposed to play a
role in the development of atherosclerosis preceded by
54
endothelial dysfunction. Coskun et al. found no early
findings of atherosclerosis in H. pylori infected children
using noninvasive techniques such as Doppler ultrasonography [30].
Diagnostic Tests
Besides invasive diagnostic methods (histology, culture,
and rapid urease testing following endoscopy) which
are still considered the ‘‘gold standards,’’ there are still
no 100% specific and sensitive noninvasive tests for the
diagnosis of H. pylori in children. Especially in infants,
noninvasive tests are less accurate. In a high prevalence
country, such as Turkey, 26.3% of all children younger
than 2 years of age who underwent endoscopy were
H. pylori-positive. Most of them (65%) already showed
histopathologic abnormalities such as gastritis [31].
In 2005, the Canadian Consensus group concluded
that 13C-UBT is the best available and most reliable
noninvasive test in children, but it is far less accurate in
younger children [32]. Two studies on UBT were published during the last year measuring the urea hydrolysis rate (UHR) next to the delta over baseline values
(DOB). Both were able to show that using UHR next to
DOB provided excellent results for children of all ages,
resulting in less false positive results in children under
the age of 6 years [33,34].
Monoclonal stool antigen tests are widely used and
accurate for the diagnosis of H. pylori infection in children, but their use in young children remains controversial. Ritchie et al. found a very low sensitivity (55%)
and specificity (68%) in children from 4 months to
2 years [35]. Other studies have investigated the accuracy of rapid immunochromographic stool antigen tests
(Rapid HpSA) with discrepant results. While Yang et al.
and Cardenas et al. found high sensitivities (94.6 and
100%) and specificities (98.4 and 100%) [36,37], Kuloğlu et al. found far less accurate results (pre- and posttreatment: specificity 92.3 and 100%, respectively;
sensitivity 65 and 60%, respectively) [38]. Whereas in
adults the new biprobe real-time PCR assays applied to
stools showed excellent results, Falsafi et al. found a
reasonable specificity of 92.3%, but a poor sensitivity of
62.5% in children. However, this study also noted an
association between higher scores of H. pylori in histology and more severe gastritis with positivity of stool
PCR [39]. This could explain the insufficient sensitivity
in children who, for the most part, have less severe
gastritis.
In addition to several studies published on serology,
Leal et al. published a meta-analysis on antibody-based
detection tests for the diagnosis of H. pylori in children
[40]. ELISA-IgG assays showed low sensitivity (79.2%)
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 52–57
Kindermann and Lopes
but good specificity (92.4%). Commercially available
ELISA tests varied widely in performance. Western blot
tests showed a good overall performance (sensitivity
91.3% and specificity 89%). In-house ELISA with
whole-cell antigen tests showed the highest overall performance (sensitivity 94% and specificity 96.4%). This
review showed the need for an evaluation of the serological test in the community in which it is be used.
Treatment
Francavilla et al. showed for the first time the superiority of a 10-day sequential treatment in children compared to standard treatment [41]. An overall
eradication rate of 85.2% was obtained, irrespective of
the presence of ulcer or cagA status [42].
A single-centre study from Turkey using a first-line
standard therapy (amoxicillin, clarithromycin and proton pump inhibitor (PPI)), did not show any significant
impact of the duration of treatment on eradication rate
(per-protocol analysis), 55.8 and 60.5%, in the 7- and
14-day group, respectively [43]. Furthermore, in the
subset of nonresponders, a second-line quadruple therapy protocol comprising bismuth citrate, doxycycline,
metronidazole, and PPI (7 days) obtained a 64.6% eradication rate. The contribution of a high background
resistance to clarithromycin and metronidazole to the
low global eradication rates obtained was admitted.
Nguyen et al. compared the efficacy of two 14-day
triple regimens including amoxicillin, lansoprazole and
clarithromycin or metronidazole in a randomized double-blind trial and observed an overall per-protocol
eradication performed in Vietnam similarly low in both
regimens, 62.1 and 54.7%, respectively [44].
Caristo et al. applied the fluorescent in-situ hybridization test on pediatric gastric biopsy specimens during
two consecutive 5-year periods [45]. The study confirmed high sensitivity and specificity for the co-detection of sensitive and resistance strains, further showing
that in one-third of the cases with mixed infection,
resistant strains were only seen in the fundus. This
emphasizes the relevance of fundus biopsies.
Probiotics as alternative therapeutic options have
recently emerged. Until 2006, four controlled trials
evaluated the contribution of lactic acid bacteria and
Saccharomyces boulardii to H. pylori eradication and
reduction of treatment side-effects in children, with
conflicting results [46]. Hurduc et al. compared the efficacy of standard eradication therapy (PPI, amoxicillin
and clarithromycin) for 7–10 days, plus S. boulardii,
250 mg b.i.d. for 4 weeks (intervention group) with
standard eradication therapy alone (control group)
[47]. Although the addition of S. boulardii to the
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 52–57
H. pylori in Pediatrics
standard treatment offered only a 12% additional therapeutic benefit (eradication rate of 80.9% in the control
group vs 93.3% in the intervention group) it significantly reduced the incidence of side effects (30.9 vs
8.3%, respectively).
Gotteland et al. assessed the potential additive or synergistic effect of Lactobacillus johnsonii La1 plus cranberry
juice on the inhibition of H. pylori in a multicenter, randomized, controlled, double-blind trial (3 weeks),
including asymptomatic children with infection confirmed by UBT. Eradication rates were significantly
lower in the control group (placebo juice ⁄ heat-killed
La1) (1.5%), compared to the intervention groups
(14.9, 16.9, and 22.9% in the placebo juice ⁄ La1, cranberry juice ⁄ heat-killed La1 and cranberry juice ⁄ La1
groups, respectively) [48], showing the absence of synergistic inhibitory effects of La1 plus cranberry on
H. pylori colonization.
Re-infection after successful eradication has also
received increased attention, as rates from 1.9 to 9.6%
have been reported in children, mostly attributed to
interfamilial transmission, with higher rates in developing countries [49].
Conflicts of Interest
The authors have declared no conflicts of interest.
References
1 Ko JS, Kim KM, Oh YL, Seo JK. cagA, vacA, and iceA genotypes
of Helicobacter pylori in Korean children. Pediatr Int 2008;50:
628–31.
2 Oleastro M, Cordeiro R, Ferrand J, et al. Evaluation of the clinical significance of homB, a novel candidate marker of Helicobacter pylori strains associated with peptic ulcer disease. J Infect
Dis 2008;198:1379–87.
3 Moura SB, Almeida LR, Guerra JB, Rocha GA, Camargos
Rocha AM, Melo FF, Corrêa-Oliveira R, Bittencourt P, Carvalho
SD, Magalhães Queiroz DM. Toll-like receptor (TLR2, TLR4 and
TLR5) gene polymorphisms and Helicobacter pylori infection in
children with and without duodenal ulcer. Microbes Infect
2008;10:1477–83.
4 Dzierzanowska-Fangrat K, Michalkiewicz J, Cielecka-Kuszyk J,
Nowak M, Celinska-Cedro D, Rozynek E, Dzierzanowska D,
Crabtree JE. Enhanced gastric IL-18 mRNA expression in Helicobacter pylori-infected children is associated with macrophage
infiltration, IL-8, and IL-1 beta mRNA expression. Eur J Gastroenterol Hepatol 2008;20:314–9.
5 Soylu OB, Ozturk Y, Ozer E. Alpha-defensin expression in the
gastric tissue of children with Helicobacter pylori-associated
chronic gastritis: an immunohistochemical study. J Pediatr Gastroenterol Nutr 2008;46:474–7.
6 Leach ST, Mitchell HM, Geczy CL, Sherman PM, Day AS. S100
calgranulin proteins S100A8, S100A9 and S100A12 are
expressed in the inflamed gastric mucosa of Helicobacter pyloriinfected children. Can J Gastroenterol 2008;22:461–4.
55
Kindermann and Lopes
H. pylori in Pediatrics
7 Czaja M, Szarszewski A, Kamińska B, Bogotko-Szarszewska M,
Luczak G, Kozielska E, Delińska-Galińska A, Korzon M. Serum
gastrin concentration and changes in G and D cell densities in
gastric antrum in children with chronic gastritis. Int J Clin Pract
2008;62:1044–9.
8 Tam YH, Yeung CK, Lee KH, Sihoe JD, Chan KW, Cheung ST,
Mou JW. A population-based study of Helicobacter pylori infection in Chinese children resident in Hong Kong: prevalence
and potential risk factors. Helicobacter 2008;13:219–48.
9 Siai K, Ghozzi M, Ezzine H, Medjahed N, Azzouz MM. Prevalence and risk factors of Helicobacter pylori infection in Tunisian
children: 1055 children in Cap-Bon (northeastern Tunisia). Gastroenterol Clin Biol 2008;32:881–6.
10 Kori M, Goldstein E, Granot E. Helicobacter pylori infection in
young children detected by a monoclonal stool antigen immunoassay. Pediatr Infect Dis J 2009;28:157–9.
11 Yucel O, Sayan A, Yildiz M. The factors associated with asymptomatic carriage of Helicobacter pylori in children and their
mothers living in three socio-economic settings. Jpn J Infect Dis
2009;62:120–4.
12 Mishra S, Singh V, Rao GR, Dixit VK, Gulati AK, Nath G. Prevalence of Helicobacter pylori in asymptomatic subjects - a nested
PCR based study. Infect Genet Evol 2008;8:815–9.
13 Elitsur Y, Dementieva Y, Rewalt M, Lawrence Z. Helicobacter
pylori infection rate decreases in symptomatic children: a retrospective analysis of 13 years (1993–2005) from a gastroenterology clinic in West Virginia. J Clin Gastroenterol 2009;43:
147–51.
14 Kawakami E, Machado RS, Ogata SK, Langner M. Decrease in
prevalence of Helicobacter pylori infection during a 10-year period in Brazilian children. Arq Gastroenterol 2008;45:147–51.
15 Segal I, Otley A, Issenman R, Armstrong D, Espinosa V, Cawdron R, Morshed MG, Jacobson K. Low prevalence of Helicobacter pylori infection in Canadian children: a cross-sectional
analysis. Can J Gastroenterol 2008;22:485–9.
16 Weyermann M, Rothenbacher D, Brenner H. Acquisition of
Helicobacter pylori infection in early childhood: independent
contributions of infected mothers, fathers, and siblings. Am
J Gastroenterol 2009;104:182–9.
17 Konno M, Yokota S, Suga T, Takahashi M, Sato K, Fujii N. Predominance of mother-to-child transmission of Helicobacter pylori
infectiondetected by random amplified polymorphic DNA fingerprinting analysis in Japanese families. Pediatr Infect Dis J
2008;27:999–1003.
18 Herrera PM, Mendez M, Velapatiño B, et al. DNA-level diversity and relatedness of Helicobacter pylori strains in shantytown
families in Peru and transmission in a developing-country setting. J Clin Microbiol 2008;46:3912–8.
19 Masoodpoor N, Darakhshan, Sheikhvatan M. Helicobacter pylori
infection in Iranian children with recurrent abdominal pain.
Trop Gastroenterol 2008;29:221–3.
20 Houben CH, Chiu PW, Lau JY, Lee KH, Ng EK, Tam YH, Yeung
CK. Duodenal ulcers dominate acute upper gastrointestinal
tract bleeding in childhood: a 10-year experience from Hong
Kong. J Dig Dis 2008;9:199–203.
21 Fagan RP, Dunaway CE, Bruden DL, Parkinson AJ, Gessner
BD. Controlled, household-randomized, open-label trial of the
effect of treatment of Helicobacter pylori infection on iron deficiency among children in rural Alaska: results at 40 months.
J Infect Dis 2009;199:652–60.
22 Sarker SA, Mahmud H, Davidsson L, Alam NH, Ahmed T, Alam
N, Salam MA, Beglinger C, Gyr N, Fuchs GJ. Causal relationship of Helicobacter pylori with iron-deficiency anemia or failure
56
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
of iron supplementation in children. Gastroenterology
2008;135:1534–42.
Kaya AD, Gencay E, Ozturk CE, Yavuz T. Seroprevalence of
Helicobacter pylori infection in children in northwest region of
Turkey: relationship with iron deficiency anemia. J Trop Pediatr
2008;54:353–4.
Haghi-Ashtiani MT, Monajemzadeh M, Motamed F, Mahjoub F,
Sharifan M, Shahsiah R, Kashef N. Anemia in children with and
without Helicobacter pylori infection. Arch Med Res 2008;39:
536–40.
Soylu OB, Ozturk Y. Helicobacter pylori infection: effect on malnutrition and growth failure in dyspeptic children. Eur J Pediatr
2008;167:557–62.
Cherian S, Forbes D, Sanfilippo F, Cook A, Burgner D. Helicobacter pylori, helminth infections and growth: a cross-sectional
study in a high prevalence population. Acta Paediatr
2009;98:860–4.
Chen Y, Blaser MJ. Helicobacter pylori colonization is inversely
associated with childhood asthma. J Infect Dis 2008;198:553–60.
Asilsoy S, Babayigit A, Olmez D, Uzuner N, Karaman O, Oren O,
Turgut CS, Tezcan D. Helicobacter pylori infection and gastroesophageal reflux in asthmatic children. J Trop Pediatr
2008;54:129–32.
Cam S, Ertem D, Bahceciler N, Akkoc T, Barlan I, Pehlivanoglu E.
The interaction between Helicobacter pylori and atopy: does inverse
association really exist? Helicobacter 2009;14:1–8.
Coskun S, Kasirga E, Yilmaz O, Bayindir P, Akil I, Yuksel H,
Polat M, Sanlidag T. Is Helicobacter pylori related to endothelial
dysfunction during childhood? Pediatr Int 2008;50:150–3.
Tutar E, Ertem D, Kotiloglu Karaa E, Pehlivanoglu E. Endoscopic and histopathologic findings associated with H. pylori
infection in very young children. Dig Dis Sci 2009;54:111–7.
Jones NL, Sherman P, Fallone CA, Flook N, Smaill F, Veldhuyzen van Zanten S, Hunt R, Thomson A. Canadian Helicobacter
Study Group Consensus Conference: update on the approach
to evidence-based evaluation. Can J Gastroenterol 2005;19:
399–408.
Elitsur Y, Tolia V, Gilger MA, Reeves-Garcia J, Schmidt-Sommerfeld E, Opekun AR, El-Zimaity H, Graham DY, Enmei K.
Urea breath test in children: the United States prospective,
multicenter study. Helicobacter 2009;14:134–40.
Yang HR, Ko JS, Seo JK. Does the diagnostic accuracy of the
13
C-urea breath test vary with age even after the application of
urea hydrolysis rate? Helicobacter 2008;13:239–44.
Ritchie B, Brewster D, Tran CD, McNeil Y, Zacharakis B, Davidson GP, Butler RN. Lack of diagnostic accuracy of the monoclonal stool antigen test for detection of Helicobacter pylori infection
in young Australian aboriginal children. Pediatr Infect Dis J
2009;28:287–9.
Yang HR, Seo JK. Helicobacter pylori stool antigen (HpSA) tests
in children before and after eradication therapy: comparison of
rapid immunochromatographic assay and HpSA ELISA. Dig Dis
Sci 2008;53:2053–8.
Cardenas VM, Dominguez DC, Puentes FA, Aragaki CC, Goodman KJ, Graham DY, Fukuda Y. Evaluation of a novel stool
native catalase antigen test for Helicobacter pylori infection in
asymptomatic North American children. J Pediatr Gastroenterol
Nutr 2008;46:399–402.
Kuloğlu Z, Kansu A, Kirsaçlioğlu CT, Ustündağ G, Aysev D,
Ensari A, Küçük NO, Girgin N. A rapid lateral flow stool antigen immunoassay and (14)C-urea breath test for the diagnosis
and eradication of Helicobacter pylori infection in children. Diagn
Microbiol Infect Dis 2008;62:351–6.
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 52–57
Kindermann and Lopes
39 Falsafi T, Favaedi R, Mahjoub F, Najafi M. Application of stoolPCR test for diagnosis of Helicobacter pylori infection in children.
World J Gastroenterol 2009;15:484–8.
40 Leal YA, Flores LL, Garcı́a-Cortés LB, Cedillo-Rivera R, Torres J.
Antibody-based detection tests for the diagnosis of Helicobacter
pylori infection in children: a meta-analysis. PLoS ONE
2008;3:e3751.
41 Francavilla R, Lionetti E, Castellaneta SP, et al. Improved efficacy of 10-day sequential treatment for Helicobacter pylori eradication in children: a randomized trial. Gastroenterology
2005;129:1414–9.
42 Francavilla R, Lionetti E, Cavallo L. Sequential treatment for
Helicobacter pylori eradication in children. Gut 2008;57:1178.
43 Usta Y, Saltik-Temizel IN, Demir H, Uslu N, Ozen H, Gurakan F,
Yuce A. Comparison of short- and long-term treatment
protocols and the results of second-line quadruple therapy in
children with Helicobacter pylori infection. J Gastroenterol
2008;43:429–33.
44 Nguyen TV, Bengtsson C, Nguyen GK, Hoang TT, Phung DC,
Sörberg M, Granström M. Evaluation of two triple-therapy regimens with metronidazole or clarithromycin for the eradication
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 52–57
H. pylori in Pediatrics
45
46
47
48
49
of H. pylori infection in Vietnamese children: a randomized,
double-blind clinical trial. Helicobacter 2008;13:550–6.
Caristo E, Parola A, Rapa A, Vivenza D, Raselli B, Dondi E,
Boldorini R, Oderda G. Clarithromycin resistance of Helicobacter
pylori strains isolated from children’ gastric antrum and fundus
as assessed by fluorescent in-situ hybridization and culture on
four-sector agar plates. Helicobacter 2008;13:557–63.
Vandenplas Y, Brunser O, Szajewska H. Saccharomyces boulardii
in childhood. Eur J Pediatr 2009;168:253–65.
Hurduc V, Plesca D, Dragomir D, Sajin M, Vandenplas Y. A
randomized, open trial evaluating the effect of Saccharomyces
boulardii on the eradication rate of Helicobacter pylori infection
in children. Acta Paediatr 2009;98:27–31.
Gotteland M, Andrews M, Toledo M, Muñoz L, Caceres P,
Anziani A, Wittig E, Speisky H, Salazar G. Modulation of Helicobacter pylori colonization with cranberry juice and Lactobacillus
johnsonii La1 in children. Nutrition 2008;24:421–6.
Zhang YY, Xia HH, Zhuang ZH, Zhong J. ‘‘True’’ re-infection of
Helicobacter pylori after successful eradication – worldwide
annual rates, risk factors and clinical implications. Aliment Pharmacol Ther 2009;29:145–60.
57
Helicobacter ISSN 1523-5378
Helicobacters and Extragastric Diseases
Rinaldo Pellicano,* Francesco Franceschi, Giorgio Saracco,* Sharmila Fagoonee,à Davide Roccarina and
Antonio Gasbarrini
*Department of Gastro-Hepatology, Molinette Hospital, Turin, Italy, Internal Medicine, Catholic University of Rome, Rome, Italy, àDepartment of
Genetics, Biology and Biochemistry and Molecular Biotechnology Center, University of Turin, Turin, Italy
Keywords
Extragastric disease, IHD, cirrhosis, anemia,
idiopathic thrombocytopenic purpura.
Reprint requests to: Antonio Gasbarrini, MD,
Internal Medicine, Policlinico Gemelli, Università Cattolica, Largo A. Gemelli, 8 – 00168
Rome, Italy. E-mail: agasbarrini@rm.unicatt.it
Abstract
For two decades, Helicobacter pylori has been considered as the culprit in
many extragastric manifestations. However, for several of these supposed
associations the hypothesis of an etiological role has not yet been fully
investigated. This may be due to a series of factors linked to the epidemiological features of the studies and to the diseases investigated. This review
attempts to highlight the main reported associations of H. pylori with extragastric manifestations during the last year. The most convincing data arise in
the field of idiopathic thrombocytopenic purpura (ITP) and sideropenic anemia. Long-term follow-up studies have shown that 50% of subjects with ITP
maintain a hematological response after H. pylori eradication. There is also
growing evidence of the role of H. pylori in other diseases, including ischemic heart disease even though results are not conclusive.
Since the latest decade, several studies have reported
on the link between chronic Helicobacter pylori or Helicobacter species infection and a variety of extragastric
manifestations. These include ischemic heart disease
(IHD), liver diseases, skin diseases, blood disorders, and
others [1]. For several of these supposed associations,
the hypothesis of an etiological role has not yet been
fully investigated. This is due to a series of factors
linked to epidemiological aspects and to the disease per
se. To establish a causal role for an infectious agent in
the triggering of an event, Koch’s postulates must be
fulfilled, and to assess its implication in chronic disease,
Hill’s criteria must be addressed [2]. This is very difficult in the case of multifactorial diseases (for example
IHD) where the pathogenic mechanism cannot be
explained by only one cause. The epidemiological
investigations on potential extragastric manifestations of
H. pylori have frequently involved biases in control
selection, populations of small size, and presence of
confounders, like age and socioeconomic conditions.
Non-randomized, long-period, and large studies on the
follow-up of H. pylori eradication are scarce.
This review attempts to highlight the main reported
associations of H. pylori with extragastric manifestations
published between April 2008 and March 2009. The
association with esophageal diseases, due to its peculiar
features, will not be considered here. To identify all
58
publications, the medical term ‘‘Helicobacter’’ was used
in the MEDLINE search, the studies were selected
according to our aim. The last MEDLINE search was
dated March 21, 2009.
Heart and Vascular Diseases
Atherosclerotic Disease: IHD, Stroke, and
Peripheral Arterial Involvement
Two aspects of H. pylori, H. pylori involvement in atherosclerotic disease were investigated: epidemiology and
pathogenesis. Regarding IHD, Aiello et al. evaluated the
socioeconomic and psycho-social gradients of pathogen
burden of four infectious agents (cytomegalovirus, herpes simplex virus-1, H. pylori and Chlamydia pneumoniae).
By including 999 healthy adults (mean age 59 years)
selected from the longitudinal study MESA (Multi-Ethnic Study of Atherosclerosis) aimed at identifying risk
factors for atherosclerosis, the authors showed that low
education (odds ratio (OR) 95%, confidence interval
(CI)): 1.37, 1.19–1.57) and a higher level of chronic
psycho-social stress were significant independent predictors of higher pathogen burden after adjustment for
covariates [3]. In a study from Turkey, the authors
focused on the seroprevalence of antibodies to H. pylori
in 73 patients with acute coronary syndrome, in 79
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 58–68
Pellicano et al.
patients with chronic stable angina, and in 22 control
subjects. They showed a significantly higher rate of positivity in patients than in controls (80.2 vs 54.5%,
p = .015). This difference was not evident between the
two groups of patients (86.3 vs 74.6%, respectively,
p > .05). C-reactive protein (CRP) was higher in subjects with acute coronary syndrome than in those with
stable angina. However, no adjustment for socioeconomic factors was made [4]. Similar results were
reported in India, where the seroprevalence of IgA and
IgG to H. pylori was significantly higher in 192 patients
with an incident or prevalent IHD with respect to
192 age- and sex-matched controls (for both p < .001).
The level of CRP was higher in subjects positive for
IgA, but not for IgG to H. pylori. On the basis of these
findings, the authors proposed that the association of
CRP with IgA to H. pylori be used as marker to target
the population at high risk for IHD [5]. Opposite results
were found in Iran where only serum antibodies to
C. pneumoniae were associated with late cardiac events
[6]. The study by Nikolopoulou et al. supported the
association between seropositivity for anti-H. pylori IgG
and coronary atherosclerosis, but not in its acute phase.
Furthermore, a potential causal role involving the overexpression of tumor necrosis factor alpha (TNFa) and
vascular cell adhesion molecule-1 is not supported by
data [7]. To clarify if more virulent H. pylori strains
(expressing the CagA antigen) were involved in coronary instability, Franceschi et al. performed a clinicopathological study and a meta-analysis on 4241 cases.
In their study, the authors showed that the anti-CagA
antibody titer was significantly higher in patients with
unstable angina compared to those with stable angina
(p < .02), normal coronary arteries (p < .01) or healthy
controls (p < .02). Moreover, anti-CagA antibodies recognized antigens localized inside coronary atherosclerotic plaque in all specimens from both stable and
unstable patients. In the meta-analysis, seropositivity to
CagA was significantly associated with the occurrence
of acute coronary events (OR: 1.34, 95%CI, 1.15–1.58,
p = .0003) [8]. These findings support the potential role
of more virulent H. pylori strains in the acute phase of
IHD, a pathogenic model postulated on the basis of previous observations [9], and are not mutually exclusive
with the association of the infection with increased circulating low-density lipoprotein cholesterol and triglyceride levels [10]. The implications of more virulent
strains have been confirmed by a systematic review on
15 studies, which showed an OR: 2.11 (95% CI: 1.70–
2.62) for CagA seropositivity in the development of IHD
[11]. Against a local implication in IHD [9], there is the
evidence that, contrary to C. pneumoniae, Mycoplasma
pneumoniae, herpes simplex, and cytomegalovirus [12],
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 58–68
Helicobacters and Extragastric Diseases
the infrequent detection of H. pylori DNA in the plaque
or in human arteries is possible [13,14]. Finally, Honda
et al. showed that H. pylori infection does not accelerate
the age-related progression of arteriosclerosis in a 4year follow-up [15].
Regarding stroke, in a primary care multicenter
study, a trend toward a higher prevalence of active
H. pylori infection in patients with ischemic stroke with
respect to controls (63 vs 54%) has been found. This
difference became significant when focusing on more
virulent strains (OR: 2.69, 95% CI: 1.37–5.30) [16].
This is in agreement with another study that an infection with CagA-positive H. pylori strains increases the
risk of recurrent atherosclerotic stroke with a hazard
ratio: 3.5 (95% CI: 1.9–6.4; p < .001) [17]. In the
review reported above, Zhang et al. found that the OR
of ischemic stroke for more virulent strains in 11 studies was 2.68 (95% CI: 2.20–3.27) [11]. In a prospective
study, performed in Pakistan on 326 subjects with a
2-year follow-up, three patients with active H. pylori
infection and one without infection had a stroke or
transient ischemic attack [18]. This difference was not
statistically significant. According to the authors larger,
prospective, randomized studies are needed.
Regarding other arteriopathies, Sawayama et al.
showed that the prevalence of H. pylori infection was
significantly higher in patients with peripheral arterial
disease than in controls (79.7 vs 44.8%, p < .01) [19].
Nyberg et al. investigated, with negative findings,
whether seropositivity for antibodies to H. pylori, or to a
burden of pathogens, including also C. pneumoniae,
cytomegalovirus, and herpes simplex virus, were related
to abdominal aortic aneurysm rupture [20]. In a preliminary investigation, the authors found a relationship
between H. pylori infection and cardiac syndrome X
[21]. This encourages more robust studies.
The involvement of the bacterium in metabolic disturbance or inflammatory processes potentially related
to atherosclerotic disease has been explored. Gunji et al.
reported the seroprevalence of H. pylori infection in
healthy Japanese adults with and without metabolic
syndrome. A total of 38.6% among the former vs
28.0% among the latter (p < .001) were positive for
H. pylori antibodies. Furthermore, a number of metabolic syndrome components (high systolic blood pressure, low HDL-cholesterol, and high LDL-cholesterol
levels) were found significantly associated with H. pylori
seropositivity by multiple linear regression analysis
[22]. Helicobacter pylori has also been shown to affect
the vascular risks and complications in patients with
diabetes mellitus although data concerning the prevalence of H. pylori infection among these patients are
scanty and controversial [1]. Hamed et al. evaluated
59
Helicobacters and Extragastric Diseases
the prevalence of H. pylori infection in patients with
diabetes mellitus, the association between the former
and diabetic vascular complications, and the influence
of the bacterium on atherosclerosis and inflammatory
biomarkers. The prevalence of H. pylori infection was
higher in patients compared to healthy controls. Carotid
artery intima-media thickness and inflammatory biomarkers, as interleukin (IL)-6 and TNFa, were significantly higher in infected patients. In the multivariate
analysis, blood glucose, triglycerides, erythrocytic sedimentation rate, IL-6 and TNFa increased the OR for
atherothrombotic cause of cerebral ischemia in patients
with H. pylori infection [23]. In a study performed in
Japan, Ohnishi et al. showed in 130 patients with type
2 diabetes mellitus, without history of cardiovascular
disease, that H. pylori infection was associated with arterial stiffness determined by pulse wave velocity [24].
Arrhythmias
Besides IHD, the possible association between H. pylori
infection and atrial fibrillation has been previously published. In the last year, Platonov et al. reported, in a
case–control study, that permanent atrial fibrillation is
associated with elevated CRP levels, but the latter is not
the result of earlier infection with H. pylori or C. pneumoniae [25]. This is in agreement with the conclusion
of an editorial that, in light of the existing results, the
responsibility of H. pylori infection has been excluded in
the development of atrial fibrillation [26].
Respiratory and Ear, Nose, and Throat
(E.N.T.) Diseases
A wide spectrum of manifestations linked to H. pylori
has been reported over the last year. Regarding asthma,
a study has shown that in children, the rate of H. pylori
antibodies is low and a significant difference could not
be detected in gastroesophageal reflux disease and
atopy between patients negative and positive for
H. pylori [27]. These findings are in agreement with
those of a cross-sectional analysis on 7412 participants
in a U.S. National survey. In this case, the authors
showed that H. pylori was inversely associated with a
history of asthma (95% CI, OR: 0.69, 0.45–1.06) [28].
Data from another U.S. study on 318 patients and 208
controls, also indicated that infection with more virulent strains is inversely associated with asthma (95%
CI, OR:0.57, 0.36–0.89) and is associated with an older
age of asthma onset [29]. In an animal model, H. pylori
neutrophil-activating protein (HPNAP) reduced eosinophilia, IgE, and Th2 cytokine levels in bronchoalveolar
lavage [30]. Whether HPNAP is a candidate for novel
60
Pellicano et al.
strategies of prevention and treatment of allergic diseases remains to be elucidated. In contrast, in a study
on 2437 randomly selected adults, Fullerton et al. failed
to demonstrate an association between H. pylori exposure and chronic obstructive pulmonary disease, measures of allergic disease or decline in lung function
[31].
Colonization by H. pylori of the larynx has been
shown by Titiz et al. detected H. pylori DNA by PCR in
17 of 21 samples of patients operated on for laryngeal
squamous cell carcinoma. This DNA was present both
in normal and in tumoral tissue (76.2 vs 42.9%,
p = .039). On the contrary, H. pylori DNA was not
found in samples of 19 patients with benign laryngeal
pathology (p = .0001) [32]. Grbesa et al. also detected
H. pylori by Giemsa staining and nested-PCR in 13 of 82
(16%) samples from patients with laryngeal squamous
cell carcinoma [33]. Rezaii et al. showed that seropositivity for antibodies to H. pylori was significantly associated with laryngohypopharyngeal carcinoma [34]. In
an evidence-based meta-analysis, including five case–
control studies, laryngeal cancer risk for patients with
H. pylori infection was 2.03-fold higher (95% CI 1.28–
3.23) [35].
Zycinska et al., on the basis of a study on 36 patients
with pulmonary Wegener’s granulomatosis disease, suggested that disease severity, prevalence of gastroduodenal lesions, and type and duration of treatment is
dependent upon H. pylori infection [36].
Regarding E.N.T, Fancy et al. observed, in pediatric
patients with otitis, more H. pylori DNA in adenoids of
patients than in those of controls (10 of 45 vs 6 of 37,
respectively, p = .49) [37]. Helicobacter pylori whole-cell
protein directly induced a macrophage migration inhibitory factor, macrophage inflammatory protein 2, IL-1b,
and TNFa in middle ear epithelium in experimentally
infected mice. Moreover, severe proliferation of inflammatory cells was observed in the middle ear cavity
inoculated with H. pylori whole-cell protein [38]. In a
critical evaluation of the evidence of the relationship
between H. pylori and otitis media with effusion, the
authors, after examination of six original papers, with a
total of 203 patients and 27 controls, concluded that
there is actually poor proof of correlation [39].
Using urease test, Eyigor et al. found H. pylori positivity in three of 55 adenotonsillar tissue specimens of
patients with adenotonsillitis; however, none was positive when analyzed by PCR [40]. Similar results were
reported in pediatric patients with chronic tonsillitis, in
whom H. pylori did not colonize tonsil tissue [41].
Uncertainties persist concerning the association
between H. pylori and nasal polyps. While Cvorovic
et al. found H. pylori in six of 23 specimens by urease
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 58–68
Pellicano et al.
test and by histochemical analysis with Giemsa staining
[42], Ozcan et al. detected H. pylori only in one of 25
specimens by each of these methods [43]. By using a
questionnaire, another group has shown, in a prospective study that H. pylori eradication chronic nonspecific
pharyngeal symptoms [44] but the mechanism of this
benefit should be better investigated. It probably
depends on acid inhibition rather than bacterium cure
per se. In fact, in the work by Toros et al., all patients
responded well to anti-reflux treatment but no correlation was observed between H. pylori positivity and
symptoms [45]; in the study of Oridate et al., acidsuppression therapy offered slower laryngopharyngeal
than esophageal symptom relief in laryngopharyngeal
reflux patients, and these differences were observed
independently from H. pylori status [46].
Hematologic Diseases
Idiopathic Thrombocytopenic Purpura (ITP)
After the pioneer report by Gasbarrini et al. [47], the
association between H. pylori and ITP obtained a formal
recognition in the Maastricht III Consensus report
which recommended that H. pylori infection should be
sought after and treated in patients with ITP [48].
During the last year, a Canadian prospective study
showed that in subjects with ITP, 48 months after
H. pylori eradication, 75% achieved a complete or a partial response and 50% had a long-term ongoing
response [49]. Unfortunately, the small sample size
(four H. pylori-positive patients) limits the value of the
long-term follow-up. In a 7-year follow-up prospective
study conducted in Japan and including 30 subjects,
H. pylori eradication had a short-term efficacy in about
half of the H. pylori positive ITP patients [50]. In Korea,
in patients who did not respond to steroid and ⁄ or danazol therapy for ITP, a combination therapy consisting of
H. pylori eradication plus immunosuppressive therapy
induced, after 6 months, a statistically higher response
than H. pylori eradication alone (66.7 vs 41.7%,
p = .345). Furthermore, the median response duration
was also longer in the former than in the latter group
(9 vs 3 months, p = .049) [51]. In contrast, in Australia,
four of nine ITP patients receiving eradication treatment
showed no response and underwent splenectomy, and
one relapsed after 3 months [52]. In a systematic
review, original articles reporting 15 or more total
patients were included. The authors found 25 studies
including 1555 patients, of whom 696 were evaluable
for the effect of H. pylori eradication on platelet count.
The complete response and overall response (at least
doubling of the basal count) were 42.7% (95% CI
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 58–68
Helicobacters and Extragastric Diseases
31.8–53.9) and 50.3% (95% CI: 41.6–59), respectively.
The response rate tended to be higher in countries with
a high background prevalence of H. pylori infection (e.g.
Japan) and in patients with a milder degree of ITP [53].
Suzuki et al. extracted genomic DNA from peripheral
blood of H. pylori-positive ITP patients, who received
eradication treatment, and polymorphisms of IL-1b
()31, )511), IL-1RN (long or short), TNFa ()308), and
TNFb (+252) were analyzed using PCR-restriction fragment length polymorphism. There was no statistical difference in the frequencies of polymorphisms in IL-1b,
IL-1RN, and TNFa genes between responders and nonresponders. In contrast, the frequency of responders
was significantly higher in ITP patients with the TNFb
G ⁄ G or G ⁄ A genotype than in those with the TNFb A ⁄ A
genotype. Therefore, the TNFb (+252) G ⁄ G or G ⁄ A
genotype may be considered as a good predictor of
platelet recovery in ITP patients after H. pylori eradication [54]. Asahi et al., in addition to confirming a significant benefit from H. pylori eradication therapy in
patients with ITP (61 vs 0% among H. pylori negative),
observed that the recovery in platelet numbers was
mediated through a change in FccR balance toward the
inhibitory FccRIIB [55]. The best pathogenic model postulated is based on the antibody cross-reaction between
H. pylori ureB and human platelet GP IIIa [56].
Iron-deficiency Anemia (IDA)
Several seroepidemiologic studies have suggested a link
between H. pylori infection and IDA both in adults and
in children [1,57]. Moreover, pregnant women with
IDA had a significantly high prevalence of active
H. pylori infection [58].
Some investigators observed that cure of the bacterial
infection is followed by improvement and normalization of mean cell volume, ferritin, and iron, with disappearance of anemia [59]. During a follow-up of
40 months of children in rural Alaska, H. pylori eradication modestly reduced the prevalence of iron deficiency
and substantially reduced that of IDA [60]. Different
results have been achieved in Iran, where the frequency of H. pylori infection in children with and without anemia was similar (44 vs 50%). Among infected
children, 36% had anemia vs 42.2% (p = .59) in noninfected ones [61]. Similar findings have been reported
in Northwest Turkey where authors hypothesized that
IDA might be explained by inadequate dietary intake
[62]. In Bangladeshi children, the authors observed a
significantly higher effect of iron-alone therapy compared to anti-H. pylori therapy in improving iron status.
Even anti-H. pylori treatment compared with placebo
was not effective in improving iron status at day 90. No
61
Pellicano et al.
Helicobacters and Extragastric Diseases
additional impact of combined anti-H. pylori plus iron
therapy over iron therapy alone was observed [63].
Muhsen & Cohen performed a systematic review and a
meta-analysis on H. pylori infection and iron stores.
Although very few studies controlled for multiple
potential confounders, most investigations reported a
positive association between H. pylori and decreased
body iron stores in symptomatic and asymptomatic
infected subjects. Helicobacter pylori may be considered a
risk factor for reduction of body iron stores, iron deficiency and IDA, especially in high-risk groups. The
meta-analysis showed an increased risk of IDA (OR:
2.8; 95% CI: 1.9–4.2) as well as iron deficiency (OR:
1.38; 95% CI: 1.16–1.65) [64].
In an elegant study, Lee et al. evaluated the expression of iron-repressible outer membrane proteins
(IROMPs) in H. pylori and its association with IDA.
IROMPs were found in IDA strains under iron-restricted
conditions. Thus, since specific H. pylori strains associated with IDA demonstrated an advantage in iron
acquisition due to a higher expression of IROMPs, this
explains in part why some infected patients are more
prone to developing clinical IDA under restricted iron
conditions [65].
Monoclonal Gammopathy
Monoclonal gammopathy of unknown significance is
not associated with H. pylori infection. Soler et al. compared the follow-up of 13 patients successfully treated
for H. pylori and 33 who were not cured. After a median follow-up of 19.6 months, the monoclonal component was unchanged in eradicated, and not different
between eradicated patients compared to those with
H. pylori negativity ab initio (15.6 ± 9 vs 15.9 ± 1 vs
15.7 ± 1) [66].
Hepatobiliary Diseases
There is an increasing interest in Helicobacter species’
role in human liver diseases, even though results are
still inconclusive and supported by only a few papers,
mainly based on animal models [67]. Ito et al. by using
transmission electron microscopy, found in vitro differences between hepatocytes and gastric epithelial cells in
terms of both adherence and internalization of H. pylori.
Of interest is the fact that the bacterium adhered and
was internalized into hepatocytes more efficiently than
into gastric epithelial cells (p < .05). Once inside the
hepatocytes, both VacA-positive and -negative H. pylori
strains were able to produce vacuoles, interpreted as
endocytotic vesicles. b1-integrin was identified as a
probable receptor involved in internalization of H. pylori
62
into hepatocytes [68]. The same group observed that
H. pylori infection of hepatocytes causes disturbance of
apoptosis and DNA synthesis. In particular, infection
with more virulent strains resulted in cell arrest and
increased DNA fragmentation. The difference with the
less virulent strain employed (H. pylori 401C) was significant [69]. Goo et al. induced lesions resembling
those of human primary biliary cirrhosis (PBC) in a
24-month-old male C57BL ⁄ 6 mouse infected with
H. pylori. Since the serum antivacuolating toxin IgG in
this mouse showed the highest value in the H. pyloriinfected group, the authors concluded that the increase
in vacuolating toxin caused by H. pylori infection may
be related to the development of PBC by molecular
mimicry [70].
Finally, an in vitro study showed that H. pylori significantly influenced human gallbladder epithelial cell
morphology, causing reduced cell growth, decreased
viability, and increased detachment. The damage was
more significant in cells treated in culture liquid ⁄ broth?
than in H. pylori sonicate extracts [71].
Diseases of the Large Intestine
The potential association between H. pylori infection
and colorectal diseases has been investigated in the last
year.
In the human colon, Helicobacter sp. DNA can be
found in 35% of cases [72]. However, its pathogenic
role, if any, remains to be elucidated.
Regarding the field of oncology, Zhao et al. performed a meta-analysis on H. pylori and the risk of colorectal cancer, including 13 studies. The summary OR
was 1.49 (95% CI: 1.17–1.91). Moreover, with the
method of fail-safe, the effect of publication bias was
small [73]. In a large study, including 685 subjects, the
authors found that neither hypergastrinemia nor serologic evidence of H. pylori infection was associated with
an increased risk of recurrent adenoma development
[74]. Soylu et al. looked for the presence of H. pylori by
immunohistochemistry in samples of patients undergoing polipectomy during colonoscopy. They found that
21.6% of all specimens were positive, with a percentage
of 25 in the case of cancer. The presence of H. pylori in
colon polyps did not yield any correlation with polyp
size, colonic localization or histopathologic type [75].
Gynecological Diseases and Fertility
Disorders
Nausea and vomiting are very frequent complaints of
pregnant women and, when severe, may lead to
hyperemesis gravidarum (HG), characterized by weight
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 58–68
Pellicano et al.
loss, dehydration, acidosis from starvation, alkalosis
from loss of hydrochloric acid in vomitus, hypokalemia,
and transient hepatic dysfunction. While some seroepidemiologic studies showed that H. pylori infection is significantly associated with HG, others did not [1].
Sandven et al. included in a case–control study, 244
women with HG and 244 pregnant women free of HG.
They observed that the presence of H. pylori increased
the risk of HG by more than twofold (OR: 2.42, 95% CI
1.64–3.57, p < .001). The association was significantly
more evident among Africans than in non-Africans
[76]. Pugliese et al., comparing 25 pre-eclamptic
women and 25 healthy parturient, have shown that the
former had a significantly higher H. pylori seropositivity
as well as a higher anti-CagA seropositivity. On the
contrary, they did not find a difference in IL-18 levels
between the two groups [77]. The benefit of H. pylori
eradication in patients with localized vulvodynia,
reported in a study with a small sample size, remains to
be better understood [78].
Regarding infertility, Collodel et al. showed that
infertile patients infected with H. pylori had a low sperm
quality compared to uninfected ones. A significant
reduction of sperm motility and fertility was observed,
particularly in CagA-positive patients, whereas apoptosis and necrosis were increased (p < .05). In these, the
mean values of TNFa levels were higher than those of
uninfected patients. The percentage of immaturity and
the related defective organelles did not seem to be
influenced by the presence of the bacterium [79]. Based
on a study in which both the anti-H. pylori antibodies
in serum and follicular fluids were measured, Kurotsuchi et al. hypothesized the presence of an antigenic
mimicry between the flagella of H. pylori and spermatozoa. Thus, antibodies produced against H. pylori flagella
may cross-react with spermatozoid flagella, increasing
the risk of infertility [80].
Neurologic and Psychiatric Diseases
In this field, in the last year more hypotheses and
reviews than original data have been published [81,82].
Among the latter, Kountouras et al. investigated the
benefit of H. pylori eradication in the management of
Alzheimer’s disease. They showed that the prevalence
of the bacterial infection was significantly higher in
patients than in age-matched controls (88 vs 46.7%,
p < .001). Helicobacter pylori eradication was obtained in
84.8% of the cases. After a 2-year follow-up, patients
who were cured of the infection had a significant
improvement in cognitive and functional status parameters (measured by specific scales) compared to those
who failed eradication [83]. Although it is difficult to
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 58–68
Helicobacters and Extragastric Diseases
come to a definite conclusion on the casuality of the
relationship between H. pylori and Alzheimer’s disease,
and the consistency of an association based on published studies is poor [84], this prospective study on a
small sample size provides the basis for well-designed
trials with larger populations.
Regarding Parkinson’s disease, Lee et al. showed that
infected patients had a longer L-dopa ‘‘onset’’ time and
a shorter ‘‘on-time’’ duration than uninfected patients
(p < .05). Helicobacter pylori eradication improved the
delay in the L-dopa ‘‘onset’’ time and the short ‘‘ontime’’ duration. According to the authors, these data
demonstrate that the bacterium could interfere with
the absorption of L-dopa and provoke motor fluctuations [85].
In a study on sera from 120 individuals affected by
neuropsychiatric lupus compared to those from 140
geographic controls, Zandman-Goddard et al. failed to
find an association between this disease and seropositivity for H. pylori antibodies [86].
Other Diseases
Confirming a previous study by Demir et al. [87], a
seroepidemiological investigation conducted on a random sample of patients obtained from the previously
cited MESA study, did not show an association between
H. pylori infection and type 2 diabetes mellitus [88]. On
the contrary, in South America, Fernandini-Paredes
et al. found that in diabetic patients, glycosylated
hemoglobin levels were higher in infected than in
uninfected individuals (p = .03). The presence of the
bacterium was not associated with the response to the
diabetes mellitus treatment [89]. On a similar trend,
another group showed that H. pylori infected patients
had a significantly higher HOMA-IR level (diagnostic
standard of insulin resistance) when compared with
uninfected ones [90]. In a Japanese case report, the
authors reported the onset of type 1 diabetes mellitus
after H. pylori eradication [91]. The link with an autoimmune mechanism remains unclear.
The circulating levels of ghrelin and leptin, two hormones involved in body weight regulation and food
intake, in relation to H. pylori status in adult males have
been investigated. Chuang et al. observed that, before
H. pylori eradication, males had lower plasma ghrelin
levels than females (p < .001), but thereafter these levels were similar. Such a gender difference was not evident for leptin levels [92]. Based on previous work
leading to the hypothesis that gastric H. pylori
colonization reduced circulating levels of leptin and
ghrelin, Roper et al. examined gastric, circulating, and
gastric juice levels of leptin and ghrelin in fasting
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Pellicano et al.
Helicobacters and Extragastric Diseases
H. pylori-positive and -negative adult male subjects.
They showed that bacterial colonization was associated
with reduced circulating leptin levels, independent of
body mass index, and fundic ghrelin and leptin levels
were directly related. Levels of ghrelin in infected and
uninfected patients were similar. Ghrelin was present
in gastric juice over a large concentration range, and
was strongly correlated with gastric pH [93]. Gao et al.
observed that ghrelin concentration and ghrelin ⁄ obestatin ratios were lower in H. pylori infected subjects than
in uninfected individuals [94]. Obestatin is a peptide
derived from preproghrelin and a physiologic opponent
to ghrelin. Interestingly, a group found that autoantibodies against appetite-regulating peptide hormones
and neuropeptides were displayed by both healthy
humans and rats. The authors hypothesized a potential
link between gut microflora and appetite control [95].
Helicobacter pylori infection also seems to play a role
in conjunctival MALT lymphoma, for which a mechanism similar to those of gastric MALT lymphoma has
been postulated [96], but not in glaucoma [97]. However, in the latter, Deshpande et al. found a higher seroprevalence of H. pylori IgG antibodies in patients with
primary open angle glaucoma compared with those
with pseudo-exfoliation glaucoma. This difference was
not evident upon analysis of the aqueous humor [98].
Choi et al. investigated the association between H. pylori
infection and Posner–Schlossman syndrome and found
that patients had a significantly higher seroprevalence
than controls (80 vs 56.2%, p = .014) [99].
As reported in the section on respiratory diseases, the
relationship between H. pylori infection and allergic diseases is of increasing interest. All studies converge
towards a lack of positive association. In a large cohort
of 1953 Japanese university students, allergic diseases
were frequent and negatively associated with H. pylori
infection, especially in men [100]. This is in agreement
with other data [101,102]. Cam et al. observed a counteractive Th1 and Th2 cytokine interaction between
H. pylori infection and atrophy [103]. This effect was not
protective, as opposed to conclusions made in a study
by Konturek et al., in which H. pylori infection was
associated with a decreased risk of food allergy [104].
Two nested case–control studies, including 104 [105]
and 87 [106] patients with pancreatic cancer, concluded
that H. pylori infection was not associated with the
development of this neoplasm. However, in the latter
investigation, an association was found in subjects who
were not smokers (OR: 3.81; 95% CI: 1.06–13.63)
[106].
With regard to dermatology, two intervention studies
have reported opposing results: H. pylori infection was not
associated with chronic urticaria in Germany [107] to the
64
contrary of India, where it has been suggested to include
the detection of this bacterium in the diagnostic work-up
of this disease [108]. The data by Abdel-Hafez et al. supported the hypothesis that H. pylori infection is not associated with alopecia areata [109]. The clearance of chronic
psoriasis after eradication therapy for H. pylori infection
has been the focus of a case report [110], and a case report
of Helicobacter cinaedi bacteremia in a previously healthy
person with cellulitis has also been described [111].
Ozel et al. observed that H. pylori eradication in
patients with familial Mediterranean fever led to a
decreased level of IL-6. These findings were not evident
in subjects homozygous for M694V mutation [112].
One case report has shown that anti-H. pylori treatment can reduce, for a limited time, the recurrence of
oral aphthous ulcers in patients with Behcet’s syndrome [113]. It is important to understand if this temporary benefit is due to the antibiotics or to H. pylori
eradication. A study on 23 patients with recurrent aphthous stomatitis showed that, after bacterial eradication,
there was a significant reduction of the recurrence and
amelioration time [114].
In a study on patients with sudden infant death syndrome, a significant prevalence of active H. pylori infection (by stool antigen) among infant death cases
compared with live controls was observed [115].
Conflicts of Interest
The authors have not declared any conflicts of interest.
References
1 Moyaert H, Franceschi F, Roccarina D, Ducatelle R,
Haesebrouck F, Gasbarrini A. Extragastric manifestations of
Helicobacter pylori infection: other Helicobacters. Helicobacter
2008;13(S1):47–57.
2 Lowe AM, Yansouni CP, Behr MA. Causality and gastrointestinal infections: Koch, Hill, and Crohn’s. Lancet Infect Dis
2008;8:720–6.
3 Aiello AE, Diez-Roux A, Noone A-M, Ranjit N, Cushman M,
Tsai MY, Szklo M. Socioeconomic and psychosocial gradients
in cardiovascular pathogen burden and immune response: the
multi-ethnic study of atherosclerosis. Brain Behav Immun
2009;23:663–71.
4 Tamer GS, Tengiz I, Ercan E, Duman C, Alioglu E, Turk UO.
Helicobacter pylori seropositivity in patients with acute coronary
syndromes. Dig Dis Sci 2009;54:1253–6.
5 Jha HC, Prasad J, Mittal A. High immunoglobulin A seropositivity for combined Chlamydia pneumoniae, Helicobacter pylori
infection, and high-sensitivity C-reactive protein in coronary
artery disease patients in India can serve as atherosclerotic
marker. Heart Vessels 2008;23:390–6.
6 Sarrafzadegan N, Rezaporian P, Kaypour M, Mohseni M,
Sadeghi M, Asgary S, Sabet B. Prognostic value of infection
and inflammation markers for late cardiac events in an Iranian
sample. East Mediterr Health J 2008;14:1246–56.
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 58–68
Pellicano et al.
7 Nikolopoulou A, Tousoulis D, Antoniades C, et al. Common
community infections and the risk for coronary artery disease
and acute myocardial infarction: evidence for chronic overexpression of tumor necrosis factor alpha and vascular cells
adhesion molecule-1. Int J Cardiol 2008;130:246–50.
8 Franceschi F, Niccoli G, Ferrante G, et al. CagA antigen of
Helicobacter pylori and coronary instability:insight from a
clinico-pathological study and a meta-analysis of 4241 cases.
Atherosclerosis 2009;202:535–42.
9 Berrutti M, Pellicano R, Fagoonee S, Astegiano M, Smedile A,
Saracco G, Repici A, Leone N, Rizzetto M. Potential relationship between Helicobacter pylori and ischemic heart disease: any
pathogenic model? Panminerva Med 2008;50:161–3.
10 Kucukazman M, Yacuz B, Sacikara M, et al. The relationship
between updated Sydney system score and LDL cholesterol
levels in patients infected with Helicobacter pylori. Dig Dis Sci
2009;54:604–7.
11 Zhang S, Guo Y, Ma Y, Teng Y. Cytotoxin-associated gene-Aseropositive virulent strains of Helicobacter pylori and atherosclerotic disease: a systematic review. Chin Med J
2008;121:946–51.
12 Reszka E, Jegier B, Wasowicz W, Lelonek M, Banach M, Jaszewski R. Detection of infectious agents by polymerase chain reaction in human aortic wall. Cardiovasc Pathol 2008;17:297–302.
13 Iriz E, Crak MY, Engin ED, Zor MH, Erer D, Ozdogan ME,
Turet S, Yener A. Detection of Helicobacter pylori DNA in aortic
and left internal mammary artery biopsies. Tex Heart Inst J
2008;35:130–5.
14 Ciervo A, Mancini F, Sale P, Russo A, Cassone A. Real-time
polymerase chain reaction and laser capture microdissection:
an efficient combination tool for Chlamydophila pneumonate
DNA quantification and localization of infection in atherosclerotic lesions. Int J Immunopathol Pharmacol 2008;21:421–8.
15 Honda C, Adachi K, Arima N, Tanaka S, Yagi J, Morita T,
Tanimura T, Furuta K, Kinoshita Y. Helicobacter pylori infection
does not accellerate the age-related progression of arteriosclerosis: a 4-year follow-up study. J Gastroenterol Hepatol
2008;23:373–8.
16 De Bastiani R, Gabrielli M, Ubaldi E, et al. High prevalence of
cag-A positive H. pylori strains in ischemic stroke: a primary
care multicenter study. Helicobacter 2008;13:274–7.
17 Diomedi M, Stanzione P, Sallustio F, Leone G, Renna A,
Misaggi G, Fontana C, Pasqualetti P, Pietroiusti A. Cytotoxinassociated gene-A-positive Helicobacter pylori strains infection
increases the risk of recurrent atherosclerotic stroke. Helicobacter 2008;13:525–31.
18 Wasay M, Jafri W, Khealani B, Azam I, Hussaini A. Helicobacter
pylori gastritis and risk of ischemic stroke. J Pak Med Assoc
2008;58:368–70.
19 Sawayama Y, Hamada M, Otaguro S, Maeda S, Ohnishi H,
Fujimoto Y, Taira Y, Hayashi J. Chronic Helicobacter pylori
infection is associated with peripheral arterial disease. J Infect
Chemother 2008;14:250–4.
20 Nyberg A, Skagius E, Nilsson I, Englund E, Nilsson I, Ljungh A,
Henriksson AE. Abdominal aortic aneurysm and the impact of
infectious burden. Eur J Vasc Endovasc Surg 2008;36:292–6.
21 Assadi M, Saghari M, Ebrahimi A, Reza Pourbehi M, Eftekhari M,
Nabipour I, Abbaszadeh M, Nazarahari M, Nasiri M, Assadi S.
The relationship between Helicobacter pylori infection and cardiac syndrome X: a preliminary study. Int J Cardiol
2009;134:124–5.
22 Gunji T, Matsuhashi N, Sato H, Fujibayashi K, Okumura M,
Sasabe N, Urabe A. Helicobacter pylori infection is signficantly
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 58–68
Helicobacters and Extragastric Diseases
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
associated with metabolic syndrome in the Japanese population. Am J Gastroenterol 2008;103:3005–10.
Hamed SA, Amine NF, Galal GM, Helal SR, Tag El-Din LM,
Shawky OA, Ahmed EA, Abdel Rahman MS. Vascular risks
and complications in diabetes mellitus: the role of Helicobacter
pylori infection. J Stroke Cerebrovasc Dis 2008;17:86–94.
Ohnishi M, Fukui M, Ishikawa T, Ohnishi N, Ishigami N,
Yoshioka K, Hasegawa G, Yoshikawa T, Nakamura N. Helicobacter pylori infection and arterial stiffness in patients with type
2 diabetes mellitus. Metabolism 2008;57:1760–4.
Platonov P, Ekesbo R, Hansson A, Andsberg E, Meurling CJ,
Nilsson I, Ljungh A, Wadsrom T, Olsson SB. Permanent atrial
fibrillation in patients without structural heart disease is not
associated with signs of infection by Chlamydia pneumoniae and
Helicobacter pylori. Acta Cardiol 2008;63:479–84.
Lunetta M, Fazio G, Avena V, Corrado E, Sutera L, Arnone E,
Novo G, Novo S. Helicobacter pylori and atrial fibrillation. J Cardiovasc Med 2009;10:4–5.
Asilsoy S, Babayigit A, Olmez D, Uzuner N, Karaman O, Oren O,
Turgut CS, Tezcan D. Helicobacter pylori infection and gastroesophageal reflux in asthmatic children. J Trop Med
2008;54:129–32.
Chen Y, Blaser MJ. Helicobacter pylori colonization is inversely
associated with childhood asthma. J Infect Dis 2008;198:
553–60.
Reibman J, Marmor M, Filner J, Fernandez-Beros ME, Rogers L,
Perez-Perez GI, Blaser MJ. Asthma is inversely associated with
Helicobacter pylori status in an urban population. PLoS ONE
2008;3:e4060.
Codolo G, Mazzi P, Amedei A, Del Prete G, Berton G, D’Elios
MM, de Bernard M. The neutrophil-activating protein of
Helicobacter pylori down-modulates Th2 inflammation in
ovalbumin-induced allergic asthma. Cell Microbiol
2008;10:2355–63.
Fullerton D, Britton JR, Lewis SA, Pavord ID, McKeever TM,
Fogarty AW. Helicobacter pylori and lung function, asthma,
atopy and allergic disease. A population-based cross-sectional
study in adults. Int J Epidemiol 2009;38:419–26.
Titiz A, Ozcakir O, Ceyhan S, Yilmaz YF, Unal A, Akyon Y.
The presence of Helicobacter pylori in the larynx pathologies.
Auris Nasus Larynx 2008;35:534–8.
Grbesa I, Marinkovic M, Ivkic M, Kruslin B, Novak-Kujundzic
R, Pegan B, Bogdanovic O, Bedekovic V, Gall-Troselj K. Loss
of imprinting of IGF2 and H19, loss of heterozygosity of IGF2R
and CTCF, and Helicobacter pylori infection in laryngeal squamous cell carcinoma. J Mol Med 2008;86:1057–66.
Rezaii J, Tavakoli H, Esfandiari K, Asheg H, Hasibi M, Ghanei
G, Khosh-Batn M, Rashidi A. Association between Helicobacter
pylori infection and laryngohypopharyngeal carcinoma: a case
control study and review of the literature. Head Neck
2008;30:1624–7.
Zhuo XL, Wang Y, Zhuo WL, Zhang XY. Possible association of
Helicobacter pylori infection with laryngeal cancer risk: an evidence-based meta-analysis. Arch Med Res 2008;39:625–8.
Zycinska K, Wardyn KA, Zycinski Z, Smolarczyk R. Correlation between Helicobacter pylori infection and pulmonary
Wegener’s granulomatosis activity. J Physiol Pharmacol
2008;6:845–51.
Fancy T, Mathers PH, Ramadan HH. Otitis media with effusion: a possible role for Helicobacter pylori? Otolaryngol Head
Neck Surg 2009;140:256–8.
Kariya S, Okano M, Fukushima K, Nomiya S, Kataoka Y,
Nomiya R, Akagi H, Nishizaki K. Expression of inflammatory
65
Pellicano et al.
Helicobacters and Extragastric Diseases
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
66
mediators in the otitis media induced by Helicobacter pylori
antigen in mice. Clin Exp Immunol 2008;154:134–40.
Sudhoff H, Rajagopal S, Baguley DM, Ebmeyer J, Schmelzer
A, Schreiber S, Moffat DA. A critical evaluation of the evidence on a causal relationship between Helicobacter pylori and
otitis media with effusion. J Laryngol Otol 2008;122:905–11.
Eyigor M, Eyigor H, Gultekin B, Aydin N. Detection of Helicobacter pylori in adenotonsillar tissue specimens by rapid urease
test and polymerase chain reaction. Eur Arch Otorhinolaryngol
2009; [Epub ahead of print].
Vayisoglu Y, Ozcan C, Polat A, Delialioglu N, Gorur K. Does Helicobacter pylori play a role in the development of chronic adenotonsillitis? Int J Pediatr Otorhinolaryngol 2008;72:1497–501.
Cvorovic L, Brajovic D, Strbac M, Milutinovic Z, Cvorovic V.
Detection of Helicobacter pylori in nasal polyps: preliminary
report. J Otolaryngol Head Neck Surg 2008;37:192–5.
Ozcan C, Polat A, Otağ F, Görür K. Does Helicobacter pylori play
a role in etiology of nasal polyposis? Auris Nasus Larynx
2009;36:427–30.
Aladag I, Eyibilen A, Guven M, Erkokmaz U. Effects of Helicobacter pylori eradication on chronic nonspecific pharyngeal
symptoms. J Otolaryngol Head Neck Surg 2008;37:623–7.
Toros SZ, Toros AB, Yuksel OD, Ozel L, Akkaynak C, Naiboglu
B. Association of laryngopopharyngeal manifestations and gastroesophageal reflux. Eur Arch Otorhinolaryngol 2009;266:403–9.
Oridate N, Takeda H, Asaka M, Nishizawa N, Mesuda Y, Mori
M, Furuta Y, Fukuda S. Acid-suppression therapy offers varied
laryngopharyngeal and esophageal symptom relief in laryngopharyngeal reflux patients. Dig Dis Sci 2008;53:2033–8.
Gasbarrini A, Franceschi F, Tartaglione R, Landolfi R, Pola P,
Gasbarrini G. Regression of autoimmune thrombocytopenia
after eradication of Helicobacter pylori. Lancet 1998;352:878.
Malfertheiner P, Mégraud F, O’Morain C, et al. Current concepts in the management of Helicobacter pylori infection: the
Maastricht III Consensus Report. Gut 2007;56:772–81.
Jackson SC, Beck P, Buret AG, O’Connor PM, Meddings J,
Pineo G, Poon M-C. Long-term platelet responses to Helicobacter pylori eradication in Canadian patients with immune
thrombocytopenic purpura. Int J Hematol 2008;88:212–8.
Tsumoto C, Tominaga K, Okazaki H, et al. Long-term efficacy
of Helicobacter pylori eradication in patients with idiopathic
thrombocytopenic purpura: 7-year follow-up prospective
study. Ann Hematol 2009;88:789–93.
Song MK, Chung JS, Shin JS, Choi YJ, Cho G. Outcome of
immunosuppressive therapy with Helicobacter pylori eradication
therapy in patients with chronic idiopathic thrombocytopenic
purpura. J Korean Med Sci 2008;23:445–51.
Sivapathasingam V, harvey MP, wilson RB. Helicobacter pylori
eradication: a novel therapeutic option in chronic immune
thrombocytopenic purpura. Med J Aust 2008;189:367–70.
Stasi R, Sarpatwari A, Segal JB, Osborn J, Evangelista ML,
Cooper N, Provan D, Newland A, Amadori S, Bussel JB. Effects
of eradication of Helicobacter pylori infection in patients with
immune thrombocytopenic purpura: a systematic review.
Blood 2009;113:1231–40.
Suzuki T, Matsushima M, Shirakura K, Koike J, Masui A,
Takagi A, Shirasugi Y, Ogawa Y, Shirai T, Mine T. Association of inflammatory cytokine gene polymorphisms with
platelet recovery in idiopathic thrombocytopenic purpura
patients after the eradication of Helicobacter pylori. Digestion
2008;77:73–78.
Asahi A, Nishimoto T, Okazaki Y, Suzuki H, Masaoka T,
Kawakami Y, Ikeda Y, Kuwana M. Helicobacter pylori
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
eradication shifts monocyte inhibitory FccRIIB in immune
thrombocytopenic purpura patients. J Clin Invest
2008;118:2939–49.
Bai Y, Wang Z, Bai X, Yu Z, Cao L, Zhang W, Ruan C. Crossreaction of antibody against Helicobacter pylori urease B with
platelet glycoprotein IIIa and its significance in the pathogenesis of immune thrombocytopenic purpura. Int J Hematol
2009;89:142–9.
Carter D, Maor Y, Bar-Meir S, Avidan B. Prevalence and predictive signs for gastrointestinal lesions in premenopausal women
with iron deficiency anemia. Dig Dis Sci 2008;53:3138–44.
Mulayim B, Celik NY, Yanik FF. Helicobacter pylori infection
detected by 14C-urea breath test is associated with iron deficiency anemia in pregnant women. J Obstet Gynaecol Res
2008;34:980–5.
Cardamone M, Laex G, Harari MD, Moss WP, Oliver MR.
Severe iron-deficiency anemia in adolescents: consider Helicobacter pylori infection. J Paediatr Child Health 2008;44:647–50.
Fagan RP, Dunaway CE, Bruden DL, Parkinson AJ, Gessner
BD. Controlled, household-randomized, open-label trial of the
effect of treatment of Helicobacter pylori infection on iron deficiency among children in rural Alaska: results at 40 months.
J Infect Dis 2009;199:652–60.
Haghi-Ashtiani MT, Monajemzadeh M, Motamed F, Mahjoub
F, Sharifan M, Shahsiah R, Kashef N. Anemia in children with
and without Helicobacter pylori infection. Arch Med Res
2008;39:536–40.
Kaya AD, Gencay E, Ozrurk CE, Yavuz T. Seroprevalence of
Helicobacter pylori infection in children in Northwest of Turkey:
relationship with iron deficiency anemia. J Trop Pediatr
2008;54:353–4.
Sarker SA, Mahmud H, Davidsson L, Alam NH, Ahmed T,
Alam N, Salam MA, Beglinger C, Gyr N, Fuchs GJ. Causal
relationship of Helicobacter pylori with iron-deficiency anemia
or failure of iron supplementation in children. Gastroenterology
2008;135:1534–42.
Muhsen K, Cohen D. Helicobacter pylori infection and iron
stores: a systematic review and meta-analysis. Helicobacter
2008;13:323–40.
Lee JH, Choe YH, Choi YO. The expression of iron-repressible outer membrane proteins in Helicobacter pylori and its
association with iron deficiency anemia. Helicobacter
2009;14:36–39.
Soler J-A, Güell M, Bricullé M, Gavarró A, Roig I, Sanchez J,
Gisbert JP, Garcia P, Villoria A, Calvet X. H. pylori eradication
does not reduce paraprotein levels in monoclonal gammopathy of unknown significance (MGUS): a prospective cohort
study. Ann Hematol 2009;88:769–73.
Pellicano R, Ménard A, Rizzetto M, Mégraud F. Helicobacter
species and liver diseases: association or causation? Lancet Infect
Dis 2008;8:254–60.
Ito K, Yamaoka Y, Ota H, El-Zimaity H, Graham DY. Adherence, internalization, and persistence of Helicobacter pylori in
hepatocytes. Dig Dis Sci 2008;53:2541–9.
Ito K, Yamaoka Y, Yoffe B, Graham DY. Disturbance of apoptosis and DNA synthesis by Helicobacter pylori infection of
hepatocytes. Dig Dis Sci 2008;53:2532–40.
Goo MJ, Ki MR, Lee HR, et al. Primary biliary cirrhosis, similar
to that in human beings, in a male C57BL ⁄ 6 mouse infected with
Helicobacter pylori. Eur J Gastroenterol Hepatol 2008;20:1045–8.
Chen DF, Hu L, Yi P, Liu WW, Fang DC, Cao H. Helicobacter
pylori damages human gallbladder epithelial cells in vitro. World
J Gastroenterol 2008;14:6924–8.
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 58–68
Pellicano et al.
72 Keenan JI, Beaugie CR, Jasmann B, Potter HC, Collett JA, Frizelle FA. Helicobacter species in the human colon. Colorectal Dis
2008; [Epub ahead of print].
73 Zhao YS, Wang F, Chang D, Han B, You DY. Meta-analysis of
different test indicators: Helicobacter pylori infection and the risk
of colorecatl cancer. Int J Colorectal Dis 2008;23:875–82.
74 Robertson DJ, Sandler RS, Ahnen DJ, Greenberg ER, Mott LA,
Cole BF, Baron JA. Gastrin, Helicobacter pylori, and colorectal
adenomas. Clin Gastroenterol Hepatol 2009;7:163–7.
75 Soylu A, Ozkara S, Alis H, Dolay K, Kalayci M, Yasar N, Kumbasar AB. Immunohistochemical testing for Helicobacter pylori
existence in neoplasms of the colon. BMC Gastroenterol
2008;8:35.
76 Sandven I, Abdelnoor M, Wethe M, Nesheim BI, Vikanes A,
Gjønnes H, Melby KK. Helicobacter pylori infection and hyperemesis gravidarum. An institution-based case-control study. Eur
J Epidemiol 2008;23:491–8.
77 Pugliese A, Beltramo T, Todros T, Cardaropoli S, Ponzetto A.
Interleukin-18 and gestosis: correlation with Helicobacter pylori
seropositivity. Cell Biochem Funct 2008;26:817–9.
78 Geva A, Sabo E, Levy J, Blumenthal M, Ophir E, Geva H,
Bornstein J. A search for Helicobacter pylori in localized vulvodynia. Gynecol Obstet Invest 2008;66:152–6.
79 Collodel G, Moretti E, Campagna MS, Capitani S, Lenzi C,
Figura N. Infection by CagA-positive Helicobacter pylori strains
alter the sperm quality of men with fertility disorders and
increase the systemic levels of TNF-a. Dig Dis Sci 2009; [Epub
ahead of print].
80 Kurotsuchi S, Ando H, Iwase A, Ishida Y, Hamajima N, Kikkawa F. The plausibility of Helicobacter pylori-related infertility in
Japan. Fertil Steril 2008;90:866–8.
81 Kountouras J, Zavos C, Gavalas E, Boziki M, Katsinelos P.
Helicobacter pylori may hold a variable role in multiple sclerosis
based on ethnicity. Med Hypotheses 2008;71:614–5.
82 Dobbs RJ, Dobbs SM, Weller C, et al. Helicobacter hypothesis
for idiopathic Parkinsonism: before and beyond. Helicobacter
2008;13:309–22.
83 Kountouras J, Boziki M, Gavalas E, et al. Eradication of Helicobacter pylori may be beneficial in the management of Alzheimer’s disease. J Neurol 2009;256:758–67.
84 Berrutti M, Pellicano R, Fagoonee S, Saracco G, Rizzetto M.
Helicobacter pylori and dementia. Which consistency for an
association? Panminerva Med 2007;49:227–30.
85 Lee WY, Yoon WT, Shin HY, jeon SH, Rhee PL. Helicobacter
pylori infection and motor fluctuations in patients with Parkinson’s disease. Mov Disord 2008;23:1696–700.
86 Zandman-Goddard G, Berkun Y, Barzilai O, Boaz M, Ram M,
Anaya JM, Shoenfeld Y. Neuropsychiatric lupus and infectious
triggers. Lupus 2008;17:380–4.
87 Demir M, Gokturk HS, Ozturk NA, Kulaksizoglu M, Serin E,
Yilmaz U. Helicobacter pylori prevalence in diabetes mellitus
patients with dyspeptic symptoms and its relationship to glycemic control and late complications. Dig Dis Sci 2008;53:2646–9.
88 Lutsey PL, Pankow JS, Bertoni AG, Szklo M, Folsom AR. Serological evidence of infections and type 2 diabetes: the Multiethnic Study of Atherosclerosis. Diabet Med 2009;26:149–52.
89 Fernandini-Paredes GG, Mezones-Holguin E, Vargas-Gonzales
R, Pozo-Briceño E, Rodriguez-Morales AJ. In patients with
type 2 diabetes mellitus, are glycosylated hemoglobin levels
higher for those with Helicobacter pylori infection than those
without infection? CID 2008;47:144–5.
90 Eshraghian A, Hashemi SA, Jahromi AH, Eshraghian H, Masoompour SM, Davarpanah MA, Eshraghian K, Taghavi SA.
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 58–68
Helicobacters and Extragastric Diseases
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
Helicobacter pylori infection as a risk factor for insulin resistance. Dig Dis Sci 2008; [Epub ahead of print].
Tada A, Komiya N, Shimada A, Katsuki T, Oikawa Y, Itoh H.
Eradication of Helicobacter pylori may trigger onset of type 1
diabetes: a case report. Ann NY Acad Sci 2008;1150:208–9.
Chuang C-H, Sheu B-S, Yang H-B, Lee S-C, Kao A-W, Cheng
H-C, Chang W-L, Yao W-J. Gender difference of circulating
ghrelin and leptin concentrations in chronic Helicobacter pylori
infection. Helicobacter 2009;14:54–60.
Roper J, Francois F, Shue PL, Mourad MS, Pei Z, Olivares de
Perez AZ, Perez-Perez GI, Tseng CH, Blaser MJ. Leptin and
ghrelin in relation to Helicobacter pylori status in adult males.
J Clin Endocrinol Metab 2008;93:2350–7.
Gao XY, Kuang HY, Liu XM, Duan P, Yang Y, Ma ZB. Circulating ghrelin ⁄ obestatin ratio in subjects with Helicobacter pylori
infection. Nutrition 2009;25:506–11.
Fetissov SO, Hamze Sinno M, Coëffier M, Bole-Feysot C,
Ducrotté P, Hökfelt T, Déchelotte P. Autoantibodies against
appetite-regulating peptide hormones and neuropeptides:
putative modulation by gut microflora. Nutrition
2008;24:348–59.
Ferreri AJ, Dolcetti R, Du MQ, et al. Ocular adnexal MALT
lymphoma: an intriguing model for antigen-driven lymphomagenesis and microbial-targeted therapy. Ann Oncol
2008;19:835–46.
Kurtz S, Regenbogen M, Goldiner I, Horowitz N, Moshkowitz
M. No association between Helicobacter pylori infection or CagAbearing strains and glaucoma. J Glaucoma 2008;17:223–6.
Deshpande N, Lalitha P, Krishna das SR, Jethani J, Pillai RM,
Robin A, Karthi K. Helicobacter pylori IgG antibodies in aqueous
humor and serum of subjects with primary oepn angle and
pseudo-exfoliation glaucoma in a South Indian population.
J Glaucoma 2008;17:605–10.
Choi CY, Kim MS, Kim JM, Park SH, Park KM, Hong C. Association between Helicobacter pylori infection and Posner-Schlossman
syndrome. Eye 2009;???:???–??? [Epub ahead of print].
Shiotani A, Miyanishi T, Kamada T, Haruma K. Helicobacter
pylori infection and allergic diseases: epidemiological study
in Japanese university students. Helicobacter 2008;23:e29–33.
Baccioglu A, Kalpaklioglu F, Guliter S, Yakaryilmaz F. Helicobacter pylori in allergic inflammation-fact or fiction? Allergol
Immunopathol 2008;36:85–9.
Pfefferle PI, Krämer A. Helicobacter pylori-infection status and
childhood living conditions are associated with signs of allergic
diseases in an occupational population. Eur J Epidemiol
2008;23:635–40.
Cam S, Ertem D, Bahceciler N, Akkoc T, Barlan I, Pehlivanoglu E. The interaction between Helicobacter pylori infection and
atopy: does inverse association really exist? Helicobacter
2009;14:1–8.
Konturek PC, Rienecker H, Hahn EG, Raithel M. Helicobacter
pylori as a protective factor against food allergy. Med Sci Monit
2008;14:CR452–8.
de Martel C, Llosa AE, Friedman GD, Vogelman JH, Orentreich N, Stolzenberg-Solomon RZ, Parsonnet J. Helicobacter
pylori infection and development of pancreatic cancer. Cancer
Epidemiol Biomarkers Prev 2008;17:1189–94.
Lindkvist B, Johansen D, Borgstrom A, Manjer J. A prospective study of Helicobacter pylori in relation to the risk for pancreatic cancer. BMC Cancer 2008;8:321.
Hellmig S, Troch K, Ott SJ, Schwarz T, Fölsch UR. Role of Helicobacter pylori infection in the treatment and outcome of
chronic urticaria. Helicobacter 2008;13:341–5.
67
Helicobacters and Extragastric Diseases
108 Yadav MK, Rishi JP, Nijawan S. Chronic urticaria and Helicobacter pylori. Indian J Med Sci 2008;62:157–62.
109 Abdel-Hafez HZ, Mahran AM, Hofny ER, Attallah DA, Sayed
DS, Rashed HA. Is Helicobacter pylori infection associated with
alopecia areata? J Cosmet Dermatol 2008;8:52–5.
110 Ali M, Whitehead M. Clearance of chronic psoriasis after eradication therapy for Helicobacter pylori infection. JEADV
2008;22:745–75.
111 Holst H, Andresen K, Blom J, Højlyng N, Kemp M, Krogfelt
KA, Christensen JJ. A case of Helicobacter cinaedi bacteraemia
in a previously healthy person with cellulitis. Open Microbiol J
2008;2:29–31.
112 Ozel AM, Demiturk L, Aydogdu A, Gultepe M, Yazgan Y, Imirzalioglu N, Gurbuz AK, Narin Y. Effect of Helicobacter pylori
68
Pellicano et al.
infection and eradication therapy on interleukin-6 levels in
patients with Familial Mediterranean Fever. Int J Clin Pract
2008;62:754–61.
}
}
113 Yildirim B, Oztürk
MA, Unal
S. The anti-Helicobacter pylori
antibioticotherapy for the treatment of recurrent oral aphthous
ulcers in a patients with Behcet’s syndrome. Rheumatol Int
2009;29:477–8.
114 Karaca S, Seyhan M, Senol M, Harputluoglu MM, Ozcan A.
The effect of gastric Helicobacter pylori eradication on recurrent
aphthous stomatitis. Int J Dermatol 2008;47:615–7.
115 Stray-Pederson A, Vege A, Rognum TO. Helicobacter pylori
antigen in stool is associated with SIDS and sudden infant
deaths due to infectious disease. Pediatr Res 2008;64:
405–10.
ª 2009 The Authors
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Helicobacter ISSN 1523-5378
Helicobacter spp. Other Than Helicobacter pylori
Arinze S. Okoli,* Armelle Menard
à
and George L. Mendz*
*School of Medicine, Sydney, The University of Notre Dame Australia, Sydney, NSW, Australia, INSERM U853, Bordeaux, France, àUniversité Victor
Segalen Bordeaux 2, Bordeaux, France
Keywords
Enterohepatic Helicobacter spp., new
Helicobacter spp., detection of infection,
animal studies, prevention, eradication.
Reprint requests to: George L. Mendz, School
of Medicine, Sydney, The University of Notre
Dame Australia, 160 Oxford St. Darlinghurst,
NSW 2010, Australia.
E-mail: gmendz@nd.edu.au
Abstract
Non-H. pylori Helicobacter species (NHPHS) are associated with several important human and animal diseases. In the past year research into this group of
bacteria has continued to gain attention, and novel species have been
described in new niches owing to improvements in detection methods. Polymerase chain reaction and ⁄ or sequencing remain the gold standard for the
detection of this genus. New insights into the pathogenesis of the NHPHS in
hepatobiliary, gastric, and intestinal diseases were gained. In particular, data
revealed interaction between hepatic steatosis and infectious hepatitis in
the development of hepatocellular carcinoma. Evidence of an association
between hepatitis C virus and Helicobacter spp. in hepatocarcinoma development was also provided; and male sex hormone signaling appeared to
influence infectious hepatitis induced by Helicobacter hepaticus. More findings
support an association between Helicobacter heilmannii and gastric adenocarcinoma; and in mice, mucins MUC4 and MUC5 but not MUC1 influence the
colonization and pathogenesis of Helicobacter felis. Data indicated that the
roles of the adaptive immune system in H. hepaticus-induced intestinal
tumorigenesis are different in the small and large intestines, and environmental factors, such as bile acids may modulate H. hepaticus carcinogenic
potential. New reports in the prevention and eradication of NHPHS showed
a protective response against Helicobacter suis induced by vaccine administration, and a successful cross-foster rederivation method successfully
eradicated Helicobacter spp. from contaminated mice litters. Overall, the studies provided insights into the pathophysiology of Helicobacter species other
than Helicobacter pylori.
Detection Methods, New Species and
Prevalence in Animal Hosts
Molecular biology techniques provide invaluable tools
for the identification of Helicobacter spp., and the gold
standards in the detection of this genus are PCR and ⁄ or
sequencing. Evaluation of 16S rDNA gene-based PCR
assays for genus-level identification of Helicobacter spp.
in fecal samples demonstrated that five of the six methods examined were appropriate to eliminate PCR inhibitors from the samples [1]. The method recommended in
this work was the application of PCR-differential gradient gel electrophoresis to fecal samples reported previously [2]. A PCR assay performed at the low annealing
temperature of 50 C was developed to amplify a 261-bp
sequence spanning two of the seven variable regions in
the 16S rDNA gene of Helicobacter species [3]. This assay
combined with that of Bohr et al. [4] and sequencing
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Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 69–74
served to detect the presence of Helicobacters in commercially bred mice supposedly free of Helicobacter
infection and to identify different species of Helicobacter
and their relative proportions infecting a single animal.
A real-time PCR assay that amplifies a fragment from
the 16S rDNA gene with subsequent species identification by melting curve analysis using SYBR Green chemistry was designed to detect Helicobacter pullorum-like
organisms in chicken products [5]. The method allows
identification of these bacteria from healthy poultry
carcasses and caeca with a sensitivity of 1 CFU ⁄ g. It
confirmed the inadequacy of culture methods in the
detection of H. pullorum-like bacteria, and showed that
these organisms are common in healthy chickens with
a prevalence similar to that of Campylobacter jejuni [6].
As H. pullorum is considered to be zoonotic [7], this
PCR assay will serve to better assess the potential
human health risks posed by this bacterium.
69
Okoli et al.
Other Helicobacters
Identification based on the 16S rDNA gene remains
the most frequently used method of detection; however, this gene may be a poor target owing to horizontal transfer of 16S rDNA gene fragments and the
creation of mosaic molecules with loss of phylogenetic
information [8]. Other phylogenetically informative
genes such as the 23S rDNA could be employed for species detection, but lack of sequence information limits
their potential use as targets. Indeed, among the enterohepatic Helicobacters only the genome of Helicobacter
hepaticus has been fully sequenced and annotated. This
situation improved recently when the Broad Institute
Genome Sequence Platform performed the sequencing
of the genomes of Helicobacter bilis ATCC 43879, Helicobacter canadensis MIT 98-5491, Helicobacter cinaedi CCUG
18818, H. pullorum MIT 98-5489, and Helicobacter winghamensis ATCC BAA-430. The final assembly and annotation of these genomes has not been finalized, but the
non-assembled contigs are available in the NCBI microbial genomes database.
Helicobacter suis has been accepted as a new gastric
Helicobacter taxon corresponding to type 1 H. heilmannii
[9]. The cells of the new species are tightly coiled spirals
with up to six turns, are motile and have bipolar tufts of
4–10 sheathed flagella blunt ended or ending in spherical
knobs [9]. An analysis of current data on the prevalence
of different species of non-H. pylori gastric Helicobacter
spp. in humans concluded that H. suis is a zoonotic agent
[10].
During the past year active investigations were conducted on the presence of Helicobacter spp. in wild, husbandry and pet animals, and the zoonotic potential of
Helicobacter spp. was evaluated owing to the potential
transmission of these bacteria from animals to humans.
Evidence for transmission of Helicobacter spp. in the
marine environment was obtained from pools of captive
mammals through PCR amplification and sequencing of
DNA. The gastric Helicobacter spp. detected were homologous to Helicobacter cetorum, and the enterohepatic Helicobacter spp. were homologous to that isolated from a
Northern sea lion [11]. Helicobacter DNA with very high
homology to H. cetorum was detected in South American
fur seals indicating a wide host range for this Helicobacter
species initially isolated from whales and dolphins [12].
Helicobacter DNA was detected by PCR in river water
but not in soil in Sapporo, Japan, and its presence was
not related to that of Acanthamoeba, initially suspected
to be involved in Helicobacter survival [13]. A study of
the survival in water of seven gastric and enterohepatic
Helicobacter spp. did not show relationship between survival time in water and the niche occupied in the host,
and concluded that water would have similar roles in
the transmission of these species [14].
70
Several studies provided new information on Helicobacter colonization of mammals. For the first time Helicobacter 16S rDNA was detected in the stomach of lynx
and foxes. Phylogenetic analyses grouped the isolates in
a cluster of H. heilmannii, Helicobacter salomonis, H. felis,
and Helicobacter bizzozeronii [15].
The prevalence of the new species Helicobacter equorum in foals is age dependent, and the differences in
prevalence may be related to the presence of protective
maternal immunity in the very young foals [16].
No significant relationship was found in pet dogs
between chronic gastritis and Helicobacter infection
[17], and none of the common culturable species found
in the stomach of dogs including H. salomonis, H. felis,
H. bizzozeronii, and Helicobacter rappini was identified
[17]. Genus-specific Helicobacter-positive samples were
found in the saliva or feces of domestic and feral cats in
Korea; all samples were negative for the detection of
H. felis and H. pylori with species-specific probes [18].
Mixed infections of bacteria of the genera Campylobacter, Helicobacter, and Anaerobiospirillum were found in
cats and dogs, but no significant statistical correlation
was found between the presence of diarrhea in either
cats or dogs and any isolate of the three genera, or the
various co-infection rates [19].
Helicobacter spp. detected by PCR amplification of
16S rDNA sequences in gastric washings of cats
showed high homology with those of H. heilmannii
and Helicobacter acynonychis [20]. The data suggest that
the proposed method was a valuable alternative technique to gastric biopsy. Since virtually all healthy
adult cats harbor Helicobacters in their gastric mucosa,
the possibility of cats as potential zoonotic agents of
H. heilmannii may have important public health
implications [20].
A review on the Helicobacter spp. infections of domestic cats and dogs, farm animals, birds, and several wild
animals concluded that a common pathogenic mechanism is the induction of a Th1-driven chronic inflammatory response mounted by the host against the
bacteria [21].
Diseases
Hepatobiliary Diseases
In the past year, the potential association between Helicobacter spp. and diseases of the hepatobiliary tract continued to gain attention. Exposing the mouse
hepatocyte cell line H2.35 to H. pullorum sonicates
resulted in the hepatic cell death with morphological
features of necrosis, which occurred without caspase-3
activation [22]. The necrosis and eventual cell death
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 69–74
Okoli et al.
was attributed to features characteristic of mitotic catastrophe, such as chromatin condensation, formation of
multinuclear distended cell micronucleation, and intranuclear pseudoinclusions. The toxic factor in the sonicates had similar properties to those of the cytolethal
distending toxin secreted by H. pullorum [23,24].
The significance of the route of infection in H. hepaticus-induced hepatitis on the development of hepatocellular carcinoma (HCC) was evaluated in a mouse model
by testing the hypothesis that perinatal exposure to H.
hepaticus is required for liver tumorigenesis [25]. Male
A ⁄ JCr mice infected with H. hepaticus by intragastric
treatment developed early hepatic changes after exposure as well as marked increase in oxidative DNA damage, but rarely any liver tumor, confirming earlier
reports [26,27]. In contrast, infection of A ⁄ JCr mice by
intraperitoneal injection of H. hepaticus before breeding
led to a high incidence of progressive hepatitis and a
significant number of multiple liver tumors, including
HCC, in the male offspring [25]. Contributing perinatal
factors include high sensitivity of neonatal liver to
tumor initiation, and ⁄ or modulation of immune
response by H. hepaticus or its toxins [25].
The oncogenic potential of H. hepaticus was further
illustrated using the susceptible mouse strains AB6F1
and B6AF1 derived from A ⁄ JCr and C57BL ⁄ 6NCr mice,
respectively [28]. The results suggested synergistic interactions between hepatic steatosis and infectious hepatitis leading to HCC. The study provides an alternative
novel mouse model to investigate the association
between chronic microbial hepatitis and fatty liver in
the pathogenesis of liver cancer.
The influence of male sex hormone signaling on
infectious hepatitis induced by H. hepaticus was studied
in A ⁄ JCr mice [29]. At 4 months, castrated males and
animals receiving the competitive androgen receptor
antagonist flutamide had significantly less severe hepatitis than intact controls. The results raised the possibility of targeted hormonal therapy in young male
patients with infectious HCC.
In patients suffering from cholangiocarcinoma in
Thailand, a high cross reactivity was found between the
immune response to antigens obtained from H. pylori
and H. bilis to the extent that infection with the two
species cannot be distinguished serologically in most
subjects given the high prevalence of H. pylori in the
population studied [30]. Retrospective analyses of
serum antibody responses to cell surface proteins of
H. pullorum, H. bilis, H. hepaticus, and H. pylori suggested
an association between hepatitis C virus and the development of HCC [31]. In contrast, no association was
found between Helicobacter spp. and biliary tract cancers
[32].
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 69–74
Other Helicobacters
Gastric Diseases
Several studies on animals reported an association
between NHPHS and gastric diseases. Helicobacter heilmannii induced low-grade mucosa-associated lymphoid
tissue-type (MALT) lymphoma in mice increasing the
microcirculatory network surrounding the lymphoma
tissue [33]. In pet cats, H. heilmannii infection was associated with the development of gastritis and feline MALT
lymphoma [34]. In Iranian pet dogs, 93% of gastric
samples from animals with chronic gastritis or histopathological changes in the gastric mucosa showed the
presence of Helicobacter spp. DNA [17].
Long-term H. heilmannii infection causes Th1 and Th2
immune response and increases mucosal thickness of
the stomach of C57BL ⁄ 6 mice [35]. Interestingly,
co-infection with H. bilis and H. pylori in this mouse
breed induce less severe gastritis, atrophy, mucous
metaplasia and hyperplasia, as well as less severe
intestinal metaplasia and dysplasia than H. pylori
infection alone [36]. The explanation suggested for the
reduced pathology is the migration of H. bilis-primed
immune regulatory cells in the lower bowel to the
gastric compartment and downregulation of the Th1
response.
The inflammation induced by H. pullorum in human
gastric and intestinal epithelial cell lines occurs via
bacterial adherence probably through lipopolysaccharide-induced IL-8 secretion and is mediated by NF-jB
signaling [37].
Helicobacter felis attachment to gastric epithelial cells in
vitro was limited by the constitutively expressed glycoprotein of gastric epithelium mucin MUC1 [38]. However, this mucin did not impact on the bacterial in vivo
colonization or pathogenesis in contrast to previous
observations with H. pylori. The results provide evidence
that H. felis colonizes and elicits inflammation in vivo
without direct association with the gastric mucosa, and
that in mice MUC1 shed by epithelial cells does not play
an important role in limiting colonization or pathogenesis of these non-adherent bacteria. The data suggest that
inflammation induced by H. felis infection results from
shed antigens which act independently of MUC1 [38].
Alterations in gastric mucins and trefoil factors
expression were investigated in two C57BL ⁄ 6 mouse
strains infected with H. felis as the disease provoked by
the presence of the bacterium progresses from gastritis
through dysplasia and metaplasia to gastric carcinoma.
The expression of mucins MUC4 and MUC5b increased,
and that of MUC5ac decreased; these changes were
similar to those found in the expression of human mucins in H. pylori infection and the data suggested a role
for MUC4 and MUC5b in disease progression in mice.
71
Other Helicobacters
At variance with the observations in human disease,
other murine mucins and trefoil factors remained
unchanged [39].
Earlier reports of an association between H. heilmannii infection with gastric adenocarcinoma in humans
[40] were supported by the finding that biomarkers of
gastrointestinal cancers were elevated in patients suffering from gastric ulcer and cancer caused by H. heilmannii infection [41].
Intestinal Diseases
New insights have been obtained on the pathogenicity
of enterohepatic Helicobacter spp. employing mouse animal models. Co-infection of IL-10-deficient mice with
Helicobacter rodentium and Helicobacter typhlonius resulted
in more severe inflammatory bowel disease and neoplasia compared to the disease caused by either H. rodentium
or H. typhlonius [42]. The anti-inflammatory effects of an
antibiotic quadruple therapy in Helicobacter-infected
and non-infected IL-10) ⁄ ) mice with colitis suggested
that together with Helicobacter spp. other microbiota
drive the inflammatory process in these mice [42].
The urease activity of H. hepaticus is not involved in
cecal colonization of A ⁄ JCr male mice but is essential
for hepatic colonization and plays a crucial role in liver
inflammation and the severity of hepatitis [43]. Urease
activity was also associated with higher total IgG, Th1associated IgG2a and Th2-associated IgG1 in vivo. The
sequences of H. hepaticus UreA and UreB are very similar to those of H. pylori, but these proteins are not as
immunodominant as the H. pylori ones. The proline utilization A (PutA) flavoenzyme of H. hepaticus is not
involved in the colonization efficiency of mice but
rather in inflammation, suggesting a role for proline
metabolism in H. hepaticus pathogenicity [44].
Studies of infection of BALB-Min and BALB-RagMin
mice with H. hepaticus indicated that the bacterium promotes colon but not small intestine tumorigenesis, and
suggested that H. hepaticus promotion of tumors differs
between organs and does not necessarily correlate with
severity of inflammation [45]. The data also indicate
that the roles of the adaptive immune system in tumorigenesis are different in the small and large intestines.
Environmental factors, such as bile acids present in the
colon may modulate H. hepaticus carcinogenic potential.
Induction of colon cancer by H. hepaticus infection in
recombinase-activating gene-2-deficient Rag2) ⁄ )mice is
mediated by inflammation, increased TNF-a and nitric
oxide production (NO) production [46]. Concurrent
administration of an inducible nitric oxide synthase
inhibitor prevents NO production, abrogats epithelial
pathology and inhibits the onset of cancer [46].
72
Okoli et al.
The pathogenic potential of the H. hepaticus genomic
island HHGI1 was investigated in IL-10) ⁄ ) mice employing the isogenic bacterial mutant HhPAId1 that lacks 19
predicted genes within HHGI1. Helicobacter hepaticus
HhPAId1 did not cause typhlocolitis and hyperplasia in
IL-10) ⁄ ) mice [47]. Colonization levels of HhPAId1
were significantly higher in the cecum and similar in the
colon compared to wild-type H. hepaticus. The results
suggested that genes in HHGI1 contribute to the
pathogenicity of H. hepaticus, at least in part via upregulation of proinflammatory mediators IFN-c, TNF-a, and IL17a [47].
Testing of the hypothesis that prior infection of
BALB ⁄ c-IL-10 null mouse with H. hepaticus increases
the incidence, multiplicity and ⁄ or progression of either
colitis-associated adenocarcinomas or colon tumors
induced by the organotropic carcinogen azoxymethane
(AOM) showed that prior infection with H. hepaticus
had no effect on the incidence of colitis-associated adenocarcinomas, and resulted in a significant increase in
incidence but not multiplicity or progression, of AOMinduced polypoid tumors [48]. On the other hand,
Munday et al. [48] found no association between Helicobacter spp. infection and ovine small intestinal adenocarcinomas in New Zealand sheep [49].
Enterohepatic and gastric Helicobacter spp. were identified in fecal specimens from children diagnosed with
Crohn’s disease using PCR. The data suggest that in a
considerable proportion of children Helicobacter spp.
may have a pathogenic role in the development of the
disease [50].
The effects of Helicobacter infection on the toxicity of
the contaminant 2,3,7,8-tetrachloro-dibenzo-p-dioxin
was investigated in rats. The infection appeared to have
little influence on the susceptibility of rats for the compound [51].
Prevention and Eradication of Infection
The effects of prophylactic immunization of BALB ⁄ c mice
against H. suis using whole cell lysate or supernatant
antigens from in vitro cultured bacteria showed that a
protective response against the bacterium can be
induced by administering a vaccine by intranasal route
with homologous (H. suis) as well as heterologous
(H. bizzozeronii and Helicobacter cynogatricus) antigens [52].
A successful cross-foster rederivation method was
devised for the elimination of Helicobacter spp. from contaminated mice litters [53].
Triple therapies using amoxicillin and two other
active components showed high efficacy against gastric
Helicobacter infections in C57BL ⁄ 6J mice [54] and cats
and dogs [55]. Amoxicillin resistance in H. hepaticus is
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 69–74
Okoli et al.
dependent on the hefA gene expressing a TolC component of a putative efflux system and its expression is
induced by bile acids [56].
The role of a second urease expressed by the gastric
Helicobacter acinonychis, H. felis, and Helicobacter mustelae
which does not require activation by accessory proteins
or nickel was proposed as an adaptation to the nickelrestricted diet of carnivores [57].
Conclusions
This past year saw continued interest in the study of Helicobacter species other than H. pylori that resulted in significant amount of information on improvement of
detection methods for the genus, identification of novel
species and prevalence in animal hosts, pathogenic
mechanisms of disease causation, prevention, and eradication of infection. Understandably, a greater proportion
of the investigations focused on the relationship between
Helicobacter spp. and diseases of the hepatobiliary and
gastrointestinal tracts, and provided new insights into
the potential mechanisms that buttress the association of
these bacteria with liver, stomach, and intestinal cancer.
Continued study in this area is required given the global
need to eradicate these malignancies.
Conflict of Interest
The authors have declared no conflicts of interest.
References
1 Moyaert H, Pasmans F, Ducatelle R, Haesebrouck F, Baele M.
Evaluation of 16S rRNA gene-based PCR assays for genus-level
identification of Helicobacter species. J Clin Microbiol
2008;46:1867–9.
2 Al-Soud WA, Bennedsen M, On SL, Ouis IS, Vandamme P,
Nilsson HO, Ljungh A, Wadstrom T. Assessment of PCR-DGGE
for the identification of diverse Helicobacter species, and application to faecal samples from zoo animals to determine Helicobacter prevalence. J Med Microbiol 2003;52:765–71.
3 Poynter S, Phipps JD, Naranjo-Pino A, Sanchez-Morgado JM.
Difficulties in the molecular diagnosis of Helicobacter rodent
infections. Vet Microbiol 2009;134:272–8.
4 Bohr UR, Primus A, Zagoura A, Glasbrenner B, Wex T, Malfertheiner P. A group-specific PCR assay for the detection of Helicobacteraceae in human gut. Helicobacter 2002;7:378–83.
5 Gonzalez A, Piqueres P, Moreno Y, Canigral I, Owen RJ, Hernandez J, Ferrus MA. A novel real-time PCR assay for the
detection of Helicobacter pullorum-like organisms in chicken
products. Int Microbiol 2008;11:203–8.
6 Atabay HI, Corry JE, On SL. Identification of unusual Campylobacter-like isolates from poultry products as Helicobacter pullorum. J Appl Microbiol 1998;84:1017–24.
7 De Groote D, Ducatelle R, Haesebrouck F. Helicobacters of possible zoonotic origin: a review. Acta Gastroenterol Belg
2000;63:380–7.
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 69–74
Other Helicobacters
8 Dewhirst FE, Shen Z, Scimeca MS, Stokes LN, Boumenna T,
Chen T, Paster BJ, Fox JG. Discordant 16S and 23S rRNA gene
phylogenies for the genus Helicobacter: implications for phylogenetic inference and systematics. J Bacteriol 2005;187:6106–18.
9 Baele M, Decostere A, Vandamme P, Ceelen L, Hellemans A,
Mast J, Chiers K, Ducatelle R, Haesebrouck F. Isolation and
characterization of Helicobacter suis sp. nov. from pig stomachs.
Int J Syst Evol Microbiol 2008;58:1350–8.
10 Baele M, Pasmans F, Flahou B, Chiers K, Ducatelle R, Haesebrouck F. Non-Helicobacter pylori helicobacters detected in the
stomach of humans comprise several naturally occurring Helicobacter species in animals. FEMS Immunol Med Microbio
2009;55:306–13.
11 Goldman CG, Matteo MJ, Loureiro JD, et al. Detection of Helicobacter and Campylobacter spp. from the aquatic environment of
marine mammals. Vet Microbiol 2009;133:287–91.
12 Goldman CG, Loureiro JD, Matteo MJ, Catalano M, Gonzalez AB,
Heredia SR, Zubillaga MB, Solnick JV, Cremaschi GA. Helicobacter
spp. from gastric biopsies of stranded South American fur seals
(Arctocephalus australis). Res Vet Sci 2009;86:18–21.
13 Kawaguchi K, Matsuo J, Osaki T, Kamiya S, Yamaguchi H.
Prevalence of Helicobacter and Acanthamoeba in natural environment. Lett Appl Microbiol 2009;48:465–71.
14 Azevedo NF, Almeida C, Fernandes I, Cerqueira L, Dias S,
Keevil CW, Vieira MJ. Survival of gastric and enterohepatic
Helicobacter spp. in water: implications for transmission. Appl
Environ Microbiol 2008;74:1805–11.
15 Morner T, Brojer C, Ryser-Degiorgis MP, Gavier-Widen D, Nilsson HO, Wadstrom T. Detection of gastric Helicobacter species in
free-ranging lynx (Lynx lynx) and red foxes (Vulpes vulpes) in
Sweden. J Wildl Dis 2008;44:697–700.
16 Moyaert H, Haesebrouck F, Dewulf J, Ducatelle R, Pasmans F.
Helicobacter equorum is highly prevalent in foals. Vet Microbiol
2009;133:190–2.
17 Shabestari AS, Mohammadi M, Jamshidi S, Sasani F, Bahadori A,
Oghalaie A. Assessment of chronic gastritis in pet dogs and its
relation with Helicobacter-like organisms. Pak J Biol Sci 2008;11:
1443–8.
18 Ghil HM, Yoo JH, Jung WS, Chung TH, Youn HY, Hwang CY.
Survey of Helicobacter infection in domestic and feral cats in
Korea. J Vet Sci 2009;10:67–72.
19 Rossi M, Hanninen ML, Revez J, Hannula M, Zanoni RG.
Occurrence and species level diagnostics of Campylobacter spp.,
enteric Helicobacter spp. and Anaerobiospirillum spp. in healthy
and diarrheic dogs and cats. Vet Microbiol 2008;129:304–14.
20 Pregel P, Rota A, Palmerini D, Guarda F, Appino S. Detection of
Helicobacter in gastric washing of cats. J Vet Diagn Invest 2008;20:
80–2.
21 Harbour S, Sutton P. Immunogenicity and pathogenicity of
Helicobacter infections of veterinary animals. Vet Immunol Immunopathol 2008;122:191–203.
22 Ceelen LM, Haesebrouck F, D’Herde K, Krysko DV, Favoreel H,
Vandenabeele P, Ducatelle R, Decostere A. Mitotic catastrophe as
a prestage to necrosis in mouse liver cells treated with Helicobacter
pullorum sonicates. J Morphol 2009;270:921–8.
23 Young VB, Schauer DB. Cytolethal distending toxin: a bacterial
toxin which disrupts the eukaryotic cell cycle. Chem Res Toxicol
2000;13:936–9.
24 Young VB, Chien CC, Knox KA, Taylor NS, Schauer DB, Fox JG.
Cytolethal distending toxin in avian and human isolates of
Helicobacter pullorum. J Infect Dis 2000;182:620–3.
25 Diwan BA, Sipowicz M, Logsdon D, Gorelick P, Anver MR,
Kasprzak KS, Anderson LM. Marked liver tumorigenesis by
73
Other Helicobacters
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
74
Helicobacter hepaticus requires perinatal exposure. Environ Health
Perspect 2008;116:1352–6.
Avenaud P, Le Bail B, Mayo K, Marais A, Fawaz R, BioulacSage P, Megraud F. Natural history of Helicobacter hepaticus
infection in conventional A ⁄ J mice, with special reference to
liver involvement. Infect Immun 2003;71:3667–72.
Ihrig M, Schrenzel MD, Fox JG. Differential susceptibility to
hepatic inflammation and proliferation in AXB recombinant
inbred mice chronically infected with Helicobacter hepaticus. Am
J Pathol 1999;155:571–82.
Garcı́a A, Ihrig MM, Fry RC, Feng Y, Xu S, Boutin SR, Rogers AB,
Muthupalani S, Samson LD, Fox JG. Genetic susceptibility to
chronic hepatitis is inherited codominantly in Helicobacter
hepaticus-infected AB6F1 and B6AF1 hybrid male mice, and
progression to hepatocellular carcinoma is linked to hepatic
expression of lipogenic genes and immune function-associated
networks. Infect Immun 2008;76:1866–76.
Theve EJ, Feng Y, Taghizadeh K, Cormier KS, Bell DR, Fox JG,
Rogers AB. Sex hormone influence on hepatitis in young male
A ⁄ JCr mice infected with Helicobacter hepaticus. Infect Immun
2008;76:4071–8.
Pisani P, Whary MT, Nilsson I, Sriamporn S, Wadstrom T, Fox
JG, Ljungh A, Forman D. Cross-reactivity between immune
responses to Helicobacter bilis and Helicobacter pylori in a population in Thailand at high risk of developing cholangiocarcinoma.
Clin Vaccine Immunol 2008;15:1363–8.
Lonngren V, Nilsson I, Verbaan H, Wadstrom T, Ljungh A. High
levels of serum antibodies to cell surface proteins of Helicobacter
pullorum and Helicobacter pylori in hepatitis C virus-infected
patients. Scand J Gastroenterol 2009;44:505–6.
de Martel C, Plummer M, Parsonnet J, van Doorn LJ, Franceschi S. Helicobacter species in cancers of the gallbladder and
extrahepatic biliary tract. Br J Cancer 2009;100:194–9.
Nakamura M, Takahashi S, Matsui H, Murayama SY, Aikawa C,
Sekiya Y, Nishikawa K, Matsumoto T, Yamada H, Tsuchimoto
K. Microcirculatory alteration in low-grade gastric mucosa-associated lymphoma by Helicobacter heilmannii infection: its relation
to vascular endothelial growth factor and cyclooxygenase-2.
J Gastroenterol Hepatol 2008;23:S157–60.
Bridgeford EC, Marini RP, Feng Y, Parry NM, Rickman B, Fox JG.
Gastric Helicobacter species as a cause of feline gastric lymphoma:
a viable hypothesis. Vet Immunol Immunopathol 2008;123:106–13.
Park JH, Seok SH, Baek MW, Lee HY, Kim DJ. Gastric lesions
and immune responses caused by long-term infection with Helicobacter heilmannii in C57BL ⁄ 6 mice. J Comp Pathol
2008;139:208–17.
Lemke LB, Ge Z, Whary MT, Feng Y, Rogers AB, Muthupalani S,
Fox JG. Concurrent Helicobacter bilis infection in C57BL ⁄ 6 mice
attenuates pro-inflammatory H. pylori-induced gastric pathology.
Infect Immun 2009;77:2147–58.
Varon C, Duriez A, Lehours P, Menard A, Laye S, Zerbib F,
Megraud F, Laharie D. Study of Helicobacter pullorum proinflammatory properties on human epithelial cells in vitro. Gut
2009;58:629–35.
Every AL, Chionh YT, Skene CD, McGuckin MA, Sutton P.
Muc1 limits Helicobacter felis binding to gastric epithelial cells but
does not limit colonization and gastric pathology following
infection. Helicobacter 2008;13:489–93.
Schmitz JM, Durham CG, Ho SB, Lorenz RG. Gastric mucus
alterations associated with murine Helicobacter infection. J Histochem Cytochem 2009;57:457–67.
Yang H, Li X, Xu D. Helicobacter heilmannii infection in a patient
with gastric cancer. Dig Dis Sci 1995;40:1013–4.
Okoli et al.
41 Duttala SV, Majumdar AP, Parikh RK, Levi E, Patel BB. H. heilmannii infection and gastric carcinogenesis. Indian J Gastroenterol
2008;27:131–2.
42 Chichlowski M, Sharp JM, Vanderford DA, Myles MH, Hale LP.
Helicobacter typhlonius and Helicobacter rodentium differentially affect
the severity of colon inflammation and inflammation-associated
neoplasia in IL10-deficient mice. Comp Med 2008;58:534–41.
43 Ge Z, Lee A, Whary MT, Rogers AB, Maurer KJ, Taylor NS,
Schauer DB, Fox JG. Helicobacter hepaticus urease is not required
for intestinal colonization but promotes hepatic inflammation
in male A ⁄ JCr mice. Microb Pathog 2008;45:18–24.
44 Krishnan N, Doster AR, Duhamel GE, Becker DF. Characterization of a Helicobacter hepaticus putA mutant strain in host
colonization and oxidative stress. Infect Immun 2008;76:3037–44.
45 Nagamine CM, Sohn JJ, Rickman BR, Rogers AB, Fox JG,
Schauer DB. Helicobacter hepaticus infection promotes colon
tumorigenesis in the BALB ⁄ c - Rag 2) ⁄ ) Apc min ⁄ + mouse.
Infect Immun 2008;76:2758–66.
46 Erdman SE, Rao VP, Poutahidis T, et al. Nitric oxide and TNFalpha trigger colonic inflammation and carcinogenesis in Helicobacter hepaticus-infected, Rag2-deficient mice. Proc Natl Acad
Sci U S A 2009;106:1027–32.
47 Ge Z, Sterzenbach T, Whary MT, et al. Helicobacter hepaticus
HHGI1 is a pathogenicity island associated with typhlocolitis in
B6.129-IL10 tm1Cgn mice. Microbes Infect 2008;10:726–33.
48 Nagamine CM, Rogers AB, Fox JG, Schauer DB. Helicobacter
hepaticus promotes azoxymethane-initiated colon tumorigenesis
in BALB ⁄ c-IL10-deficient mice. Int J Cancer 2008;122:832–8.
49 Munday JS, Keenan JI, Beaugie CR, Sugiarto H. Ovine small
intestinal adenocarcinomas are not associated with infection by
herpesviruses, Helicobacter species or Mycobacterium avium subspecies paratuberculosis. J Comp Pathol 2009;140:177–81.
50 Man SM, Zhang L, Day AS, Leach S, Mitchell H. Detection of
enterohepatic and gastric Helicobacter species in fecal specimens
of children with Crohn’s disease. Helicobacter 2008;13:234–8.
51 Kransler KM, McGarrigle BP, Russell RJ, Olson JR. Effects of Helicobacter infection on developmental toxicity of 2,3,7,8-tetrachlorodibenzo-p-dioxin in Holtzman rats. Lab Anim 2008;37:171–5.
52 Flahou B, Hellemans A, Meyns T, Duchateau L, Chiers K, Baele
M, Pasmans F, Haesebrouck F, Ducatelle R. Protective immunization with homologous and heterologous antigens against
Helicobacter suis challenge in a mouse model. Vaccine
2009;27:1416–21.
53 Artwohl JE, Purcell JE, Fortman JD. The use of cross-foster
rederivation to eliminate murine norovirus, Helicobacter spp.,
and murine hepatitis virus from a mouse colony. J Am Assoc
Lab Anim Sci 2008;47:19–24.
54 Matsui H, Aikawa C, Sekiya Y, Takahashi S, Murayama SY,
Nakamura M. Evaluation of antibiotic therapy for eradication
of ‘‘Candidatus Helicobacter heilmannii’’. Antimicrob Agents Chemother 2008;52:2988–9.
55 Jergens AE, Pressel M, Crandell J, Morrison JA, Sorden SD,
Haynes J, Craven M, Baumgart M, Simpson KW. Fluorescence
in situ hybridization confirms clearance of visible Helicobacter
spp. associated with gastritis in dogs and cats. J Vet Intern Med
2009;23:16–23.
56 Belzer C, Stoof J, Breijer S, Kusters JG, Kuipers EJ, van Vliet AH.
The Helicobacter hepaticus hefA gene is involved in resistance to
amoxicillin. Helicobacter 2009;14:72–9.
57 Stoof J, Breijer S, Pot RG, van der Neut D, Kuipers EJ, Kusters JG,
van Vliet AH. Inverse nickel-responsive regulation of two urease
enzymes in the gastric pathogen Helicobacter mustelae. Environ
Microbiol 2008;10:2586–97.
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd, Helicobacter 14 (Suppl. 1): 69–74
GUIDELINES FOR AUTHORS
Helicobacter recognizes the critical role that has been established for
Helicobacter pylori in peptic ulcer, gastric adenocarcinoma, and primary
gastric lymphoma. New helicobacter species are now regularly being
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(Continued on last page)
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