HELICOBACTER PYLORI

UPDATE
Dr.T.V.Rao MD

DR.T.V.RAO MD

HISTORY OF H. PYLORI
1890s: Spirochetes in animal stomachs

1900s: Spirochetes in human stomachs

1954: No bacteria in gastric biopsies of 1000 patients 1975: Gram negative bacteria in 80% of GUs (Pseudomonas) 1983: Warren and Marshall characterize H. pylori

2005 Nobel prize in 2005

HELICOBACTER PYLORI
Background Human stomach long considered inhospitable for bacteria Spiral shaped organisms occasionally visualized in gastric mucous layer, but no evidence of disease association Organism classified first as Campylobacter pylori Now Helicobacter pylori Other species of Helicobacter isolated from stomach, intestine of other animals Marshall and Warren culture organism from human gastric mucosa and show association with gastric inflammation DR.T.V.RAO MD 3

HELICOBACTER ( WARREN AND MARSHAL )

Campylobacter like organisms Spiral shaped colonizes Gastric mucosa Etiological agent in Gastritis and peptic ulcer

Most important bacteria.

Helicobacter pylori

Colonizes 50 % of the Individuals

DR.T.V.RAO MD

WARREN AND MARSHAL WINS NOBEL PRIZE

DR.T.V.RAO MD

GENERAL CHARACTERISTICS OF HELICOBACTER

Helicobacter pylori is major human pathogen associated with gastric antral epithelium in patients with active chronic gastritis Stomach of many animal species also colonized Urease (gastric strains only), mucinase, and catalase positive highly motile microorganisms Other Helicobacters: H. cinnaedi and H. fenneliae Colonize human intestinal tract

Isolated from homosexual men with proctitis, proctocolitis, enteritis, and bacteremia and are often transmitted through sexual practices
DR.T.V.RAO MD

A silver stain of H. pylori on gastric mucussecreting epithelial cells (x1000). From Dr. Marshall's stomach biopsy taken 8 days after he drank a culture of H. pylori (1985).

DR.T.V.RAO MD

HELICOBACTER PYLORI
Gram ve spiral shaped , motile with unipolar tuft of lopotrichus flagella
DR.T.V.RAO MD

H. PYLORI BACTERIA
Gram negative
Spiral rod Unipolar flagella Microaerophilic Urease positive*

*Most important
character
*Scanning microscopic view of H. pylori

MORPHOLOGY & PHYSIOLOGY OF HELICOBACTER

Gram-negative; Helical (spiral or curved) (0.5-1.0 um X 2.5-5.0 um); Blunted/rounded ends in gastric biopsy specimens; Cells become rod-like and coccoid on prolonged culture

Produce urease, mucinase, and catalase

H. pylori tuft (lophotrichous) of 4-6 sheathed flagella (30um X 2.5nm) attached at one pole

Single polar flagellum on H. fennellae & H. cinaedi

Smooth cell wall with unusual fatty acids
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H. PYLORI INFECTION TRANSMISSION

Transmissible
Oral-oral and oralfecal

Infects the human stomach Produces inflammatory response This brings up the point of the importance of hand washing

DYNAMICS OF H.PYLORI INFECTION

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CULTURING AND BIOCHEMICAL CHARACTERS

Grows on chocolate agar, Campylobacter media
Grows under Microaerophilic conditions With presence of 5 20% co2 Oxidase + Catalase

Urease strongly +++

H2S
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H. PYLORI PATHOGENESIS BACTERIAL VIRULENCE FACTORS

(CAG- PAI)( 37000 B-P 29 GENES)

Type IV secretions apparatus (1) (translocate cag A)

Possible insertion by needle like organelle coated with a sheath (Cag 7 protein) [Rohde et al]
Phosphorylated + binds to SHP-2 tyrosine Phosphates

Cytokine Production IL- 8+ chemokines

Growth Factor Like cellular response

(1) Odenbreit S, et al. Science 2000;287:1497-1500

H. PYLORI PATHOGENESIS
BACTERIAL VIRULENCE FACTORS
Ingestion Evasion + Entrance of Mucus
1 2 3 4 Layer (Motility + Urea I) Binding Insertion Intra cellular pathway

HELICOBACTER PYLORI AND PEPTIC ULCER DISEASE HISTOPATHOLOGY WITH SPECIAL STAINS .

DR.T.V.RAO MD

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H. PYLORI PATHOGENESIS THE ROLE OF CYTOKINES

I. Alter secretion of mucus

II. TNF ILI, INF- 1Y

Gastrin release Stimulate parietal cells

Acid secretion

I. TNF

D cells number
Somatostatin

Acid secretion

PATHOLOGY AND PATHOGENESIS

H.pylori colonizes gastric mucosa Spread by oral oral contact Feco oral spread prominent Poverty and overcrowding predisposes Poor Hygiene Causes mild to acute gastritis Gastric antrum - causes gastric metaplasia Any part of the stomach can be involved Colonizes overlying mucosa but donot invade mucosa
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MAJOR LOCATION OFH.PYLORI INFECTIONS

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Pathogenesis of Helicobacter Infections

Colonize mucosal lining of stomach & duodenum in man & animals
Adherent to gastric surface epithelium or pit epithelial cells deep within the mucosal crypts adjacent to gastric mucosal cells Mucosa protects the stomach wall from its own gastric milleu of digestive enzymes and hydrochloric acid Mucosa also protects Helicobacter from immune response

Most gastric adenocarcinomas and lymphomas are concurrent with or preceded by an infection with H. pylori

H.PYLORI INFECTING MUCOSAL LAYER

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PATHOGENESIS OF H.PYLORI.

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Virulence Factors of Helicobacter

Multiple polar, sheathed flagella
Corkscrew motility enables penetration into viscous environment (mucus)

Adhesins: Hemagglutinins; Sialic acid binding adhesin; Lewis blood group adhesin Mucinase: Degrades gastric mucus; Localized tissue damage Urease converts urea (abundant in saliva and gastric juices) into bicarbonate (to CO2) and ammonia
Neutralize the local acid environment Localized tissue damage

Acid-inhibitory protein

H. Pylori Specific T

Cell and B Cell Responses

MECHANISM OF H.PYLORI INFECTION

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Urea Hydrolysis
Urea

C=O(NH2)2 + H+
And then

Urease + 2H2O HCO3- + 2 (NH4+)

Bicarbonate Ammonium ions

CO2 + OH-

HCO3-

Virulence Factors of Helicobacter )

Tissue damage:
Vacuolating cytotoxin: Epithelial cell damage Invasin(s)(??): Poorly defined (e.g., hemolysins; phospholipases; alcohol dehydrogenase) Protection from phagocytosis & intracellular killing: Superoxide dismutase Catalase

H. Pylori Pathogenesis and Application of Cutting Edge Technologies

Molecular biology

Genetics

Imaging

Cell culture models

INDICATIONS FOR NONINVASIVE TESTING FOR H. PYLORI *

Strongly Recommended
Dyspepsia

History of/active peptic ulcer disease

Gastric MALT lymphoma Following gastric cancer resection

Following peptic ulcer surgery

First-degree relative with gastric cancer Long-term Non-steroidal anti-inflamatory drugs (NSAID) therapy
* In the absence of alarm signs for gastric cancer or ulcer disease 1. Malfertheiner P, et al. Aliment Pharmacol Ther. 2002;16:167. 2. Talley NJ et al. Aliment Pharmacol Ther. 1999;12:1135.

TYPES OF H. PYLORI TESTS

Endoscopy
Rapid urease tests Histology Culture Serologic (antibody)

Stool antigen tests

13C Urea blood

test Urea breath tests 14C-urea 13C-urea

Malfertheiner P, et al. Aliment Pharmacol Ther. 2002;16:167.

13C

UREA BREATH TEST

Detects active infection

Sensitive and specific

Non-radioactive No special handling requirements Easy to collect and handle sample

Not indicated in pediatric population

1. Graham DY et al. Am J Gastroenterol. 2001;96:1741. 2. Leodolter A et al. Am J Gastroenterol. 1999;94:2100.

LABORATORY DIAGNOSIS
Diagnosed by Invasive and Non Invasive tests

Invasive, Endoscopic Biopsy of Gastric mucosa

Microscopy Biopsy Culture Staining by special stains Gram staining

Culture more sensitive 3 7 days

Biopsy testing for urease detection in urea medium
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Laboratory Identification
Recovered from or detected in endoscopic antral gastric biopsy material; Multiple biopsies are taken Many different transport media Culture media containing whole or lysed blood Microaerophilic Grow well at 37oC, but not at 25 nor 42oC Like Campylobacter, does not use carbohydrates, neither fermentatively nor oxidatively

DIAGNOSIS BY NON INVASIVE METHODS

Serology ELISA

Urea breath test patient swallows urea solution

In this test patient drinks urea solutions labeled with an isotope carbon If H.pylori is present in the urea is converted to ammonia and co2 in the breath measured.
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SUGGESTED GUIDELINES FOR TREATMENT OF PATIENTS WITH GI OR ULCER DISEASE

History & Physical Exam
Peptic ulcer disease Undifferentiated dyspepsia Symptoms of GERD Use of NSAIDs or aspirin

Positive Eradication therapy Confirmation of cure

Test for H. pylori

Malfertheiner P, et al. Aliment Pharmacol Ther. 2002;16:167.

SUGGESTED GUIDELINES FOR TREATMENT OF PATIENTS WITH GI OR ULCER DISEASE

History & Physical Exam
Peptic ulcer disease Undifferentiated dyspepsia Symptoms of GERD Use of NSAIDs or aspirin

Positive Eradication therapy Confirmation of cure

Test for H. pylori

Negative Treat for PUD, Initiate PPI therapy, or discontinue NSAIDs

Malfertheiner P, et al. Aliment Pharmacol Ther. 2002;16:167.

TREATMENT
Use of antibiotics, bismuth salts Ingestion of Bismuth subsalicylate Antibiotics Tetracycline's and metronidazole for two weeks Use of Omeprazole Clarithromycin Do not treat for Asymptomatic colonization Drug resistance is a growing problem
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EMERGING DRUG RESISTANCE IN H.PYLORI

Antibiotic treatment does not always completely inhibit or kill H. pylori with potential for antibiotic resistance. Resistance to antibiotics is the single most important factor for declining H. pylori eradication rates. In Japan, resistance to antibiotic drugs has increased 400% while in Taiwan, it is 500%. This means that those who are infected while in these countries may find the bacterium rather resistant to their antibiotic treatments.

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EPIDEMIOLOGY OF HELICOBACTER INFECTIONS

Developed Countries:

United States: 30% of total population infected

Of those, ~1% per year develop duodenal ulcer ~1/3 eventually have peptic ulcer disease(PUD) 70% gastric ulcer cases colonized with H. pylori Low socioeconomic status predicts H. pylori infection Developing Countries: Hyperendemic About 10% acquisition rate per year for children between 2 and 8 years of age Most adults infected but no disease Protective immunity from multiple childhood infections
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H.PYLORI CONTINUES TO BE AN IMPORTANT PATHOGEN

H. pylori is a transmissible, infectious disease with potentially serious outcomes H. pylori infection may be asymptomatic or cause dyspepsia Eradication therapy can cure H. pylori infection and prevent morbidity and downstream events such as PUD and gastric cancer Patients with symptoms of upper-GI disease, and who use aspirin or NSAIDs should be tested for H. pylori infection

 Programme Created by Dr.T.V.Rao MD for Medical and Health Care Workers in the Developing World
Email

doctortvrao@gmail.com

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