ORIGINAL RESEARCH REPORT
Helicobacter pylori status and associated upper gastrointestinal endoscopic diagnosis in a tertiary hospital: A retrospective study
Adani, Abdulkamil Abdullahi; Jeele, Mohamed Osman Omar; Guler, Ilkay1; Hassan-Kadle, Mohamed Abdulkadir2; Mohamud, Abdirahman Ahmed3Author Information
Journal of Clinical Sciences 20(4):p 118-122, Oct–Dec 2023. | DOI: 10.4103/jcls.jcls_53_23
- Open
Abstract
Background:
We aimed to analyze the prevalence of Helicobacter pylori infection and the endoscopic diagnoses in dyspeptic patients presenting to the only tertiary care hospital in Somalia.
Methods:
This study was a retrospective study based on the data of adult (age ≥ 18 years) patients referred to our center for upper gastrointestinal endoscopy due to dyspepsia between November 2021 and April 2022. Demographic data, histopathological diagnoses, the presence or absence of H. pylori infection, and the correlation between H. pylori infection and endoscopic diagnoses were analyzed.
Results:
Overall, 634 patients were included. Among these, 363 (57.3%) were male and 271 (42.7%) were female, and the mean age was (standard deviation) 45.42 (±15.71). The H. pylori infection was detected in 299 (47.2%) patients. It was more common in males than females (57.1% vs. 42.9%) and aged between 31 and 45 years (37%). Gastritis was the most common endoscopic diagnosis (n = 184, 29%), followed by duodenal ulcer (n = 145, 22.9%) and gastric ulcer (n = 89, 14%). The least common diagnosis was gastrointestinal stromal tumor (GIST) (n = 10, 1.6%). There was a strong correlation between H. pylori infection and gastritis (95% confidence interval [CI]: 1.494–3.006, odds ratio [OR]: 2.119, P < 0.00005). However, H. pylori infection was also correlated with duodenal ulcer (95% CI: 1.123–2.371, OR: 1.631, P < 0.010), gastric cancer (95% CI: 2.809–14.646, OR: 6.414, P < 0.001), gastric ulcer (95% CI: 2.792–7.995, OR: 4.725, P < 0.005), and GIST (95% CI: 1.305–82.306, OR: 10.366, P < 0.027).
Conclusion:
H. pylori infection was found to be associated with gastritis duodenal ulcer, gastric cancer, gastric ulcer, and GIST.
INTRODUCTION
Helicobacter pylori infection is one of the most frequent human infections; nearly 50% of the world’s population is infected with this bacterium. Africa is one of the most common breeding grounds for this infection, with a rate ranging from 55% to 92%.[1,2] In addition, it is more common in males than females and adults than children.[3]
H. pylori infection can lead to unfavorable conditions such as chronic gastritis, peptic ulcer disease, and gastric cancer.[4] A systematic review published in 2018 reported a significant difference between developed and developing countries regarding the prevalence of H. pylori infection; it was 34.7% and 50.8% in developed and developing countries, respectively. The authors of this review ascribed this difference to the variations in the economic and social standards between the countries.[3] In line with this, it was previously reported that high income, high educational background, good hand hygiene, and healthy eating habits, including decreased consumption of fried foods, could reduce the rates of H. pylori infection.[5,6]
The diagnosis of H. pylori infection includes invasive methods such as histopathological analyses (rapid urease test, hematoxylin and eosin [H and E], or modified Giemsa staining) performed on endoscopic biopsy specimens or noninvasive methods and urea breath and stool antigen tests.[7] In Ethiopia, a neighboring country, a study conducted with dyspeptic patients revealed that 37.6% were H. pylori positive according to stool antigen test.[8] In another study from Ethiopia, the authors worked on university students with gastritis in a Somali majority region.[9] They reported an H. pylori infection rate of 71%.
In Somalia, however, there is a paucity of data concerning H. pylori infection, including its rate and endoscopic diagnoses among dyspeptic patients with this infection.[10] It is estimated that the country’s economic conditions and the past civil war led to a suitable environment for this infection. However, there are no peer-reviewed data on the rate of H. pylori and its endoscopic reflections in patients with dyspepsia in the Somali adult population. According to the only nonpeer-reviewed paper published in 2016 and based on the data collected from 323 patients who presented to a secondary-care facility in Somalia, the rate of H. pylori infection was 42.7%.[10] Our study aimed to analyze the rate of H. pylori infection and the endoscopic diagnoses in dyspeptic patients presenting to the only tertiary care hospital in Somalia.
METHODS
This study was designed as a retrospective, descriptive study based on the patient database that was routinely updated between November 2021 and April 2022. The study population consisted of adult (age ≥18 years) patients with dyspepsia and referred to our tertiary care center for upper gastrointestinal endoscopy. The ethical approval was obtained from the Ethical Review Committee of the Somali Turkish Training and Research Hospital (Approval Number: 8876). In addition, all patients previously consented through written statement to the use of their data anonymously for study purposes were examined.
The patients were grouped according to their age as 18–30, 31–45, 46–60, and >60 years. Demographic data (age and gender), histopathological H. pylori test results, endoscopy diagnoses, and distribution of these diagnoses between different age groups were analyzed. Our study also included a correlation analysis between H. pylori positivity and the endoscopic diagnoses.
All patients underwent endoscopy with an empty stomach in the morning. All endoscopy procedures were performed by a trained physician using the flexible endoscopy instrument (Fujinon 4400 endoscopy, Japan). All patients received a topical pharyngeal spray containing 10% of lidocaine as a premedication. In addition, patients who required minor sedation were given intravenous midazolam (2–5 mg). Biopsies were taken from the stomach, duodenum, and esophagus if needed. The biopsy samples were histologically evaluated by a pathologist using H and E and modified Giemsa stains to diagnose or exclude H. pylori infection.
All statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) version 26 (IBM Corporation, Armonk, NY, USA). Descriptive analyses were presented using means, standard deviations, and medians. The proportions were presented using tables of frequencies and percentages. The Chi-square test was used to compare the proportions in different groups. A bivariate correlation was used to assess the associations between variables. P < 0.05 was considered statistically significant. The binary logistic regression was employed to calculate the odds ratio (OR) and confidence intervals (CIs).
RESULTS
Overall, 634 patients were enrolled in this study. Among these patients, 363 (57.3%) were male and 271 (42.7%) were female [Table 1]. The mean age of the participants was 45.42 ± 15.71 years. The minimum age of our patients was 19 years, while the maximum age was 90 years. Most (n = 198, 31.2%) patients were aged between 31 and 45 years [Table 2].
The H. pylori test results revealed that most (n = 335, 52.8%) patients were H. pylori negative, while 47.2% were H. pylori positive [Table 1]. Among the 299 H. pylori-positive patients, 171 (57.1%) were male, while 128 (42.9%) were female. The subgroup analysis regarding age elucidated that H. pylori infection was more common in patients aged between 31 and 45 years (n = 110, 37%), followed by those between 18 and 30 years (n = 75, 25%), 46 and 60 years (n = 61, 20%), and those older than 60 years (n = 53, 18%).
Among 634 patients, gastritis (n = 184, 29%) was the most common endoscopic diagnosis, while the second most common diagnosis was duodenal ulcer (n = 145 patients, 22.9%). Gastric ulcer (n = 89, 14%), duodenitis (n = 77, 12.1%), esophageal cancer (n = 73, 11.5%), and gastric cancer (n = 43, 6.8%) were also detected. Of note, the least common endoscopic diagnosis was a gastrointestinal stromal tumor (GIST) diagnosed in 10 (1.6%) cases. Only 13 (2.1%) patients did not have any abnormal endoscopic findings [Table 2].
Gastritis and duodenitis were more common in males than females; 54% of the gastritis cases and 61% of the duodenitis cases were male. As such, gastric and esophageal cancers were more common in male than female patients. Our analysis revealed that 60.4% of gastric cancer and 53.4% of the esophageal cancer cases were male patients [Table 2].
The correlation analysis showed a strong correlation between H. pylori infection and gastritis (P < 0.00005). Patients with H. pylori infection were two times more likely to develop gastritis than H. pylori-negative patients (95% CI: 1.494–3.006, OR: 2.119). Furthermore, there was a positive correlation between H. pylori infection and duodenal ulcer (95% CI: 1.123–2.371, OR: 1.631, P < 0.01). Furthermore, H. pylori infection was correlated with gastric cancer (95% CI: 2.809–14.646, OR: 6.414, P < 0.0001) and gastric ulcer (95% CI: 2.792–7.995, OR: 4.725, P < 0.005). Furthermore, there was a significant association between H. pylori infection and GIST (95% CI: 1.305–82.306, OR: 10.366, P < 0.027). Patients with H. pylori infection were ten times more likely to develop GIST than patients without this infection [Table 3].
DISCUSSION
H. pylori is a Gram-negative, microaerophilic bacterium known as the main causative agent of gastritis, gastric or duodenal ulcers, and stomach cancer.[11-13]
Despite its significance and the regional risks, the rate of H. pylori infection and its association with gastric and duodenal diseases has not been deservedly investigated in Somalia. Therefore, to our knowledge, this is the first study reporting the rate of H. pylori infection and its association with endoscopic diagnoses among dyspeptic patients in this country.
In this study, the prevalence of H. pylori infection was 47.2% among dyspeptic patients. According to our findings, Somalia has a slightly lower rate of H. pylori infection compared to many African countries. For example, it was reported in a study including 961 patients that the rate of H. pylori infection was 75% in Rwanda.[1] On the other hand, a study from Kenya concluded that the rate of H. pylori infection was 54.8% in adults.[14] In 2011, another study from Ethiopia, which included 119 dyspeptic and 119 asymptomatic patients, found that the rate of H. pylori infection was 53%.[15] However, a recent study from the same country reported that the H. pylori infection rate was 37.6% among dyspeptic patients.[8] Aje et al. noted that H. pylori infection was present in 67% of the dyspeptic patients in Nigeria.[16] Salih et al. reported an H. pylori infection rate of 56.3% in Sudan.[17]
In our study, patients aged 46–60 and older than 60 years had lower rates of H. pylori infection than those in younger age groups. Zendehdel and Roham reported that H. pylori infection tended to be more chronic and resistant to eradication therapies in old patient groups.[18] In our study, we did not analyze the response to treatment among age groups.
Our analysis revealed that the H. pylori infection was more common in males than in females. This finding is in line with the results of the systematic review published by Zamani et al.[3] These authors reviewed the data of 410,879 patients, and they reported that globally, the rate of H. pylori infection was higher in males (46.3%) than in females (42.7%). In consistency with this, a study involving 1539 patients in India also found a male predominance (63%) in the H. pylori infection rates.[19] On the other hand, Hong et al. worked on 53,260 patients from China and reported that females are more commonly infected with H. pylori than males.[20]
The most common endoscopic diagnosis in our study was gastritis. Among all patients, 29% and 22.9% were diagnosed with gastritis and duodenal ulcer, respectively. In a retrospective study from Nigeria, Odeghe et al. also found that gastritis (49%) was the most common endoscopic diagnosis in dyspeptic patients.[21] However, contrary to these findings, a meta-analysis including nine studies revealed that erosive esophagitis was the most common endoscopic diagnosis.[22]
Our study found a strong relationship between H. pylori infection and gastritis. Patients with H. pylori infection were two times more likely to develop gastritis than patients without this infection. It also determined that gastritis was more common in males compared to females. However, the fact that most (57.3%) of our patients were male should be considered while evaluating this finding. Nordenstedt et al. reported that H. pylori infection was common in patients with gastritis worldwide, regardless of the patient gender.[23]
Smith et al. worked on H. pylori infection and the challenges encountered in Africa.[24] These authors stated that 73% of children in Kenya, 44.3% of children <12 years in Uganda, and 40.7% of children aged between 6 and 10 years in Nigeria had gastritis due to H. pylori infection.[24] In addition, they noted that 54.8% of adult gastritis patients in Kenya were detected with this infection. Yao and Smolka reported that in patients with H. pylori infection, gastritis was induced by the alterations in the secretion of gastrin and somatostatin hormones and thus in acid homeostasis.[25]
Our study agrees with the current literature regarding the association between H. pylori infection and gastric cancer. In this study, we found that patients with H. pylori infection were 6.5 times more likely to develop gastric cancer than patients without this infection. It was reported that gastric cancer was the fifth most common cancer in the world, and H. pylori bacterium was considered a class 1 human carcinogen in this regard.[26,27] Therefore, its prevention and eradication could play an essential role in decreasing gastric cancer rates globally.
Our analysis also found a strong relationship between GIST and H. pylori infection. In 2020, Kagihara et al. worked on 147 patients with GIST and found an association between H. pylori and GIST.[28] These researchers suggested that H. pylori infection could play an essential role in the pathogenesis of GIST.
Our study has some limitations that must be considered while evaluating its findings. First, it is a retrospective study, including only the patients referred to a tertiary care center. Second, the sample size was relatively small, and the study period was relatively short. On the other hand, as a strength, it should be noted that our study represents the first peer-reviewed data regarding the rates and clinical significance of H. pylori infection in dyspeptic patients in Somalia. Of note, Somalia was the only East African country without any reported data regarding this subject until this publication.
CONCLUSION
Despite the weaknesses mentioned above, we conclude that the H. pylori infection rate is 47.2% among dyspeptic patients in Somalia. This infection is more common in Somali men than women and is associated with gastritis, duodenal ulcer, gastric cancer, gastric ulcer, and GIST. Future researches should focus on patient-specific factors contributing to the relatively high rate of this infection in Somalia. These efforts will reduce the rates of H. pylori infection and decrease the rates of the associated gastrointestinal tract diseases in this country.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Acknowledgment
We especially thank Mogadishu Somalia Turkish Training and Research Hospital Education Department Director Associate Professor Doctor Sertac Cimen for the mentorship during this project and for proofreading the manuscript.
REFERENCES
1. Walker TD, Karemera M, Ngabonziza F, Kyamanywa P. Helicobacter pylori status and associated gastroscopic diagnoses in a tertiary hospital endoscopy population in Rwanda. Trans R Soc Trop Med Hyg 2014;108:305–7.
2. Asombang AW, Kelly P. Gastric cancer in Africa:What do we know about incidence and risk factors?. Trans R Soc Trop Med Hyg 2012;106:69–74.
3. Zamani M, Ebrahimtabar F, Zamani V, Miller WH, Alizadeh-Navaei R, Shokri-Shirvani J, et al. Systematic review with meta-analysis:The worldwide prevalence of Helicobacter pylori infection. Aliment Pharmacol Ther 2018;47:868–76.View full references list
Keywords: