helicobacter pylori infection and its consequences
TRANSCRIPT
Helicobacter pylori Helicobacter pylori infection and its infection and its consequencesconsequences
We pathologists We pathologists knew squat knew squat
about gastritis about gastritis before before H pyloriH pylori
was discovered.was discovered.
H pylori infects the H pylori infects the whole stomach, but whole stomach, but it induces a chronic it induces a chronic gastritis that is most gastritis that is most intense in the antal intense in the antal mucosamucosa
Classic H pylori gastritis: Classic H pylori gastritis: the great blue biopsythe great blue biopsy
Plasmacytosis Plasmacytosis (superficial) in(superficial) in
the lamina propriathe lamina propria
Induced lymphoid follicles Induced lymphoid follicles at the base of the mucosaat the base of the mucosa
Activity withActivity withPMNs in the necksPMNs in the necks
In most cases, the bacteria In most cases, the bacteria can be found in the H and E can be found in the H and E stained section, on the surface stained section, on the surface epithelium, often over the epithelium, often over the intecellular junctions and intecellular junctions and beneath the surface mucus beneath the surface mucus coat. They appear as tiny thin coat. They appear as tiny thin rods often with a bend in the rods often with a bend in the center, like a set of wings.center, like a set of wings.
Bugs on the surface of the epitheliumBugs on the surface of the epitheliumBugs on the surface of the epitheliumBugs on the surface of the epithelium
Often they hide in the detached mucusOften they hide in the detached mucus
Not allNot all H pylori H pylori gastritis is the same gastritis is the same..
There may beThere may be population differencespopulation differences individual differencesindividual differences minimal disease with tons of bugsminimal disease with tons of bugs intense disease with few bugsintense disease with few bugs variable eosinophils variable eosinophils variable activityvariable activity
H pyloriH pylori identification when they identification when they are difficult to find on H&E; are difficult to find on H&E; other stains have been used.other stains have been used.
Silver Silver
Diff-quickDiff-quick
H pyloriH pylori identification when identification when they are difficult to find on H&Ethey are difficult to find on H&E
Immunostain, our current methodImmunostain, our current method
Active Active H pyloriH pylori antral gastritisantral gastritis
H pylori H pylori GastritisGastritis
Untreated Plasmacytosis Activity Bugs Lymphoid hyperplasia
Treated Bugs disappear Activity stops Plasmacytosis recedes Lymphoid follicles atrophy
H pyloriH pylori
killerkiller
H pyloriH pylori
killerkiller
Biopsies that Biopsies that look like look like treated treated H pyloriH pylori gastritis are gastritis are commoncommon
Superficial Superficial PlasmacytosisPlasmacytosis
No activity. No activity. No bugs on No bugs on the surface.the surface.
Usually, this inactive Usually, this inactive chronic gastritis has chronic gastritis has
no no H pyloriH pylori
These days, a few biopsies of inactive chronic These days, a few biopsies of inactive chronic gastritis have bugs gastritis have bugs on immunostainon immunostain,, often deep in often deep in the the pitspits and even in the and even in the glandsglands and and not on the not on the surface.surface. Thid may result from chronic Thid may result from chronic PPI usePPI use
In the pitsIn the pitsIn the glandsIn the glands
Otherwise, this common inactive Otherwise, this common inactive chronic gastritis without chronic gastritis without H pylori H pylori has no name and no literature.has no name and no literature. But we keep seeing it.But we keep seeing it.
Chronic Chronic inactiveinactive gastritis, gastritis,with no bugs: WHY?with no bugs: WHY?
Biopsy missed bugsBiopsy missed bugs different causedifferent cause proton pump inhibitorsproton pump inhibitors antibioticsantibiotics
Approach to patients with Approach to patients with heartburn and dyspepsiaheartburn and dyspepsia
First, acid suppression, First, acid suppression, commonly commonly Proton Proton Pump Inhibitors (PPIs)Pump Inhibitors (PPIs)If no response, then upper If no response, then upper endoscopy and potential endoscopy and potential biopsiesbiopsies
Protein pump inhibitor effectsProtein pump inhibitor effectsParietal cell acid secretionParietal cell acid secretion
HypergastrinemiaHypergastrinemia Parietal cell hypertrophy: Parietal cell hypertrophy: snoutssnouts ?Parietal cell hyperplasia?Parietal cell hyperplasia ?Polyps containing fundic glands?Polyps containing fundic glands ECL cell stimulation in humans ECL cell stimulation in humans unclearunclear
antral pHantral pH
Protein pump inhibitor effectsProtein pump inhibitor effectsParietal cell acid secretionParietal cell acid secretion antral pHantral pH
Treats antral Treats antral H pylori:H pylori:Bugs migrate proximally Bugs migrate proximally or deeply or deeply activity disappearsactivity disappears Plasmacytosis recedesPlasmacytosis recedes lymphoid follicles atrophylymphoid follicles atrophy
H pyloriH pyloriCauses:Causes:
peptic ulcers ( mechanism peptic ulcers ( mechanism unknown), unknown), a clinical diseasea clinical disease chronic active gastritis, chronic active gastritis, mostly antralmostly antral, , not a clinical not a clinical diseasedisease
Complications of H pylori infectionPeptic ulcers, mainly in the duodenumAdenocarcinoma, secondary to dysplasias that develop in atrophic gastritis (see atrophic gastritis module for definitions and diagnostic criteria)B cell lymphomas, both low and high grade, probably developing in the induced lymphoid follicles at the base of the mucosa
There is a second There is a second bacterium that causes an bacterium that causes an active chronic gastritis, active chronic gastritis, similar to, but less similar to, but less intense than, intense than, H pylori H pylori gastritis.gastritis.
Helicobacter heilmanniiHelicobacter heilmannii
Helicobacter heilmannii is Helicobacter heilmannii is really rare around here.really rare around here.The bugs:The bugs: 7-10 microns7-10 microns Urease +Urease + Dog and cat transmittedDog and cat transmitted
The disease:The disease: 39 cases in 15,180 antral bxs 39 cases in 15,180 antral bxs (Heilmann & Borchard, Gut 32:137, 1991(Heilmann & Borchard, Gut 32:137, 1991 Antrum 100%; body 20%Antrum 100%; body 20% Chronic active -it is, less than H pyloriChronic active -it is, less than H pylori
H heilmanniiH heilmannii comes from household comes from household pets, so don’t share eating utensiles with pets, so don’t share eating utensiles with your cats and dogs unless you eat first.your cats and dogs unless you eat first.