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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 30  |  Issue : 5  |  Page : 607-614

Helicobacter pylori infection a risk for upper gastrointestinal diseases among patients in North Central Nigeria


1 Department of Int. Medicine, Federal Teaching Hospital Gombe, Nigeria
2 Department of Int. Medicine , Abubakar Tafawa Balewa Teaching Hospital Bauchi, Nigeria
3 Department of HIV/AIDS Research, USDOD Walter Reed Program Abuja, Nigeria
4 Department of Int. Medicine, Federal Medical Center Yola, Adamawa, Nigeria
5 Public Health Department, Ministry of Health, Jalingo, Taraba, Nigeria
6 Department of Int. Medicine, Dalhatu Arafat Specialist Hospital, Lafiya, Nasarawa, Nigeria
7 Department of Int. Medicine Jos University Teaching Hospital, Plateau, Nigeria

Date of Submission01-Mar-2021
Date of Decision31-Aug-2021
Date of Acceptance07-Sep-2021
Date of Web Publication11-Oct-2021

Correspondence Address:
Dr. Jacob A Dunga
Abubakar Tafawa Balewa Teaching Hospital, Bauchi
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/NJM.NJM_45_21

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  Abstract 


Background: Since the discovery of the Upper Gastrointestinal (UGI) fiber optic endoscope machine in 1868 and following the discovery of Helicobacter pylori (H- Pylori) infection and its association with most gastroduodenal diseases in 1983 by Robin Warren and Barry Marshal, Our knowledge of diagnosis and treatment of most UGI diseases has significantly improved. Aim: The study aimed to establish the presence of H. pylori as a risk factor for common UGI disease as confirmed by UGI endoscopy and the pattern of findings in UGI endoscopy. Methodology: This study is a descriptive cross-sectional study that was carried out at the Endoscopy Unit of Jos University Teaching Hospital. A total of 260 patients referred for UGI endoscopy from August 2013 to April 2014 were recruited and investigated for H. pylori from the biopsy specimens taken during UGI endoscopy. The diagnosis of H. pylori was made by histology. Result: A total of 260 patients were studied, 159 (61.2%) males and 101 (38.8%) females. H. pylori were present in 169 (65%) and absent in 91 (35%). More females had H. pylori compared to males (67.3% and 63.5%). The common endoscopic findings were present in the stomach. Gastritis 57 (21.9%) was the most common abnormality seen in the stomach, while gastroesophageal reflux disease was the most commonly seen in the esophagus and duodenal ulcer in the duodenum. Conclusion: There is a positive correlation between H. pylori infection with endoscopic abnormalities seen among patients.

Keywords: Endoscopic finding, Helicobacter pylori, upper gastrointestinal diseases


How to cite this article:
Zawaya KP, Dunga JA, Adamu Y, Bathnna SJ, Liman HU, Musa JJ, Yusuf SY, Vakkai I, Adabe R, Okeke E N, Agaba E I. Helicobacter pylori infection a risk for upper gastrointestinal diseases among patients in North Central Nigeria. Niger J Med 2021;30:607-14

How to cite this URL:
Zawaya KP, Dunga JA, Adamu Y, Bathnna SJ, Liman HU, Musa JJ, Yusuf SY, Vakkai I, Adabe R, Okeke E N, Agaba E I. Helicobacter pylori infection a risk for upper gastrointestinal diseases among patients in North Central Nigeria. Niger J Med [serial online] 2021 [cited 2021 Nov 29];30:607-14. Available from: http://www.njmonline.org/text.asp?2021/30/5/607/327962




  Introduction Top


Upper gastrointestinal (UGI) diseases are a heterogeneous group of organic and functional diseases affecting the esophagus, stomach, and duodenum. They are the leading causes of morbidity and mortality globally,[1] majority of patients commonly present with dyspepsia. Most of the UGI diseases diagnosed include esophagitis, gastroesophageal reflux disease (GORD), gastritis, gastric and duodenal ulcers, non-ulcer dyspepsia (NUD), gastric mucosa-associated lymphoid tissue (MALT) lymphoma, and gastric cancers. Peptic ulcer disease (PUD), GORD, and cancers are the leading UGI diseases and affect millions of people worldwide.[2],[3],[4]

Besides the carcinomas, these diseases were originally thought to result primarily from various degrees of imbalance between gastric acid secretion and mucosal protective mechanisms in the stomach and duodenum.

Helicobacter pylori is a spiral-shaped Gram-negative urease-producing flagellated bacterium found in the gastric antrum,[5] particularly under the mucus layers in gastric pits. Within the gastric antrum, H. pylori cause severe gastritis which is the first step in the development of many gastroduodenal diseases. Although its mode of transfer is unclear,[6],[7],[8] intrafamilial clustering may suggest person-to-person spread, either oro-oral or feco-oral, mainly in children.[6],[9] Poor sanitation, lack of safe drinking water, and basic hygiene, as well as poor diets and overcrowding, are all responsible for the increase in the overall prevalence of infection.[9] Approximately 10%–20% of those colonized by H. pylori will ultimately develop gastric and duodenal ulcers.[6],[10] H. pylori infection is also associated with a 1%–2% lifetime risk of stomach cancer and a <1% risk of gastric MALT lymphoma.[10],[11]

About 50% of the world's population is infected with H. pylori.[5],[7] The prevalence of H. pylori is highly variable based on geography, ethnicity, age, and socioeconomic factors.[6],[9] The prevalence is highest in developing countries when compared to the developed world,[9] with values as high as 90% recorded in African communities and 25% in European communities.[9] Although colonization with the organism does not translate to infection, as only a minority of patients develop gastroduodenal disease, up to 95% of the patients who have duodenal ulcers have H. pylori infection.[6] This association shows that the organism is a major risk factor for duodenal ulcers.

H. pylori infection among patients with positive UGI endoscopic findings has been previously described in various parts of the world. In a Japanese study, a correlation between gastritis and H. pylori infection was found,[12] also demonstrated a clear-cut association between H pylori and duodenal ulcer among patients.[13] Similarly, in Kenya, all the gastric ulcers and 88.2% of the duodenal ulcers were associated with H. pylori infection.

In Nigeria and other developing countries, H. pylori is a public health issue and the high prevalence of the infection means that public health interventions may be required.[9] Therapeutic vaccination may become the only strategy that will make a decisive difference in the prevalence and incidence of H. pylori infection throughout the world.

Various diagnostic tests for H. pylori have been developed, and these are endoscopic (invasive) and nonendoscopic (noninvasive) tests.[6],[14] An endoscopic test uses endoscopic biopsy samples for histology, culture, Campylobacter-like organism urease test, molecular approach (polymerase chain reaction), and fluorescence in situ hybridization, with >90% sensitivity and specificity.[15] The nonendoscopic tests include 13C and 14C urea breath test, immunoglobulin G and M serology, stool antigen test, saliva antibody test, and urinary antibody test.[15] These have variable sensitivity and specificity but are generally below that of endoscopic (invasive) tests.[14]

H. pylori are present in half the population of the world, but this prevalence varies from one country to the other and between different regions or areas in the same country.[16]

The mode of transmission is usually through direct contact between subjects;[16] transmission can also be through contaminated water sources and food.[17] Other less common modes of transmission include iatrogenic transmissions like during medical procedures[17] and zoonotic transmission.[17]

The economic burden of H. pylori infection cannot be underestimated; H. pylori has been established as the causative agent for chronic gastritis and PUD and has been associated with gastric cancer and MALT.[18] It is also a risk factor in other gastroduodenal diseases.[18]

There is a paucity of data in developing countries on the cost of managing H. pylori infection and its complications.[17]

Endoscopy is not easily available in Nigeria and most developing countries, and is usually expensive and requires a skilled workforce.[1],[9]

The study of the correlation of H. pylori infection and upper endoscopic findings could stimulate further debate on H. pylori eradication using the public health approach. Such studies of the correlation between UGI endoscopic findings and H. pylori infection in North Central Nigeria are scarce. Therefore, this study was undertaken to assess the prevalence of H. pylori among patients presenting with UGI symptoms in Jos and to see if the presence of the bacteria could be associated with specific pathological conditions.


  Methodology Top


This study is a descriptive cross-sectional hospital-based study that was carried out from August 2013 to April 2014 at Jos University Teaching Hospital (JUTH), North Central Nigeria. The study populations were adults aged 18 years and above, referred for UGI endoscopy, and the primary source document is the endoscopic register of patients referred with signs and symptoms suggestive of UGI diseases to the Endoscopic Unit of JUTH, North Central Nigeria.

Patients were excluded from this study if they were <18 years, declined to consent, have received antibiotics, proton-pump inhibitors, bismuth compound in the last four weeks, or were not sure of the treatment received for their disease condition within four weeks before referral.

Endoscopic examination was carried out using gastroduodenoscopy, Olympus (TJF-20), and video scope on all recruited patients regardless of the indications for it, except where there was a clear contraindication (s) for the patient not to have UGI endoscopy at presentation. The endoscopic diagnosis was made and verified independently by two gastroenterologists.

The sample size was calculated using the sample size calculator by the creative research system. The only available local prevalence found is 78.5% from a study in Maiduguri Northeastern Nigeria.[11] With a Confidence level at 95% CI and a precision of 0.5% we arrived at a sample size of 265.

Biopsies were taken from the duodenum (first part), antrum, and corpus, and then, it was fixed in fresh 10% formaldehyde and transferred to the histopathology laboratory for processing. Four-micron thick paraffin sections were stained with routine hematoxylin and eosin and Giemsa for detection of H. pylori and other gastroduodenal disease conditions like gastritis. Slides were examined microscopically for H. pylori by the pathologist. The presence of Helicobacter-like organisms was regarded as positive while absence was regarded as negative. The use of H. pylori-like organisms became necessary because histology was used for the diagnosis of H. pylori in this study instead of culture.[19]

Statistical analysis

Epi Info 7 statistical software version 3.4.3 (Centers for Disease Control, Atlanta, Georgia, USA) was used to analyze the data. Continuous variables were expressed as mean ± standard deviation for the normally distributed data; the Student's t-test was used to compare means and odds ratio at 95% CI. Categorical variables expressed as proportions were compared with Chi-square. A significant P value was taken as <0.05.


  Results Top


Demographic characteristics of the subjects

The mean age of the patients from 18 years to 96 years was 44.5 ± 1.18 years. There were 159 (61.2%) males and 101 (38.8%) females. There were more subjects within the age of 35–44 years 67 (25.8%) and fewer patients aged 75 years and above 17 (6.5%) in this study [Table 1].
Table 1: Demographic characteristics of the subjects

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Clinical Characteristics of patients at presentation

The most common presenting symptoms among the patients were epigastric pain in 193 (74.2%), vomiting in 122 (46.9), weight loss in 121 (46.5%), abdominal discomfort in 88 (33.9%), and heartburn 82 (31.5%). Others were hematochezia 22 (8.5%) and odynophagia 8 (3.1%). Common physical examination findings before UGI endoscopy were epigastric tenderness 96 (36.9%), wasting 84 (32.4%), pallor 67 (25.8%), and finger clubbing 57 (21.9%). The least occurring physical findings were oral thrush 5 (1.9%), lymphadenopathy 13 (5.0%), and hepatosplenomegaly 22 (8.5%), as shown in [Table 2]. The mean liver span was 9.53 ± 2.9 cm, pulse rate 82.69 ± 13.91 bpm, systolic blood pressure 122.65 ± 16.07 mmHg, and diastolic blood pressure 79.83 ± 11.04 mmHg.
Table 2: Clinical characteristics of patients at presentation

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Sociodemographic characteristics and presence of Helicobacter pylori

There were 28 (77.8%) cases of H. Pylori among subjects <25 years and among 25 -34 years, there were 29 (16.3%) cases of H. Pylori, while among 35 - 44 years there was 47 (70.1%). Similarly, between age group 45-54, 55-64, 65 -74 and >75 there were 26 (57.8%), 19 (54.3%), 10(45.5%) and 10(58.8%) cases of H. pylori observed respectively. The presence of H pylori and increasing age was not statistically significant (P = 0056).

Similarly, there was no significant relationship between sex (P = 0.532), alcohol intake (0.393), and cigarette smoking (P = 0.745) [Table 3].
Table 3: Relationship between some sociodemographic characteristics and presence of Helicobacter pylori

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The age group with the highest infection rate was 25–34, 29 (76.3%), and the least is the age group 65–74, 10 (45.5%) (P = 0.056), as shown in [Table 3].

A total of 159 males participated in the study. H. pylori was present in 101 (63.5%). Among the 101 female participants, 68 (67.3%) had H. pylori infection (P = 0.531) [Table 3].

Endoscopic abnormality

A total of 260 patients had UGI endoscopy, out of which 246 (94.6%) had abnormal endoscopic findings and 14 (5.4%) had normal findings [Table 4].
Table 4: Endoscopic abnormality

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Endoscopic findings and pattern of upper gastrointestinal lesions

Two hundred and sixty patients had UGI endoscopy, out of which 14 (5.4%) had normal GI findings (no lesion was detected). Most lesions were seen in the stomach, followed by the esophagus and then the duodenum. The most common lesion seen in the stomach was gastritis 57 (21.9%) followed by gastric ulcer 47 (18.1%). In the esophagus, GORD was the most common lesion seen in 44 (16.9%) and varied seen in 41 (15.8%). In the duodenum, there were 55 (21.2%) cases of duodenal ulcers [Table 6] and [Figure 1].
Figure 1: Pattern of endoscopic findings

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Correlation between Helicobacter pylori and upper gastrointestinal endoscopic findings

Out of the 260 patients examined, a total of 169 (65%) had H. pylori with 160 (94.7%) of them having endoscopic abnormalities and 9 (5.3%) having no abnormality. Furthermore, of the 91 (35%) patients who were not infected by H. pylori, 86 (94.5%) had endoscopic abnormalities while 5 (5.5%) had no abnormality at endoscopy (P = 0.581) [Table 5], [Table 6], [Table 7].
Table 5: Prevalence of Helicobacter pylori

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{
Table 6: Endoscopic findings and pattern of upper gastrointestinal lesions (n=260)

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Table 7}

Correlation between Helicobacter pylori and common gastroduodenal endoscopic findings

A total of 47 of the patients had GU, out of which 23 (48.9%) had H. pylori infection and 24 (51.1%) were not infected (P = 0.011). Portal hypertensive gastropathy was seen in 14 patients, out of which 4 (28.6%) had H. pylori infection and 10 (71.4%) were not infected (P = 0.005). Forty-four subjects had GORD, out of which 35 (79.4%) had H. pylori infection and 9 (20.1%) are not infected (P = 0.027). Gastritis was seen in 57 patients and 47 (82.5%) had H. pylori infection and 10 (17.5%) had no H. pylori infection (P = 0.002).

A total of 41, 55, and 19 persons had esophageal varices, duodenal ulcers, and gastric malignancy, out of which 17 (41.5%), 43 (78.2%), and 16 (84.2%) were positive for H. pylori (P ≤ 0.001, 0.021, and 0.068), respectively. Fourteen subjects had normal endoscopic findings, out of which 10 (71.4%) had H. pylori infection and 4 (28.6%) were not infected (P = 0.419). Nineteen had gastric malignancy, of which 16 (84.2%) had H. pylori, P = 0.068 [Table 8].
Table 8: The correlation of common gastroduodenal diseases and presence of Helicobacter pylori

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Duodenal ulcer patients have a 3.4296 times chance of having H. pylori infection, P = 0.0077 (95% CI: 1.3845–8.4955); patients with gastric malignancies have a 7.7496 times chance of having H. pylori infection, P = 0.0052 (95% CI: 1.8420–32.0037). There was also a positive correlation as seen in the multiple regression [Table 8] and [Table 9].
Table 9: Multiple logistic regression of common gastroduodenal diseases and other factors and presence of Helicobacter pylori

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  Discussion Top


Since the discovery of H. Pylori more than three decades ago our knowledge about the aetiology of gastroduodenal diseases has improved, it is now clear that the bacterium H. pyloriis associated with several gastroduodenal conditions. This association has also been established, in various similar studies reported across the world.[11],[20],[21]

In this study, we found a high prevalence of H. pylori infection which is comparable with the high prevalence established by most studies done across the developing nations.[5],[11],[14] The prevalence of H. pylori in this study was found to be 65.0% and absent in 35.0%. In some studies, within Nigeria, the prevalence of H. pylori varied but showed similarity with this study.[5],[22]

The prevalence of H. pylori is also high in other parts of Africa. In Ghana,[23] it was found to be 75.4%, while it was 73.1% in HIV-positive and 84.6% in HIV-negative individuals in Kenya.[14] Prevalence of H. pylori in other parts of the world revealed that it is low in Switzerland (26.6%), the USA, and Canada (30%). This is probably due to clean water and environmental hygiene standards. It is high in Brazil (82%) and Chile (72%).[5],[9]

Our finding of higher prevalence of H. pylori in Jos, Plateau State, is comparable to the high prevalence seen across the developing countries.[5],[11] High prevalence of H. pylori is also seen in communities with poor sanitation,[9],[18] poor source of drinking water,[17],[24],[25] etc., These might explain the high prevalence seen in this study as the study area is in a developing country with poor sanitation and a poor source of drinking water.

In this study, there was an observed variation in the prevalence of H. pylori among male and female subjects (67.3% and 63.5%); it was also observed that H. pylori infection is more common in the younger age group (<45 years). This could be due to high chances of acquiring an infection during early childhood which could run a chronic course in developing countries.[17] This finding is in contrast with the developed world in which most infection is seen in the older age group.[26],[27] The variation in the prevalence of H. Pylori in different age groups has been documented in different countries and between regions within the same country,[9],[17],[27] for instance in Libya, age groups 1-9, 10-19 and adults had a prevalence of 50%, 84% and 94% respectively[9] whereas in India[9] the prevalence is 22%, 87% and 88% for age group 0-4, 10-19 and Adults respectively.

Our endoscopic findings during this study revealed that there were 94.6% of patients with abnormal endoscopic findings compared to 5.45% who had normal findings, this is higher than what was obtained in a similar study conducted some years back in Jos with 39.9% abnormal endoscopic findings among cases.[28],[29],[30] This could be due to improvement in skills, diagnostic acumen and increase referrals. Some countries with improved standards of water supply and hygiene like the UK, USA and Saudi Arabia have low prevalence.

Interestingly, we found that 86.4% of endoscopically normal-looking mucosa revealed gastritis histologically. This important finding will help suggest the need for biopsy during endoscopic procedures. This has been demonstrated in similar to other studies.[11] The most common site of lesion in this study was the stomach, which is similar to studies done in South-west Nigeria.[5],[31] The most common lesion seen in this study was gastritis 57 (21.9%) which was also the most common findings in a study done in North West Nigeria[6] and South-west Nigeria (Ibadan)[5] 60.5%. In Kenya[21] and India[20] studies, gastritis was the most common endoscopic findings, 31.7% and 69.0%, respectively. The finding of gastritis as a common finding in UGI endoscopy may be partly explained by the fact that gastritis is usually at the background of most H. pylori infection presentation in gastroduodenal diseases.[32],[33] DU and GU have a high frequency in this study, and this is comparable with a previous study.[6] In this study, H. pylori is positively correlated with the occurrence of PUD (DU and GU).

There were 16. 9% cases of GORD, Oesophageal varicies 15. 8%, hypertensive gastropathy 14(5.4%), duodenitis 6(2.3%), oesophageal candidiasis 5(1.9%). Others include oesophageal cancer 4(1.5%) and non-ulcer dyspepsia 4(1.5%) which is similar to studies in the south-east, west and north-central Nigeria.[35],[36],[37] Oesophageal cancer and candidiasis were seen among small proportions of patients constituting 1.5% and 1.9% respectively.

There was a positive correlation between H. pylori and common gastroduodenal diseases. Some of the variations seen with other studies across the world may be due to the sociocultural, hygiene practice, clean water sources, and ethnic differences of the study groups which may have influenced the outcome of the studies. Several factors such as the host genetic susceptibility and polymorphism, the pattern of immune response and the lifestyle together with the variable strain virulence, pathological progression of H. Pylori associated chronic gastritis might be a strong factor that can determine the types of gastroduodenal conditions related to the infection in the different communities.[21],[38],[39] The correlation of H. pylori and gastritis is statistically significant (p-value 0.002), there was also a positive correlation between H pylori with DU 78.2%48.2% and GU (P = 0.021 & 0.011).The correlation of H. pylori and gastritis is statistically significant (P = 0.002); In this study we found a positive correlation between H pylori with DU 78.2%48.2% and GU (P = 0.021 &0.011). This is similar to studies in North-east and South-west Nigeria,[5],[11],[32] which showed a high prevalence of H. pylori in patients with DU and GU. Similarly, in Kenya, 100% of the GU and 88.2% of the DU patients studied were infected with H. pylori.[14] GORD was also positively correlated with H. pylori infection 79.5% (P = 0.027). The study also showed a significant correlation between H. pylori and some gastroduodenal diseases that include esophageal varices, portal gastropathy, and gastric malignancy.


  Conclusion Top


Two hundred and sixty patients participated in this study, of which 61.2% are male and 38.8% are female. The study found the prevalence of H. pylori was high (65%) and endoscopic abnormalities were seen in the majority of the patients (94.6%). Most of the patients with endoscopic abnormalities had H. pylori infection (94.7%). Endoscopic findings showed preponderance in the stomach, esophagus, and duodenum; this study showed a statistically significant relationship between H. pylori and upper GI diseases. It is also of note that some normal mucosal linings at endoscopy were found to have H. pylori histologically.

The study was hospital-based and may not reflect the general population as subjects recruited for this study were dependent on referral for expert care from other hospitals; a multicenter study might be required. Diagnosis of H. pylori was made using an indirect method using H. pylori-like organism histologically which might be subject to interpreter error.

Ethical clearance

Ethical clearance and certificate was obtained from the Research Ethical Committee of JUTH, and each patient signed informed consent before participating in the study.

Acknowledgments

We acknowledge the effort of all the authors toward the collection of data from various centers and the development of this manuscript from the beginning to the end. We equally want to acknowledge the head of all the organizations and the centers where this study was conducted for their approval and the conducive environment given to our authors.

Availability of data and materials

The data sets collated and analyzed during this study are available from the corresponding author on request.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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