European Journal of Cardiovascular Medicine

Gastritis is a common clinical condition encountered by physicians, with a global incidence of over 50%. The causes of gastritis vary, including bacterial infections and autoimmune disorders, with Helicobacter pylori (H. pylori) being the most common cause. H. pylori, a microaerophilic bacterium residing in the human gastric mucosa, infects about 50% of the world's population, with a higher incidence in developing countries than in developed ones 1. The prevalence of H. pylori varies widely and is influenced by factors such as geographic distribution, age, race, and socioeconomic status. Risk factors for acquiring the pathogen include smoking, alcohol consumption, dietary habits, waterborne exposures, social factors, and family history of gastric disease 2. H. pylori is also strongly associated with gastric carcinoma and MALT lymphoma. The inflammatory response and histopathological characteristics seen in biopsies are determined by the virulence factors, bacterial colonization, and host immune response. Chronic infection with H. pylori can lead to severe mucosal injury and histopathological changes such as multifocal atrophic gastritis, intestinal metaplasia, glandular dysplasia, and adenocarcinoma 3. Regular treatment and lifestyle modifications can improve and normalize histology of lesions. The diagnosis of H. pylori infection includes endoscopic and non-endoscopic tests. Serologic tests for antibodies indicate exposure to the bacteria but do not assess active infection, while histological diagnosis combined with other tests such as culture and rapid urease tests provide accurate identification for confirming the diagnosis 4.

The aim of this study was to determine the prevalence of H. pylori infection among cases of gastritis and its correlation with histopathological findings and associated rapid urease test results

A prospective cross-sectional study was conducted in the Department of Surgery in association with the Department of Pathology at MKCG Medical College and Hospital in Berhampur. The study period was twelve months, from January 2017 to December 2017. Patients attending the outpatient section with symptoms suggestive of gastritis (both acute and chronic) were enrolled in the study. The study protocol was approved by the institutional ethical committee, and its guidelines were followed throughout the study period. Socio-demographic data were collected through interviews and recorded on pre-designed questionnaire sheets in the local language. Information on age, sex, socioeconomic status, personal hygiene, and risk factors such as smoking and alcohol consumption was noted. A detailed history of symptom duration, complaints, medication history, and previous gastrointestinal surgeries was taken by an experienced surgeon.

All consenting patients with signs and symptoms of gastritis underwent upper GI endoscopy, and two tissue samples were taken from different sites based on ulcer localization. One biopsy sample was processed for histopathological examination, while the other was used for a rapid urease test (CLO test HP fast test kit). The histopathological examination tissue was transported in 10% formalin to the histopathology lab, processed, embedded in paraffin, cut, and stained with haematoxylin and eosin (H&E) and Giemsa stains. The modified Sydney system of grading was used in the study, evaluating biopsies for mononuclear inflammatory cellular infiltrates, inflammatory activity (neutrophilic infiltrations), glandular atrophy, metaplasia, reparative atypia, and dysplasia. Additionally, the cases were graded according to the Houston-updated Sydney system, which assesses the intensity of mononuclear inflammatory cellular infiltrates within the lamina propria: absent inflammation (Grade 0), mild inflammation (Grade 1), moderate inflammation (Grade 2), and severe inflammation (Grade 3). The rapid urease test results were indicated by a color change in the medium from yellow to pink, signalling the presence of the urease enzyme.

All collected data were entered into a Microsoft Excel spreadsheet and corrected. The data was analysed in R software. The Chi-square test was used to determine statistical significance, with a p-value <0.05 considered statistically significant.

In this one-year prospective study, 325 cases meeting the inclusion criteria were enrolled. Males comprised 66.15% (215 cases) and females 33.85% (110 cases). The majority of cases were over 60 years old (26.15%), followed by the age groups 51-60 years (23.08%), 41-50 years (20.62%), 31-40 years (17.54%), and 21-30 years (12.62%) (Table 1). The number of cases increased with age progression. The average age of the participants was 39.12±2.8 years; males averaged 37.29±1.8 years, and females 38.24±2.0 years. The age range of the participants was 21 to 82 years, with an age span of 68 years.

Table 1: Age-wise distribution of cases in the study

Heartburn was the most common complaint (75.38%), followed by dysphagia (65.85%), abdominal pain (60.92%), discomfort with food (32%), and vomiting (26.15%) (Table 2). Smoking was reported by 38.5% of the participants, and 46.5% reported alcohol consumption.

Table 2: Symptoms of cases in the study

Endoscopy was performed on all study participants, revealing that 81.54% had endoscopic gastritis, 6.77% had endoscopic duodenitis, 3.38% had gastroesophageal reflux disease (GERD), 2.46% had hiatus hernia, and 6.15% had normal gastric mucosa. Among the 265 cases with endoscopic gastritis, 165 had hyperemia, 65 had erosions, 20 had nodularity, and 15 had ulcerations. The rapid urease test was positive in 272 cases (83.69%) and negative in 53 cases (16.31%) (Table 3). These findings were statistically significant (p<0.05).

Table 3: Findings on endoscopy and results of urease test among the cases in the study

*GERD: Gastroesophageal reflux disorder.

Table 4: Distribution of endoscopic findings and histopathological findings and rapid urease test with modified Sydney system of grading

Table 4 summarizes the distribution of endoscopic findings, histopathological findings, and rapid urease test results according to the modified Sydney system of grading. In gastric biopsies, inflammatory cellular infiltrates were found in 365 cases with varying intensity levels: Grade 1 (G1) in 170 cases, Grade 2 (G2) in 31 cases, and Grade 3 (G3) in 30 cases. Lymphoid follicles were observed in 75 cases, and active inflammation with polymorph infiltration into the lamina propria or glandular lamina in 95 cases. Additionally, 20 cases demonstrated glandular atrophy, and 15 cases had metaplasia (Table 4). The rapid urease test was positive in 85 cases with active inflammatory changes and 59 cases with G3; 49 with G2, and 29 with G1. In our study, cases graded as G0 were rapid urease test negative.

Table 5: Comparison between histological staining and rapid urease test in the study cases

Table 5 compares histological staining and rapid urease test results for H. pylori among the study cases. The data indicate that the rapid urease test is more sensitive than histological staining in confirming H. pylori infection. Statistical significance was observed between the rapid urease test and H. pylori positive cases (p<0.05).

Gastritis associated with H. pylori infection is considered a significant risk factor for gastric carcinoma, leading to management protocols focused on preventing H. pylori infection. Accurate diagnosis of H. pylori is crucial, and various diagnostic methods are available, with histopathological diagnosis by staining and biochemical diagnosis by the urease test being both sensitive and specific 5. Our study emphasizes histopathological diagnosis and grading to evaluate the risk of complications such as mucosal atrophy, metaplasia, and carcinoma.

Our study showed a higher prevalence of gastritis symptoms in males compared to females. This male predominance aligns with the findings of Bello et al., who reported 72% male cases, although Sharma et al. found a higher prevalence in females (51%) compared to males (49%) 6. The increase in gastritis incidence with age observed in our study is consistent with Böhmer et al.'s findings. Heartburn was the most common complaint, followed by dysphagia, similar to Mabeku et al.'s findings. Smoking and alcoholism were significantly associated with gastritis due to H. pylori, as described in many studies 7.

Endoscopic gastritis was the most common finding in our study, followed by endoscopic duodenitis. Mandal et al. reported similar findings but with a higher incidence (87%) and a higher proportion of duodenal gastritis (23%) 8. Among the 6.15% of cases with normal gastric mucosa on endoscopy, H. pylori was positive in four cases by histopathological examination and in eight cases by rapid urease test. Hyperemia was the most common finding among endoscopic gastritis cases, which is similar to Thapa et al.'s report of 76% hyperemia in their study 9. However, Shrestha et al. found erosions and nodularity to be the most common features of endoscopic gastritis in their study. There was a statistically significant association between gastritis features and endoscopic findings in our study.

The rapid urease test was positive in 83.7% of cases, similar to Uotani et al.'s finding of 87% positive cases. However, Foroutan et al. reported only 65% positive cases, likely due to differences in geographic distribution, study populations, and the sensitivity and specificity of commercial kits used 10-14.

In our study, all grades of gastritis showed H. pylori colonization except G0, which was free of colonization. There was a statistically significant association between endoscopic findings, inflammatory infiltration, and H. pylori colonization. The relationship between G0 gastritis and hyperemia was insignificant in our study, similar to Khan et al.'s report that 32% of chronic gastritis cases had normal endoscopic findings 13-16. Our findings on gastritis grading and H. pylori colonization align with Rugge et al., who reported G1 gastritis in 51% of patients, G2 in 27.4%, and G3 in 17.2%. Chen et al. found a positive correlation between lymphoid follicles and H. pylori infection, which corresponds with our study findings. We observed intestinal metaplasia in 15 cases and atrophy in 20 cases, though the sample size was too small to compare with other studies 12-16.

The prevalence of H. pylori infection is increasing globally, necessitating urgent measures to reduce its incidence. The chronic nature of the condition and its complications pose a significant threat to health systems. Effective diagnostic methods with high sensitivity and low financial burden are crucial. Rapid urease tests and histopathological examination of biopsies provide reliable indicators of H. pylori infection and gastritis grading according to the Sydney grading system.

Funding: No funding sources 

Conflict of interest: None declared 

Ethical approval: The study was approved by the Institutional Ethics Committee

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