Print version ISSN 0043-3144
West Indian med. j. vol.59 no.3 Mona June 2010
Prevalencia de la infección por Helicobacter pylori en pacientes sometidos a endoscopía gastrointestinal superior en las Islas Turcas y Caicos
DO Whittle; R Ewing; MG Lee
Department of Medicine, The University of the West Indies, Kingston 7, Jamaica, West Indies
BACKGROUND: Helicobacter pylori infection remains a common problem and previous studies in the Caribbean revealed infection in over 50% of patients undergoing upper endoscopy. Objective: The present study determined the prevalence of H pylori infection in patients undergoing upper gastrointestinal endoscopy in the Turks and Caicos Islands over a two- year interval.
METHODS: All patients with upper gastrointestinal symptoms requiring endoscopy were evaluated clinically and H pylori testing performed histologically.
RESULTS: There were 57 patients (21 males, 36 females) with a mean age of 43 years. Twenty-six patients presented with gastroesophageal reflux, 17 with upper abdominal pain, 10 with dyspepsia and 4 with upper gastrointestinal bleeding. H pylori infection was present in 24 patients (42%) and negative in 33 (58%). Upper gastrointestinal endoscopy was normal in 27 patients, 13 (54%) were H pylori positive and 14 (43%) negative. Antral gastritis was present in 13 patients, 7 (54%) were H pylori positive and 6 (46%) negative. Duodenal ulcer was present in 6 (33% H pylori positive) and gastric ulcer in 5 patients (40% H pylori positive). Distal oesophagitis was present in 5 patients (all negative for H pylori) and gastric carcinoma in 1 (H pylori positive).
CONCLUSION: In patients with dyspepsia, 60% were positive for H pylori. H pylori infection was common in the patients in this study with gastrointestinal symptoms. However, the prevalence in endoscopic patients and peptic ulcer disease is lower than in other reports from the Caribbean.
Keywords: Endoscopy, Helicobacter pylori
ANTECEDENTES: La infección por Helicobacter pylori sigue siendo un problema común y los estudios previos en el Caribe revelaron infección en más del 50% de los pacientes sometidos a endoscopía superior.
OBJETIVO: El objetivo del presente estudio fue determinar la prevalencia de la infección por H pylori en pacientes sometidos a endoscopía gastrointestinal superior en las Islas Turcas y Caicos por un período de dos años.
MÉTODOS: Los sujetos fueron 57 pacientes (21 varones, 36 hembras) con una edad promedio de 43 años. Veintiséis pacientes se presentaron con reflujo gastroesofágico, 17 con dolor abdominal superior, 10 con dispepsia y 4 con sangramiento gastrointestinal superior. La infección por H pylori estuvo presente en 24 pacientes (42%) y fue negativa en 33 (58%). Resultados: El endoscopía gastrointestinal superior fue normal en 27 pacientes, 13 (54%) fueron positivos al H pylori y 14 (43%) fueron negativos. La gastritis antral estuvo presente en 13 pacientes, 7 (54%) dieron positivo al H pylori y y 6 (46%) dieron negativo. La úlcera duodenal estuvo presente en 6 (33% positivos a H pylori) y la úlcera gástrica en 5 pacientes (40% positivos a H pylori). Se halló esofaguitis distal en 5 pacientes (todos negativos a H pylori) y carcinoma gástrico en 1 (positivo a H pylori).
CONCLUSIÓN: Entre los pacientes con dispepsia, 60% dieron positivo positivos a H pylori. En este estudio, la infección por H pylori fue común en pacientes con síntomas gastrointestinales. Sin embargo, la prevalencia en los pacientes sometidos a endoscopía y con úlcera péptica, fue menor en relación con los otros reportes del Caribe.
Palabras claves: Endoscopía, Helicobacter pylori
Helicobacter pylori (Hpylori) is a gram negative bacilli that is found between the mucus layer and the mucosa of the stomach (1). H pylori is one of the commonest chronic infections wordwide and is associated with several important gastrointestinal diseases including, gastric ulcer, duodenal ulcer, chronic gastritis, mucosa associated lymphoid tumours (MALT) and gastric cancer (2). It is also associated with dyspepsia (3, 4).
The prevalence of H pylori infection varies between developed and developing countries (5). The number of studies on the prevalence of Hpylori infection has expanded to nearly every area of the world with developed countries typically having a lower prevalence at all ages (6). In the Caribbean, studies have revealed that over 50% of patients undergoing upper gastrointestinal endoscopy had H pylori infection on gastric biopsies (7, 8).
The Turks and Caicos Islands (TCI) are a group of 5 small islands south east of Florida, in the northern Caribbean. The TCI has a combined population of 36 605 (9). The population comprises of mainly persons of African descent. There are no previous studies on the prevalence of H pylori infection in the Turks and Caicos Islands (TCI). The present study determined the prevalence of H pylori infection in patients undergoing upper gastrointestinal endoscopy in the TCI.
SUBJECTS AND METHODS
Between June 2007 and June 2009, all patients with upper gastrointestinal symptoms who were referred to the Gastroenterology clinic in the TCI were assessed by a consultant Gastroenterologist.
Patients requiring upper gastrointestinal endoscopy were eligible for study. The procedure was explained to the patient and the need to check for H pylori infection was detailed. Informed consent was obtained from all patients.
Endoscopy was carried out with a Pentax forwardviewing flexible endoscope by a consultant gastroenterologist. Local pharyngeal anaesthesia with 10% lignocaine spray was used in all patients as well as sedation with midazolam intravenously. All patients had evaluation of the oesophagus, stomach and proximal duodenum and abnor malities were documented. Gastric biopsies for histological examination and for the presence of Hpylori organisms were performed on all patients. Five samples were taken from the stomach: two from the antrum, two from the body and one from the incisura angularis. Gastric samples for histological evaluation were sent to Quest Laboratories, Florida, USA, for analysis.
All patients having upper gastrointestinal endoscopy in the two-year interval, June 2007 to June 2009, were reviewed. Data obtained included age, gender, presenting complaints, findings on endoscopy and results of gastric biopsies.
Fifty-seven patients were studied (21 males and 36 females) with a mean age of 43 years. Twenty-six patients presented with symptoms of gastroesophageal reflux. Seventeen patients had upper abdominal pain and 10 were assessed to have dyspepsia. Upper gastrointestinal bleeding was the present ing problem in four patients (Table).
H pylori infection was present in 24 patients (42%) and negative in 33 (58%). Upper gastrointestinal endoscopy was normal in 27 patients, 13 (54%) of these were H pylori positive and 14 (42%) negative. Antral gastritis was present in 13 patients, of these 7 (54%) were Hpylori positive and 6 (46%) negative. Duodenal ulcer was present in 6 (33% pylori positive) and gastric ulcer in 5 patients (40% Hpylori positive).
Distal oesophagitis was present in 5 patients (all negative for H pylori) and gastric carcinoma in 1 (H pylori positive). In patients presenting with dyspepsia six patients (60%) were positive for Hpylori.
Helicobacter pylori infection is a healthcare issue with increased morbidity and mortality associated with peptic ulcer disease, upper gastrointestinal bleeding and cancer (10). The prevalence of H pylori infection varies among countries and within a country it is dependent on socio-economic condi tions especially poverty, overcrowding, poor sanitation and hygiene (11). Also, within countries, there may be considerable variation in prevalence by ethnic group (6). For the Caribbean area, in Jamaica, two endoscopic biopsy studies similar to the present study found H pylori infection in 55% and 60% of patients (7, 12). In Barbados, 50% of patients undergoing endoscopy were positive for infection (8). Therefore, the prevalence of Hpylori in patients undergoing upper endoscopy in the TCI of 42% is slightly lower than previous studies in the Caribbean. Studies in Latin American countries have revealed a high prevalence of infection rang ing from 30%-90%, being about 60% overall (11). The pre valence of H pylori infection has decreased over the past decades especially in developed countries, and this may reflect a birth cohort effect, with more recent studies showing lower prevalence (6, 13). Improved living conditions, especially sanitation, in developed countries have reduced the rate of infection in recent decades (14). The lower prevalence in the present study may indicate this trend in the Caribbean.
Serological studies in the Caribbean have shown a higher prevalence of H pylori infection than in endoscopic studies. The prevalence was 69.9% in an urban community in Jamaica and 72% in blood donors in Barbados (8, 15). However, positive serology indicates past exposure to H pylori and not necessarily active infection as antibody levels fall slowly over months to years with successful eradication of the organism (2). In contrast, direct methods of diagnosis, as in this study, indicate active infection.
Although the number of patients are small in the present study, only about one-third of patients with peptic ulcer disease had Hpylori infection. In the Jamaican study, 65% of patients with duodenal ulcer and 60% of patients with gastric ulcer had infection (7).
A recent endoscopic study in Jamaica revealed Hpylori infection in 33% of patients with dyspepsia, which is lower than the 60% found in the present study (4).
In this study, histology was used for diagnosis of H pylori, in patients undergoing upper gastrointestinal endoscopy. Although histology has been considered by some to be the gold standard for detecting H pylori infection it can only be utilized in patients requiring endoscopy and detection of the organism relies on the site, number and staining of the samples (3). In the present study, five samples were obtained which exceed the usual recommendations for detection of H pylori, and all samples were evaluated by a single laboratory. A significant advantage of biopsy diagnosis is the ability to evaluate for histological abnormalities such as inflammation, gastric mucosal atrophy, intestinal metaplasia and malig nancy.
The main limitation of the present study is the small number of patients studied from a referral clinic. This precludes generalization of the findings to the population of TCI.
H pylori infection was common in patients with gastrointestinal symptoms in this study from TCI. However, the prevalence of infection in patients undergoing endoscopy and in peptic ulcer disease is lower than other reports from the Caribbean. Further studies are required to determine the trend of this infection in the TCI and the Caribbean. The bur den of Hprlori infection may guide policies and programmes in the Caribbean geared at anticipating, treating and monitoring for complications related to H pylori infection.
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Professor MG Lee
Department of Medicine, The University of the West Indies
Kingston 7, Jamaica