HISTORY OF H. PYLORI• 1890’s: Spirochetes in animal stomachs• 1900’s: Spirochetes in human stomachs• 1954: No bacteria in gastric biopsies of 1000 patients• 1975: Gram negative bacteria in 80% of GU’s (Pseudomonas)• 1983: Warren and Marshall characterize H. pylori• 2005 Nobel prize in 2005
HELICOBACTER PYLORI BackgroundHuman stomach long considered inhospitable forbacteriaSpiral shaped organisms occasionally visualized ingastric mucous layer, but no evidence of diseaseassociationOrganism classified first as Campylobacter pyloriNow Helicobacter pyloriOther species of Helicobacter isolated fromstomach, intestine of other animalsMarshall and Warren culture organism from humangastric mucosa and show association with gastricinflammation 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 4
WARREN AND MARSHAL WINS NOBEL PRIZEDR.T.V.RAO MD 5
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 practicesDR.T.V.RAO MD 6
A silver stain of H. pylori on gastric mucus- secreting epithelial cells (x1000). From Dr. Marshalls stomach biopsy taken 8 days after he drank a culture of H. pylori (1985).DR.T.V.RAO MD 7
HELICOBACTER PYLORI• Gram –ve spiral shaped , motile with unipolar tuft of lopotrichus flagellaDR.T.V.RAO MD 8
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 acidsDR.T.V.RAO MD 10
H. PYLORI INFECTION TRANSMISSION• Transmissible • Oral-oral and oral- fecal• Infects the human stomach• Produces inflammatory response• This brings up the point of the importance of “hand washing”
DYNAMICS OF H.PYLORI INFECTIONDR.T.V.RAO MD 12
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 DR.T.V.RAO MD 13
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 Growth Factor IL- 8+ chemokines Like cellular response (1) Odenbreit S, et al. Science 2000;287:1497-1500
H. PYLORI PATHOGENESIS BACTERIAL VIRULENCE FACTORSIngestion Evasion + Entrance of Mucus 1 Layer (Motility + Urea I) 2 Binding 3 Insertion 4 Intra cellular pathway
HELICOBACTER PYLORI AND PEPTIC ULCER DISEASE HISTOPATHOLOGY WITH SPECIAL STAINS .
H. PYLORI PATHOGENESIS THE ROLE OF CYTOKINESI. Alter secretion of mucusII. TNF–α IL–Iß, INF- 1Y • ↑ Gastrin release Stimulate parietal cells ↑ Acid secretionI. TNF–α ↓ 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 DR.T.V.RAO MD 19
MAJOR LOCATION OFH.PYLORI INFECTIONSDR.T.V.RAO MD 20
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 Pathogenesis and Application of Cutting Edge TechnologiesMolecular Genetics Imaging Cell culture biology 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.
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 DR.T.V.RAO MD 33
Laboratory Identification Recovered from or detected in endoscopic antralgastric 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. DR.T.V.RAO MD 35
SUGGESTED GUIDELINES FOR TREATMENT OF PATIENTS WITH GI OR ULCER DISEASE History & Physical ExamPeptic ulcer Undifferentiated Symptoms Use of NSAIDs disease dyspepsia of GERD or aspirin Positive Test for H. pylori Eradication therapyConfirmation of cureMalfertheiner P, et al. Aliment Pharmacol Ther. 2002;16:167.
SUGGESTED GUIDELINES FOR TREATMENT OF PATIENTS WITH GI OR ULCER DISEASE History & Physical ExamPeptic ulcer Undifferentiated Symptoms Use of NSAIDs disease dyspepsia of GERD or aspirin Positive Test for H. pylori Negative Eradication Treat for PUD, therapy Initiate PPI therapy, or discontinue NSAIDs Confirmation of cureMalfertheiner P, et al. Aliment Pharmacol Ther. 2002;16:167.
TREATMENT• Use of antibiotics, bismuth salts• Ingestion of Bismuth subsalicylate• Antibiotics Tetracyclines and metronidazole for two weeks• Use of Omeprazole• Clarithromycin• Do not treat for Asymptomatic colonization• Drug resistance is a growing problem DR.T.V.RAO MD 38
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.DR.T.V.RAO MD 39
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 infectionsDR.T.V.RAO MD 40
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 • email@example.comDR.T.V.RAO MD 42