helicobacter pyroli &

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Helicobacter pylori and

Peptic Ulcers

Omkar Potnis

Medical Technology

Department of Biotechnical and Clinical Laboratory Sciences

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Learning Objectives

On completion of this seminar, students will be able to:

Recognize the typical clinical presentation and risk factorsfor peptic ulcer disease

Understand pathophysiology of PUD focusing onH. pylori

Describe an appropriate diagnostic plan based on

individual risk factors

Prescribe an appropriate therapy

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Case Presentation

Mr. Jones, a 45 year old male presents to yourhospital with epigastric abdominal pain x 2 weeks.

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Case Symptoms

He describes it as a burning pain which is non-radiating andis worse after he eats.

He has frequent belching with bloating sensation but deniesnausea, vomiting, diarrhea, constipation, or weight loss.

He has tried rolaids (antacids) which do help a little.

Which symptoms support the possible diagnosis of PUD?

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Signs and Symptoms of PUD

Epigastric pain is most common symptom

Pain described as gnawing or burning

May radiate to the back

Occurs 1-3 hours after meals or at night

Relieved by food, antacids or vomiting

Dyspepsia including belching/ bloating

Hematemesis or melena with GI bleeding

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Duodenal and Gastric Ulcers

http://www.medicinenet.com/peptic_ulcer/


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Aggressive Factors Acid/Pepsin

H. pyloriinfection

NSAIDs

Smoking

Defensive Factors Mucus-bicarbonate barrier

Barrier of apical membrane

Mucosal blood flow

Prostaglandins

Epithelial cell restitution

Defensive

Factors

Aggressive

Factors I II

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Risk Factors


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A silver stain ofH. pylori on gastric mucus-secreting

epithelial cells (x1000).

From Dr. Marshall's stomach biopsy taken 8 days

after he drank a culture of H. pylori (1985).

H.pylori

Robbins and Cotran PATHOLOGIC BASIS OF DISEASE, 7th Edi t ion


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Helicobacter Pylori

Most common cause of PUD

Gram negative

Spiral shaped

Microaerophilic

Corkscrew motility by 4-6polar flagella.

Unable to ferment or oxidizecarbohydrates

Slow-growing

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13/48Areas with H. pylori

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(Bulletin of the World Health Organization, 2001, 79: 455460)

Epidemiology


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Mode of transmission

Humans are principal reservoir

Possible environmental reservoirs include contaminatedwater sources.

Oral-oral- Saliva or vomit

Fecal-oral

- Water contaminated with human wastes- Factors linked to poor hygiene

Iatrogenic and Occupational- Contaminated endoscopes or pH probes

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Location of the H.pylori

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Virulence Factors

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Disorders caused by H.pylori

H. pyloriis the cause of most cases of Peptic UlcerDisease (PUD) Increases risk of both duodenal and gastric ulcers

found in 90% of duodenal ulcers and 70% of gastriculcers

Lifetime risk of peptic ulcer in pt withH. pyloriis ~3%.

H. pyloriis a primary risk factor for gastric cancerand adenocarcinoma Categorized as a group I carcinogen

H. pyloriincreases risk of MALT lymphoma

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Typical endoscopic, endosonographic and histological pictures in

MALT-lymphomaRobbins and Cotran PATHOLOGIC BASIS OF DISEASE, 7th Edi t ion

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Epithelial cell proliferation is increased with gastricHelicobacter pylori infection

(a) an uninfected stomach tissue(b) thirty-six weeks post-infection withH. pylori

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Sequence of histological and endoscopic events inH. pylori infectedstomach

Transformation of chronic atrophic gastritis to chronic active gastritis

with polyp, intestinal metaplasia and dysplasia to cancer.

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Diagnosis

Invasive

tests

Non-invasive

tests

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Non-invasive

tests

Urea Breath test

C13 UBT

C14 UBTStool Tests

PCR

Detection of Ag

Detection ofAntibodies

Serum

Urine

Saliva

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Urea Breath Test

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Solution of labeled ureaingested by the patient

IfH. pylori is present inthe stomach

Solution is rapidly

hydrolyzed

Labeled CO2 is absorbedby the blood and exhaled

and detected in expired air.

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H. pyloristool antigen test (HpSA)

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Techniques :

Enzyme immunoassay

Immunochromatography

Detects active infection

Uses polyclonal anti-H.pyloriantibodies

Simple, inexpensive

HpSATM Immunocard kits.

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Serological Techniques Techniques :

Complement fixation test

Latex agglutination test

ELISA

Antigens used for diagnosis :

Urease and flagellar proteins

Several Virulence factors

Antibodies detected :

IgG is the predominant class even in children

IgM rarely observed

IgA elevated in majority of infected cases but not all

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Invasive

tests

Specimens

CultureUrease Molecular

Tests

Endoscopic biopsy

Gastric juice

Blood

Liver biopsy Rarely used

Microscopy

Bacteriology

Histopathology

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Endoscopy

Duodenal ulcer

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Molecular methods

PCR for detection ofH. pylori

PCR for detection of pathogenic factors

Genes involved in adherence

Genes involved in pathogenicity

Real Time PCR using SYBR green dye or

fluorescence resonance energy transfer (FRET)principle

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Histopathological diagnosis

Stains

Grams stain Giemsa stainWarthin silver starry stainHematoxylin & Eosin stain Acridine orange stain

Immunostaining (Dako,Denmark) Helicobacter py lor iobserved on a gastric biopsysmear after acridine orange staining.Magnification, x1,000

A silver stain (Warthin Starry) ofHelicobacterpylor i

on gastric mucus-secreting epithelial cells (x1000).

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Growth on horse blood agar

E-test

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Urea in substrate pad reacts with urease

NH3

NH3 passes through the semi-porousmembrane

dark blue or purple color on the yellow pHpaper directly above anH. pylori-infected

biopsy

A piece of gastric mucosa is placed in a

small well.

The presence ofurease is an indicator ofthe presence ofH. pyloriand results in acolor change fromyellowtopink

Phenotypic Tests - Urease

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http://www.ganfyd.org/index.php?title=Ureasehttp://www.ganfyd.org/index.php?title=Urease


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Mr. Jones Prior Ulcer History On further questioning, Mr. Jones states he had

similar abdominal pain three years ago and was

told by his physician at that time that it wasmost likely due to an ulcer.

He had no definitive diagnostic tests done at thattime.

What would you do at this time?

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Case Diagnosis Mr. Jones Upper GI series showed radiologic findings of

thickened fold within the stomach

Outpatient esophagogastroduodenoscopy (EGD)was performed

Biopsy of antral part of the stomach wasconsistent with moderate gastritis. No tumor was seen 3+ to 4+ of bacterial organism was found

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Case Study

Gastric biopsy photomicrograph from

J Natl Med Assoc. 2007 January; 99(1): 3134.

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H. pylori

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Key Information Pointing to Diagnosis

Presence of bacterial organism

Evidence of moderate gastritis visualizedin biopsy

Past medical history of gastric ulcer

Symptoms of dyspepsia and abdominalpain

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Results Mr. Jones is suffering from Chronic gastritis

The causative organism isHelicobacter pylori

Confirmed by histopathologic examination ofbiopsy specimen

How do we treat the infection?

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PPI(H2blocker)

or

Bismuth

TwoAntibiotics+

ClarithromycinAmoxicillinTetracycline

MetronidazoleFurazolidone

Colloidal Bismuth

Subcitrate (CBS)

Treatment

Triple Therapy

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Future Development

Currently : Vaccine using urease and

HspB are on trial in animal models

Prevention Probiotics may prevent infection Reduction of risk factors such as poor

socioeconomic status Improving living conditions and hygiene

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Lets review.


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In Summary

H. pylori is the most common cause of PUD and is a risk factor forgastric cancer

Clean and hygienic living conditions help prevent infections

Transmission is via person to person

Threat is prevalent, about half of the worlds population is infected.

Severity of symptoms depend on region, age, and lifestyle.

Disease involves chronic gastritis, gastric and duodenal ulcers.

H. pyloriinfection increases risk of PUD, gastric CA, and MALTlymphoma

Typical symptoms are nausea, epigastric pain, vomiting, anorexia

Diagnostic tests include biopsy, urea breath test, histopathology etc.

Triple therapy for treatment

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ReferencesAlgood HMS, Cover TL.Helicobacter pylori persistence: an overview of interactions betweenH.

pylori and host immune defenses. Clin Microbiol Rev 2006;19:597-613.

Dunn BE, Cohen H, Blaser MJ.Helicobacter pylori. Clin Microbiol Rev 1997;10:720-41.

Kusters JG, van Vliet AHM, Kuipers EJ. Pathogenesis ofHelicobacter pylori infection. ClinMicrobiol Rev 2006;19:449-90.

Malfertheiner P, Megraud F, O'moraina C, Hungin APS, Jones R, Axon A et al. Current

concepts in the management ofHelicobacter pylori infection. The Maastricht 2-2000 ConsensusReport. Aliment Pharmacol Ther 2002;16:167-80.

Mgraud F, Lehours P.Helicobacter pylori detection and antimicrobial susceptibility testing.Clin Microbiol Rev 2007;20:280-322.

Polk DB, Peek RM Jr. Helicobacter pylori: gastric cancer and beyond. Nat Rev Cancer2010;10:40314.

Schmidt H, Hensel M. Pathogenicity islands in bacterial pathogenesis. Clin Microbiol Rev2004;17:14-56.

Singh V, Trikha B, Nain CK, Singh K, Vaiphei K. Epidemiology ofHelicobacter pylori and pepticulcer in India. J Gastroenterol Hepatol 2002;17:659-65.

Studies onHelicobacter pylori. National Institute of Cholera And Enteric Diseases (NICED)Annual Report 2004-2005.

Wroblewski LE, Peek RM Jr, Wilson KT.Helicobacter pylori and gastric cancer: factors thatmodulate disease risk. Clin Microbiol Rev 2010;23:713-39.

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