AFRICAN JOURNAL OF CLI'NICAL AND EXPERIMENTAL MICROBIOLOGY JAN 2004 ISSN 1595-689X VOL.5 N0.1 AJCEMI2002116l2413 I COPYRIGHT 2004 AFR J CLW EXPER MlCROBlOL 3 HELICOBACTER PYLORI SEROLOGY AND EVALUATION OF GASTRODUODENAL DISEASE IN NIGERIANS WITH DYSPEPSIA IO tegbayo, J. A., 201uwasola, 0. A,, '~akubuA, ., 3O daibo, G. N., 301aleye, 0.D. Departments of ~edieine',~ a t h o l o g yan~d ~irolog?, University College Hospital, P.M.B. 5116, Ibadan, ~iGeriar. Correspondence to: Dr. J. A. Otegb ay0 (E-mail: ~tes123@yahoo.co.uk) -8 Helicobacter pylori (H. pylori) has been strongly associated with various gastroduodenal diseases worldwide with only a few studies emanating from developing countries. The objectives of this study were to determine the prevalence of serum lmmunoglobulin G (1gG) and underlying gastroduodenal pa- thology in Nigerian patients with dyspepsia and ascertain the usefulness of H. pyleri lgG screening in decreasing endoscopic workload in dyspeptics in Nigeria. Fifty-five patients with dyspepsia and 55 age and sex-matched apparently normal control were screened for H. pylon' lgG using lmmunocombRlkl its. Each of the 55 patients was also examined endoscopically with biopsies taken appropriately. Serology was positive in 94.5% andP92.7%o f dyspeptic: patients and controls respectively. Gastroduodenal In- flammation was the commonest endoscopic finding, 43 (78.18%). Other findings were malignant gastric tumour 6(10.9%), refiux oesophagitis 3 (5.45%), gastric ulcer 2 (3.64%), and duodenal ulcer in 1. (1.82%). Chronic gastritis was the main histopathologic finding in the dyspeptic patients. It is concluded that serum H. pylori IgG cannot be used as a screening procedure to reduce endoscopic workload in Nige- rian patients with dyspepsia. Keywords: dyspepsia; Helicobacterpylori serology; gastroduodenal disease ? Helicobacter py&n and gastritis' in 1985, (5Y;bseveral studies have con- , , Dyspepsia, which has been firmeb(k,7) or doubted its associa- defined as pain or discomfort cen- tion with gastroduodenal disease tered in the upper abdomen (1,2), (8) and yet some suggested its as- is a common gastrointestinal csm- sociation with non-g-a strointestinal plaint in Nigeria (3).I n Ibadan, Ni- disease (9). Serology for hi. pylori geria, over 50% of dyspeptic pa- infection has been found ts be ac- tients have been shown to have curate, rapid, cost-effective (10,11) non-ulcer (4). Since the and capable of de- l'mdmark discovery by Barry and creasing endoscopic workload in Marshal of the association between UNIVERSITY OF IBADAN LIBRARY patients with dyspepsia (12). We 74 years and the study period investigated a total of I10 subjects lasted for eighteen months. Ex- at the University College Hospital cluded from the study were pa- Ibadan, Nigeria to determine the tients who have been on non- prevalence of H. pylon' IgG serology steroidal anti-inflammatory drugs- and underlying gastroduodenal dis- (NSAIDs) in the last 3 months, ease in patients with dyspepsia and chronic liver disease (all the dys- normal controls. peptic patients were negative for hepatitis B and human immunode- MATERIAL AND METHODS ficiency viruses 1 and 11 ) as well One hundred and ten adult as pregnant women. %. a"? .subjects of both sexes, aged be- Five milliliters of venous tween 18 to 74 years consisting of blood was collected from each sub- 55 patients with dyspepsia (3.4 ject, into unheparinised bottles. males; 21 females) with no preyi- The serum was separated after :i ous treatment for H. pyl~ria nd 55;; centrifugation and frozen immedi- apparen(ly normal control' with no 3ately at -20°C till time of analyses previous or present history of dys- after the study period. Sera were peptic symptoms (33 males; 21 fe- analyzed for H. pylon' IgG using Im- males) gave informed consent to munocombRII (Manufacturer- OR- participate in the study. Dyspeptic GENICS, Yvane, Israel. Website: patients were consecutively se- http: / /www.orgenics.com) with lected from the pool of patients at- sensitivity and specificity of 95.8% tending our Gastroenterology clinic, and 76% respectively. Upper gas- based on consent and fitness to trointestinal endoscopy was carried undergo eosophagogastroduode- out in all the 55 patients with mul- noscopy (OGD). The control groups tiple biopsies taken from the gas- were apparently normal individuals tric antrum, duodenum, upper and selected from office workers and in- lower margins of cancerous lesion$& dividuals attending the hospital for and other suspicious sites in the routine check ups and hyperten- upper gastrointestinal tract. The b G sion. The control group did not un- control subjects did not undergo .< dergo OGD screening. Patients and eosophagogastroduodenoscopy. control were aged between 18 and Tissue specimens were promptly '&. 932- kf UNIVERSITY OF IBADAN LIBRARY fixed in 10% formalin and subse- Submucosal hemorrhage was quently processed in the histopa- found in 5 of the patients with gas- thology laboratory where paraffin tritis. Three patients had oesopha- sections were stained with routine gitis while 12 (28%) of the 43 pa- haematoxylin and eosin stain for tients with gastroduodenal inflam- histological:e xamination, mation also had bile reflux. Histopath ology ,. RESULT Only 45 ( 1 8 . 8 O h ) of the dys- Serology peptic patients eventually had his- Fifty-two ( 9 4 . 5 O h ) and 5 1 topathologic assessment performed (92.7%) of the dyspeptic patients on the biopsy specimens (other and normal controls were seroposi- specimens were lost in transit). Of tive for H. pylon' IgG receptively. these, 36 patients had gastric tis- Seropositivity was similar in both sue present while 27 patients had males and females. All the patients duodenal tissue included in the bi- with gastric carcinoma were posi- opsy specimen for assessment. Fol- tive for H. pylon' IgG antibody. lowing histological assessment, Endoscopy there were 5 cases of gastric ade- Endoscopic findings were nocarcinoma. Thirty-four of 36 5 % r ' i m a i n l y g a s t r o d u o d e n i t i s (94.4%) gastric biopsies assessed f i i 32(58.18%), chronic gastritis 9 had histological evidence of varying (16.36), and chronic duodenitis 2 grades of chronic gastritis and one (3.6%) Table 1. Atrophic gastritis Gpse of normal gastric mvcosa was was observed in 11 patients with rec~rdedA. ll duodenal biopsies ex- gastroduodenal inflammation. Six amined sho\ ,w histological evidence r .' patients aged 35 to 67 years had of chronic. duodenitis, but none gastric turnours (5 antral; 1 cardial) had H. pylon' on histology. H. pylon and consisted of 4 males and 1 fe- colonization was observed at histol- male. The only female patient ogy ip 14 (4 1.2%) of the 34 cases of among them was 35 years old while ch ro~ icg astritis, while one of the the men "ere between 46 and 67 five cases of gastric adenocarci- vears %th a mean age of 58 years. noma showed H. pylori colonization Keflux oesophagitis was found in 2 in the background gastric-t issue. of the patients with gastric cancer. ' h i 7'9. 933 -Pf i P t ! 4 P UNIVERSITY OF IBADAN LIBRARY &ble 1: Endoscopic features in patients with dyspepsia DISCUSSION Helicobacter pylon' has been shown by various studies to be sis of dyspepsia as well as the fact causally linked with various gastro- that in a developing country like duodenal disease (5,13,14,15). Nigeria where there is no signifi- Most of these studies were done in cant difference in the infection in developed countries of the world, dyspeptic and normal populations, with only a few studies emanating H. pylon may well be an innocent from developing countries. This bystander or an opportunist that cross-sectional study has shown a cashes in when other factors have high seroprevalence of H. pylon' rendered the mucosa susceptible to both in dyspeptic patients and ap- damage. Also, the well known fact parently normal control with no that many people infected with H. current or previous symptoms of pylori never show symptoms of dis- dyspepsia. Previous studies in Ni- ease (19) qnd finding of a similar geria and other parts of Africa have prevalence of H. pylon' infection in shorn a similar high prevalence of geographical area where incidence H. pylon' infection in normal and of dyspepsia is high in one and low dyspeptic population (16 ,117,118). in the other (20) tend to whittle These findings further strengthen down the significance of H. pglori the mealtifactorid concept of ae- infection in the pathogenesis of Piopathogene UNIVERSITY OF IBADAN LIBRARY acid peptic disease in these re- tion in our study has been a typical gions. Recently, it was shown that finding among Nigerian patients there has'&& an increase in pep- with dyspepsia with incidence of tic ulcer diseasd unrelated to H. py- frank ulceration much lower than Lori infection in developed countries findings in developed countries of (21). This finding also attests to the world (4, 22,23,24). This is polycausality of peptic ulcer dis- most likely due to rampant abuse ease. From the foregoing the mag- of over-the-counter drugs which in i , nitude of contribution of H. pylori Nigeria include antibiotics, antac- to dyspepsia in the-studied group is ids and antisecretory drugs, which difficult to determine, as preva- patients take without prescription lence of infection in asymptomatic and only presenting for hospital controls was not significantly differ- care if there is no improvement or ent from tho$&'&ho had dyspepsia. with incomplete resolution of their )The variation in host and microbial symptoms. This abuse of therapy factors, which are known to deter- may cause some degree of ulcer - mine the development of disease as healing before endoscopy is carried - well as the rnultifactorial nature of out and may account for the low dyspepsia; may account for this. incidence of ulcer recorded in these b . The extent of contribution of H. py- studies. Some of the patients with ! lo? in the population needs to be dyspepsia and gastroduodenal in- determined by further studies. flammation were found in addition Dyspeptic patients in. Nigeria to have doudenogastric reflux (bile coulg be safely presumed to be H. reflbx) but the degree of contribu- , < pylori positive until otherwise "tion bF 'this to the dyspeptic pain is ? . proven, as 94.5% of the dyspeptic difficult to quantify. Endoscopic ' % 4 . patients were sero-positive. This oesophagitis seen, in 3 (5.5%) pa- e prevalence in however slightly ffents, 2" of whom.h ad reflux in ad- i " " higher than 85% documented by dition, suggesk that gastric acid re- Malu et a1 in blood donors in Jos, flux may be contributory to dyspep- Northern Nigeria using a similar tic pain in our patients. None of 9 method. Endoscopic finding of them,~"h,o wever,, presented with mainly gastroduodenal inflamma- classical', symptoms of gastro- - - oesophageal reflux disease (GORD) 3@g.a s-k5 UNIVERSITY OF IBADAN LIBRARY before endoscopy. Six (10.9%) of group and therefore the test is not the patients were found to have discriminatory between the two gastric carcinoma (5 antral; 1 car- groups and as such cannot be used dial) with age range 35 to 67 years. to confirm dyspepsia. Also, gastro- All the patients with gastric adeno- duodenal inflammation remain the carcinoma were positive for H. py- commonest cause of dykpepsia in lori serology but only one was posl- Nigeria and ~elicobacferp ylon' is U I tive on histology. The histological commonly associated, with chronic finding of H. pylori in 4 1.2% of the gastritis in Nigeria a s is the case in gastric tissue of patients with the rest of the world. chronic gastritis is loder than IgG in the serum. This difference may ACKNOWLEDGEMENTS be attributable to the patchy pat- The study was supported by a tern of H. pylon' colonization ig gas- grant from the Senate of the Uni- tric mucosa. Also previous studies versity of Ibadan , Nigeria have show that identification of H. (SRG/ 1999/SRG/40A) pylori is less sensitive when routine elementary and eosin preparation REFERENCE , a alone is applied [as was the case in 1. Talley N J , Silverstein MD, Agreus L, et al. American this stttdy] than when it is com- Gastroenterology Association bined with special techniques such Technical Review: evaluation as Giemsa or Steiner staining (25). of dyspepsia. Gastroenterol- It is instructive that one of the pa- ogy. 1998; 114: 582-595. tients who had a normal gastric 2. Talley NJ, Stranghellini V, histology was also negative for H. Heading RC, et al. Functional pylon IgG. This we consider as a gastroduodenal disorders. Gut. 1999; 45: 1 137-1 1 42. case of non-ulcer dyspepsia type 11. 3. 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