Dig Dis Sci (2006) 51:18011809

DOI 10.1007/s10620-006-9167-4

ORIGINAL PAPER

Helicobacter pylori Infection is Associated with a High Incidence

of Intestinal Metaplasia in the Gastric Mucosa of Patients at
Inner-City Hospitals in New York
J. Schneller R. Gupta J. Mustafa R. Villanueva
E. W. Straus R. D. Raffaniello

Received: 25 August 2005 / Accepted: 1 December 2005 / Published online: 30 August 2006
C Springer Science+Business Media, Inc. 2006

Abstract Gastric carcinogenesis is a multistep process progressing from chronic gastritis, through glandular atrophy
(GA), intestinal metaplasia (IM) and dysplasia. Infection of
the stomach with H. pylori increases the risk of developing gastric cancer. Few studies have examined the degree to
which Hp-induced changes occur in specific populations. In
the present study, we examined the association between Hp
infection and histological changes in the gastric mucosa of
patients at two inner-city hospitals in New York. Patients enrolled in this study were undergoing endoscopy for gastrointestinal complaints. One antral biopsy was taken for detecting
and genotyping Hp by PCR. Additional biopsies were taken
from the antrum and fundic region for histological analysis
and were scored with respect to acute and chronic inflammation, GA, IM and Hp infestation according to the Sydney
classification. Hp strains infecting these patients were genotyped with respect to the expression of Hp virulence factors
including VacA, CagA, and BabA2. Samples were collected
from 126 patients at Kings County Hospital in Brooklyn and
St. Johns Episcopal Hospital in Queens. Hp infection rates
Support: This work was supported by grants from the Rosalyn S. Yalow
Foundation for Medical Research and the Cancer Research and Prevention Foundation.
R. D. Raffaniello (
)
Hunter College-School of Health Professions, City University of
New York, Medical Laboratory Sciences Program,
Box 617, 425 East 25th Street, New York, NY 10010
e-mail: rraffani@hunter.cuny.edu
J. Schneller E. W. Straus
Downstate Medical Center-SUNY,
450 Clarkson Avenue, Brooklyn, NY 11201
R. Gupta J. Mustafa R. Villanueva
St. Johns Episcopal Hospital,
Queens, NY 11691

were highest in Blacks (41.6%) and Hispanics (29.4%) and

lowest in Caucasians (18.8%). Scores for acute and chronic
inflammation and IM were higher in Hp-infected individuals in both the antrum and fundic regions, whereas Hp
infection did not affect the incidence or intensity of GA.
In Hp-infected individuals, the incidence of IM was greater
in the antrum (Hp-infected 37.8% vs. non-infected 9.2%,
p < 0.05) and fundic region (Hp-infected 15.1% vs. noninfected 1.8%, p < 0.05). Genotyping of the Hp strains infecting these patients revealed that the predominant VacA allele was s1bm1 and that the CagA gene was present in 69.8%
of Hp-infected samples. Interestingly, the BabA2 gene was
detected in only four samples (9.3%). The incidence of IM
in the antrum was higher in CagA + samples when compared with CagA- samples (52.2% vs. 15.4%, respectively).
Our findings indicate that the virulent Hp strain infecting
minority patients treated at inner-city hospitals in New York
City is associated with a high incidence of IM and that these
patients may be at greater risk for developing gastric cancer
than the general population.
Keywords H. pylori . Intestinal metaplasia . Gastric
cancer . Virulence factors

Introduction
Helicobacter pylori (Hp) is a gram-negative spiral-shaped
organism that colonizes the gastric epithelium in 3050% of
the worlds population. Although it is present in most geographical areas of the world, the prevalence of Hp is highest
in developing countries, reflecting the influence of socioeconomic factors. Despite its ubiquity, the majority of individuals infected with Hp develops asymptomatic gastritis and

Springer

1802

may never realize that they are infected. Nevertheless, this organism has been recognized as an important etiological factor in gastroduodenal disorders including chronic gastritis,
peptic ulcer disease, MALT-lymphoma and gastric cancer.
The factors that determine which individuals will develop
symptomatic disease in response to Hp are unclear but probably include the bacterial strain, host factors, environmental
factors and dietary factors. Hp strains express different virulence factors and the relationship between putative bacterial
virulence factors and specific gastroduodenal disorders has
been the subject of intense investigation (for a review see [1]).
Virulence factors expressed by Hp include cytotoxins like
CagA (cytotoxin-associated gene), VacA (vacuolating cytotoxin gene) and ICE (induced by contact with epithelium).
Hp also produces factors involved with adherence of the microbe to gastric epithelial cells. These adhesion molecules include BabA (blood group antigen-binding adhesin) and SabA
(sialic acid-binding adhesin) [2, 3]. Numerous studies have
demonstrated a relationship between the expression of one or
more of these virulence factors and gastrointestinal disease
although this relationship remains controversial [1, 47].
The CagA gene may be the most important Hp virulence factor and is actually one gene associated with the
Cag pathogenicity island, a region of the Hp genome that
contains 31 genes [8, 9]. Infection with CagA + strains significantly increases the risk of developing severe gastritis,
peptic ulcer disease, and gastric cancer. Gene products of the
cag pathogenicity island are involved with the translocation
of the CagA protein into gastric epithelia cells. Once inside
the cell, CagA is phosphorylated and disrupts intracellular
signaling events. This results in alterations in various mucosal cell functions including proliferation, differentiation,
apoptosis, cytokine release and motility [1012]. CagA gene
variants have been identified and may be involved in the type
and severity of Hp-induced gastrointestinal disease [13].
Two histological types of gastric adenocarcinoma have
been described: diffuse-type and intestinal-type. Diffusetype gastric carcinoma is observed in younger individuals
and consists of infiltrating neoplastic cells that do not form
glandular structures and are not associated with intestinal
metaplasia in the gastric mucosa. In contrast, the sequence
of events that lead to intestinal-type gastric carcinoma have
been well characterized and include progression from Hpinduced chronic gastritis, through glandular atrophy, intestinal metaplasia and dysplasia [14]. More than 70% of gastric carcinomas are linked to intestinal metaplasia, although
metaplasia may also be observed in the absence of neoplastic disease [15]. Hp infection is believed to be a crucial
factor in the multistep carcinogenic process of gastric cancer
[16]. Initially, Hp infection causes chronic active gastritis,
which may progress in severity and distribution throughout
the stomach. In later stages of infection, a reduction in the
inflammatory infiltrate is seen and mucosal atrophy occurs.
Springer

Dig Dis Sci (2006) 51:18011809

Chronic atrophic gastritis and intestinal metaplasia are now

considered markers for the development of intestinal-type
gastric cancer, especially in high-risk individuals [15].
Variations in the occurrence of gastric cancer have been
observed among different ethnic groups within a given region. For example, the incidence of gastric cancer in Blacks
and Hispanics in the United States was found to be three and
two times as high as that observed in Caucasians, respectively [17]. It was suggested that the increased incidence of
gastric cancer in Blacks and Hispanics reflects the higher
Hp infection rate in these ethnic groups. We have previously examined the prevalence of Hp infection as well as the
expression of putative virulence factors in patients undergoing upper endoscopy at inner-city hospitals in New York
City [18]. We found that Hp infection rates were significantly in higher Black patients (43%) when compared with
Caucasians (11%). With respect to the Hp strain infecting
Black patients, the VacA allele s1bm1 was detected in 90%
of infected individuals. Moreover, 81% of the Hp-positive
samples were also CagA positive. These findings are consistent with other studies that have found a high prevalence
the VacA s1b allele in African individuals [19]. Moreover,
the s1bm1 VacA allele was found to be strongly associated
with gastric cancer in South Africans [19]. We concluded
that inner-city Blacks are more likely to be infected with
Hp and suffer from more serious gastrointestinal disorders
than other ethnic groups. Moreover, our findings indicate
that a large portion of the patient population served by Kings
County Hospital (KCH) and St. Johns Episcopal Hospital
(SJEH) possesses several risk factors for gastric cancer including: (1) Ethnicity; (2) low socioeconomic status; and (3)
infection with an Hp strain strongly associated with gastric
cancer.
Gastric cancer often manifests at an advanced stage and,
therefore, most patients who develop this cancer do not survive. As with other cancers, prevention may be the key to
reducing mortality. While it is well accepted that Hp infection
is associated with gastric mucosal changes including chronic
inflammation, gastric atrophy, and intestinal metaplasia, the
degree to which specific strains induce these changes in a
given population has not been examined. The aim of the
present study was to examine the relationship between Hp
infection and the incidence and severity of gastric mucosal
alterations in an inner-city patient population at high risk for
gastric cancer.
Methods
Study subjects
Subjects included patients at Kings County Hospital
(KCH) and St. Johns Episcopal Hospital (SJEH) undergoing esophagogastroduodenoscopy (EGD) for gastrointestinal

Dig Dis Sci (2006) 51:18011809

complaints. Inclusion criteria included: 1. Age > 18 years,

2. Pre-selection for EGD with signed consent for EGD including gastric biopsy. Exclusion criteria included: 1. Acute
upper gastrointestinal bleeding, 2. Unstable hemodynamic
state, 3. Coagulopathy, i.e., prothrombin time >14, Platelet
count <90,000 and history of bruising or bleeding. The
protocols were approved by the Internal Review Boards at
Kings County Hospital, St. Johns Episcopal Hospital and
Hunter College.
Patient data
A patient datasheet was completed and filed for each patient
enrolled in the study and included medical information including the indication for EGD, where the procedure was performed, past and current medical conditions (gastrointestinal
and other), medications the patient is taking and has taken
over the last 12 months, histological and endoscopic diagnoses. Other information collected included the patients gender, age, ethnicity, country of origin, current residency, years
in USA, occupation, number of people in household, medical insurance and household income (to determine socioeconomic status). Information was also obtained with respect
to the patients smoking habits and alcohol consumption.
Endoscopic procedures
Standard EGD was performed in an endoscopy suite. A gastric biopsy was taken from the antrum for analysis by the
rapid urease test (CLOtest). Additional biopsy specimens
were taken from the antrum and fundic regions of the stomach for analysis of Hp infection by PCR (antral biopsy) and
for histological assessment (antral and fundic biopsies).
Rapid urease tests for Hp infection
One antral biopsy specimen per patient was used for the
rapid-urease (CLO) test. The CLOtest is performed using
a commercially available test kit (Ballard). Briefly, this involves placing the biopsy specimen in the CLOtest gel and
keeping it at room temperature. Tests are read and recorded
at 30 min, 3 h, and 24 h. If the biopsy specimen is positive
for Hp, a color change from yellow to orange or red in the gel
will be observed around the specimen. If the CLOtest gel is
still yellow after 24 h, the specimen is considered negative.
Preparation of biopsy specimens for PCR
Gastric antral biopsies were placed in a cryogenic tube and
stored at 20 C until they were processed for PCR. DNA
from biopsy specimens was extracted by incubating samples
in 150 l lysing buffer (20 mM Tris-HCl, pH 8.0) containing
0.5% Tween-20 and proteinase K (0.5 mg/ml) for 3 h at 55 C

1803
Table 1 PCR Primers used in this study. Primer names, sequences
and product sizes are listed below
Urease gene
URE-A
URE-B

(32)
294 bp
AAG CTT TTA GGG GTG TTA GGG GTT T
AAG CTT ACT TTC TAA CAC TAA CGC

CagA region
CAG1
CAG2

(32)
400 bp
AAT ACA CCA ACG CCT CCA AG
TTG TTG CCG CTT TTG CTC TC

Vac-s1a
ss1-F
VA1-R

(22)
190 bp
GTC AGC ATC ACA CCG CAA C
CTG CTT GAA TGC GCC AAA C

Vac-s1b
s1b-F
VA1-R

(22)
187 bp
AGC GCC ATA CCG CAA GAG
CTG CTT GAA TGC GCC AAA C

Vac-s1c
s1c-F
VA1-R

(5)
213c bp
CTY GCT TTA GTR GGG YTA
CTG CTT GAA TGC GCC AAA C

Vac-s2
s2
VA1-R

(22)
199 bp
GCT AAC ACG CCA AAT GAT CC
CTG CTT GAA TGC GCC AAA C

Vac-m1 and m2 (33)

m1 570 bp m2 645 bp
VAG-F
CAA TCT GTC CAA TCA AGC GAG
VAG-R
GCG TCT AAA TAA TTC CAA GG
BabA2 gene
BabA2F
BabA2R

(34)
832 bp
AAT CCA AAA AGG AGA AAA AGT ATG AAA
TGT TAG TGA TTT CGG TGT AGG ACA

BabA2 gene
BabA2F602
BabA2R602

(20)
607 bp
AAT CCA AAA AGG AGA AAA AGT ATG AAA
CTT TGA GCG CGG GTA AGC

and 98 C for 10 min to inactivate the proteinase K. Following

centrifugation (10,000 g for 5 min), the supernatant was
removed and stored at 4 C. Aliquots (5 l) were used for
analysis by PCR. The pellets were also stored.

PCR primers and methods

The primers used in the present study are listed in Table 1.
Primers specific for the Hp genomic DNA (Ure) were used
to detect the presence of Hp in biopsy samples. In addition, primers specific for the CagA and BabA genes were
used to detect CagA + and BabA + Hp strains, respectively.
Primers specific for VacA alleles (s1a, s1b, s1c, s2, m1 and
m2) were used to determine which VacA allele is expressed.
PCR products were detected by agarose gel electrophoresis and ethidium bromide staining. Hp genomic DNA was
used as a positive control. Samples from Hp-negative patients and water were used as negative controls. Gel images
were documented using a DigiGenius Documentation System (Syngene, MD).
Springer

1804

Dig Dis Sci (2006) 51:18011809

Histologic assessment of Gastric biopsies

Hp infection and alterations in the gastric mucosa

For each of the 126 patients that underwent EGD, two biopsies were sent for histologic review, one from the antrum and
one from the fundus. Two slides were prepared from each
biopsy. One was stained with Hematoxylin and Eosin, and the
other with Giemsa. Each Hematoxylin and Eosin slide was
evaluated microscopically for the presence of acute inflammation, chronic inflammation, gastric atrophy and intestinal
metaplasia. These parameters were graded on a scale of 03
(0, none; 1, mild; 2, moderate; 3, severe) according to the
Updated Sydney System [20]. The degree of Hp infestation
was judged and graded using the Giemsa stained slide. The
slides were evaluated by a single pathologist (J.S.) without
prior knowledge of the endoscopic diagnosis or PCR results.

Examples of Hp-induced alterations in the gastric mucosa

are presented in Fig. 1. Figure 1A shows a high power
view of a Giemsa-stained slide of the gastric antrum from
a patient with a moderate degree of Hp infestation. The
organisms can be seen in the mucus, just above the mucosal cells. Figure 1B is from the gastric fundus of an
Hp infected patient and shows a severe degree of acute inflammation as evidenced by the presence of numerous polymorphonuclear leukocytes both in the glandular epithelium
and in the lamina propria. A moderate degree of chronic inflammation is also seen in this slide. Note the presence of
numerous mononuclear cells (Fig. 1B). In Fig. 1C, intestinal metaplasia can be observed in these glands which show
intermittent goblet cells identified by their large clear apical
vacuoles. Mild gastric atrophy can be seen in Fig. 1D, which
is a low-power view of the field shown in 1C. In this slide,
the epithelium appears thinner and the glands more sparse
than normal.
To examine the effects of Hp on the gastric mucosa, the
degree of acute and chronic inflammation in the antrum and
fundus was examined and scored in Hp-infected and noninfected patients. In Hp-infected patients, scores for acute
and chronic inflammation were significantly higher in both
regions of the stomach when compared with non-infected patients (Table 3). With respect to gastric atrophy and intestinal
metaplasia, the severity of intestinal metaplasia was higher in
Hp-infected patients in both the antrum and fundus, whereas
the severity of gastric atrophy was not significantly affected
by Hp infection in either region of the stomach (Table 4).
We next examined the incidence of gastric atrophy and intestinal metaplasia in these groups. As shown in Table 5, the
incidence of intestinal metaplasia was higher in the antrum
and fundic regions of Hp-infected patients. Although the incidence of gastric atrophy increased in both regions of the
stomach, these changes were not significant (Table 5). With
respect to age, no differences were observed with respect to
Hp infection rates, the incidence of gastric atrophy or intestinal metaplasia in patients under 50 years of age when compared with those 50 years old. Moreover, the incidence
and severity of gastric atrophy and intestinal metaplasia in
males and females were not different.

Data analysis
Statistical analysis was performed using the chi-square test
or the Students t-test. Statistical significance was set at the
0.05 level.
Results
Study population and Hp infection
Samples were collected from 126 patients at KCH and SJEH.
With respect to the ethnicity of the study subjects, 61.1%
were Black, 13.5% were Hispanic and 25.4% were Caucasians. The study subjects were 69.8% female and 30.2%
male, and the average age was 54.9 years old. With respect
to socioeconomic status, the annual income of 85% of the
individuals enrolled in the study was <$25,000. Hp was
detected in 43 (34.1%) of the samples by PCR using the
URE primers. Consistent with what we found in our previous study, Hp infection was highest in Blacks (41.6%)
and Hispanics (29.4%), and lowest in Caucasians (18.8%)
(Table 2). Although Hp infection rates were higher in males
when compared with females (Table 2), this difference was
not statistically significant.
Table 2

Hp infection in study subjects as determined by PCR

Total
Black/Hispanic
Caucasian
Males
Females
<50 yo
>50 yo

% infected

126
94
32
38
88
45
81

34.1
39.4
18.8
39.5
31.8
33.3
34.6

Significantly different when compared with non-Black/Hispanic

patients (p = 0.03).
Springer

Genotyping of Hp strains
The Hp strains infecting the patients in the present study
were genotyped with respect to the expression of CagA,
VacA alleles and BabA2. As shown in Table 6, approximately 69.8% of Hp-infected patients were CagA + and
the predominant VacA allele was s1bm1. With respect to
VacA alleles, we were unable to detect an s and m allele

Dig Dis Sci (2006) 51:18011809

1805

Fig. 1 Hp-induced alterations in the gastric mucosa. A Hp can be

seen in the mucus just above the gastric mucosa. Using the Updated
Sydney System this would be considered to be a moderate degree of
infestation. (Giemsa 400X). B This high-power view shows numerous
polymorphonuclear leukocytes both in the lamina propria and in the
epithelium. According to the Sydney System, this would be considered
severe acute inflammation. This field also contains many mononuclear

cells, yielding a grade of moderate chronic inflammation. (H&E 400X).

C This slide demonstrates intestinal metaplasia that is identified by the
presence of Goblet cells amongst the other gastric mucosal cells. Since
relatively few Goblet cells are present, this is considered mild degree
by the Sydney System. (H&E 200X). D This is the same slide shown in
1C viewed at lower power. A mild degree of atrophy is observed (H&E
100X).

in two and four Hp-infected samples, respectively. In our

previous study we did not assay BabA2 expression [18]. In
the present study, BabA2 was detected in only two of 43
Hp-infected individuals. To ensure that the results were not
due to strain-specific variations in the BabA2 sequence, we
further examined extracts from Hp-infected individuals using a different BabA2 primer set (BabA2-607) [21]. Using
these primers, the BabA2 gene product was detected in an
additional two specimens (Fig. 2). Hence, only four of the 43
Hp-infected samples (9.3%) were BabA2-positive. We conclude that the predominant genotype of the strain infecting
this patient population is CagA + /s1bm1/BabA-.

CagA expression and gastric lesions

Table 3 Acute and chronic inflammatory scores in antral and fundic

biopsies from Hp-infected and non-infected subjects

Table 4 Atrophy and intestinal metaplasia scores in antral and fundic

biopsies from Hp-infected and non-infected subjects

Antrum
Non-infected
Hp infected
Fundic
Non-infected
Hp infected

Acute inflammation

Chronic inflammation

0.224 0.420
1.297 0.750

1.209 0.501
2.027 0.634

0.185 0.514
0.926 0.676

1.040 0.530
1.662 0.600

Significantly different when compared with non-infected patients

(p < 0.05).

The presence of the CagA gene in Hp is associated with an

increased risk for peptic ulcer disease and gastric cancer,
and is used as a marker for the Cag pathogenicity island.
As mentioned above, the CagA gene was present in 69.8%
of Hp-infected samples in the present study. We examined
the relationship between CagA expression and various histological parameters in our population. Acute and chronic
inflammation scores in CagA + and CagA- patients were
compared. CagA expression in Hp-infected individuals did
not affect the intensity of acute or chronic inflammation in

Antrum
Non-infected
Hp infected
Fundic
Non-infected
Hp infected

Atrophy

Metaplasia

0.253 0.450
0.361 0.487

0.108 0.363
0.486 0.731

0.016 0.128
0.118 0.409

0.016 0.127
0.152 0.364

Significantly different when compared with non-infected patients

(p < 0.05).

Springer

1806

Dig Dis Sci (2006) 51:18011809

Table 5 Incidence of atrophy and intestinal metaplasia in antral and

fundic biopsies from Hp-infected and non-infected subjects
Atrophy (%)
Antrum
Non-infected
Hp infected
Fundic
Non-infected
Hp infected

Metaplasia (%)

24.3
35.1

9.2
37.8

1.6
8.8

1.8
15.1

Significantly different when compared with non-infected patients

(p < 0.05).

either region of the stomach. Similarly, CagA expression in

Hp-infected individuals did not affect the intensity of gastric atrophy or intestinal metaplasia in the fundus or antrum.
However, the incidence of intestinal metaplasia in the antrum
was increased 3.5-fold in CagA + Hp-infected patients
(Table 7). These data suggest that CagA expression is associated with an increased incidence of intestinal metaplasia
in our patient population.

Discussion
While it is well established that Hp infection is associated with increased inflammation, gastric atrophy and
intestinal metaplasia in the gastric mucosa, few studies
have examined the degree to which Hp-induced changes
occur in specific populations. Just as clinical outcomes
associated with Hp vary among different populations, the
effect of Hp on the gastric mucosa may also vary. These
differences may be a result of the strain infecting the population, host factors shared among a given population, or
a combination of these and other variables. Therefore, it is
important to study the pathogenesis of Hp in specific populations since infection of high-risk populations with virulent
Hp strains may cause severe damage to the gastric mucosa
that may eventually lead to cancer. While testing and treating
all individuals for Hp infection has not been recommended,
Hp eradication in a population at high risk for gastric cancer
may be warranted, since this may decrease the incidence of
Table 6

Springer

cancer in that population. In the present study, we related the

incidence and severity of gastric mucosal changes with Hp
infection in patients being treated at two hospitals in New
York City. As explained previously, this population possesses
several risk factors for gastric cancer [18]. We also related
the expression of Hp virulence factors to the appearance of
these changes in the gastric mucosa.
Our findings indicate that Hp infection is indeed related
to an increase in the intensity of acute and chronic inflammation in both the antrum and fundus of this patient population.
Moreover, the intensity and incidence of intestinal metaplasia
Table 7 Effect of CagA expression on the incidence of atrophy and
metaplasia in Hp-infected patients

Genotyping of Hp strains infecting

Urease gene
CagA
VacA-s1a
VacA-s1b
VacA-s2
VacA-m1
VacA-m2
BabA

Fig. 2 Detection of the BabA2 gene in gastric extracts by PCR. BabA2specific PCR was performed using two sets of primers, BabA2-F and
BabA2-R (top) and BabA2-F602 and BabA2-R602 (bottom). Assays
from patient samples (lanes 16) were run and visualized on 2% E-gels
(Invitrogen, CA). PCR assays in which Hp genomic DNA was used
were run in lane 7. PCR products were detected with the Hp genomic
DNA (lane 7) and in one patient sample (lane 5) with both sets of
primers. In the present study, the BabA2-F:BabA2-607R primer pair
revealed two additional BabA2-positive samples

% Hp strains

43
30
5
33
3
33
6
4

100
69.8
11.6
76.8
7
76.7
14
9.3

Antrum (n)
CagA (13)
CagA + (23)
Fundic (n)
CagA (10)
CagA + (24)

Atrophy (%)

Metaplasia (%)

30.8
39.1

15.4
52.2

0
12.5

10
17.4

Significantly different when compared with non-infected patients

(p < 0.05).

Dig Dis Sci (2006) 51:18011809

were higher in the antrum and fundus of Hp-infected individuals. Although the intensity and incidence of gastric atrophy
were higher in Hp-infected subjects, these differences were
not statistically significant. Significant differences may be
observed with a larger study population. Nevertheless, our
findings indicate that the virulent Hp strain infecting the patient population being treated at these inner-city hospitals
results in an increase in inflammation and intestinal metaplasia in the gastric mucosa of these individuals.
In a recent study, the incidence of gastric atrophy and
intestinal metaplasia was examined in Hp-infected American, Korean and Japanese individuals [22]. The incidence of
Hp-associated gastric atrophy in the antrum was highest in
Koreans (38.7%) and Japanese (26.7%) and lowest in Americans (18.5%). Similarly, Hp-induced intestinal metaplasia
was observed in about 35% of Korean and Japanese patients.
In contrast, intestinal metaplasia was observed in only 15%
of American patients. Consistent with these results, the incidence of gastric cancer is higher in Korean and Japanese
populations when compared to Americans. In the present
study, the incidence of Hp-associated gastric atrophy and
intestinal metaplasia in the antrum observed in Hp-infected
patients (35.1 and 37.8%, respectively) is comparable to what
is observed in Korean and Japanese populations, two populations in which the incidence of gastric cancer is relatively
high [22]. These findings suggest that the inner-city patient
population served by KCH and SJEH may be at greater risk
for developing gastric cancer.
Why does Hp infection result in precancerous changes to
varying degrees in different populations? Differences in Hp
strains, host factors, diet and environmental factors may act
independently or together to affect clinical outcomes. The
Hp strains infecting our patient population were genotyped
with respect to several well-characterized Hp virulence factors. The vacuolating toxin (VacA) is expressed in all Hp
strains. However, there are several VacA alleles based on sequence heterogeneity in the signal sequence (s1a, s1b, s1c,
s2) and the middle region (m1, m2) [5, 23]. Strains with an
s1 type signaling sequence allele produce functional VacA
toxin, whereas those expressing the s2 allele do not. Consistent with what we have observed previously [18], the predominant VacA allele in our patient population was s1bm1.
Several studies have demonstrated that the s1bm1 VacA allele is associated with increased inflammation and intestinal
metaplasia [19, 24, 25].
Many Hp strains express a blood group antigen-binding
adhesin (BabA) that is involved with adhesion of the bacterium to the gastric epithelium via attachment to the Lewis
b epitope [2]. The BabA2 gene of Hp encodes this protein
and this gene is not present in all strains. In a given population, the BabA2 gene may be detected in 35 to 85% of
infecting Hp strains. Interestingly, the BabA2 gene was detected in only 9.3% of the infected patients in the present

1807

study. Efforts were made to detect BabA2 variants using different primer sets. Nevertheless, the expression of BabA2 in
Hp-infected individuals in our patient pool was much lower
than that observed in other populations. Several studies have
suggested that strains expressing the BabA2 gene are more
virulent and associated with increased gastric inflammation
and intestinal metaplasia [21, 26, 27]. Our findings indicate
that the BabA2 gene is not necessary for Hp to induce an increased inflammatory response and increase the incidence of
intestinal metaplasia. While attachment of Hp to gastric epithelial cells is most likely required to induce these changes,
it is likely that adhesion molecules other than BabA2, like
SabA, are expressed by the Hp strain infecting our patient
population [3].
The CagA gene was detected in about 70% of Hp-infected
individuals in this study. This is consistent with what we
have previously observed [18]. Hp strains that possess the
CagA gene and the associated PAI are especially virulent
and associated with gastric cancer [28, 29]. In the present
study we found that the incidence of intestinal metaplasia in
the antrum was higher in CagA-positive Hp-infected individuals. Recent studies have begun to reveal how the CagA
cytotoxin elicits pathophysiological actions. Genes within
the PAI allow CagA to gain entry into the cell via the type IV
secretion system. CagA then undergoes tyrosine phosphorylation by various members of the SRC family of kinases,
which enables it to interact with cellular proteins including
SRC homology 2 domain-containing protein tyrosine phosphatase (SHP) and carboxy-terminal SRC kinase (CSK) [11,
30]. CagA phosphorylation and interactions with other proteins alter normal cellular activity and, in cultured gastric
epithelium, may induce apoptosis. Continuous gastric mucosal apoptosis will result in an increase in the turnover of
gastric epithelial cells. The increased DNA synthesis that
accompanies cell turnover thus increases the risk of genetic
changes that may eventually lead to atrophy, metaplasia, and
malignant transformation.
Structural analysis has revealed that the CagA protein
varies in size in different Hp strains [6, 31]. East-Asian and
Western versions of CagA genes have been identified that
vary in their ability to perturb host-cell functions [13]. The
major differences observed in these CagA subtypes are the
sequence and number of tyrosine phosphorylation sites. This
heterogeneity may underlie the differences observed in the
response of the gastric mucosa to CagA + Hp strains in
various populations. We are currently examining the CagA
protein expressed in Hp strains infecting our patient population with respect to tyrosine phosphorylation sites and
SHP-2 binding.
In summary, our findings indicate that in the inner-city patient population examined in the present study, Hp induces
pre-malignant changes in the gastric mucosa similar to those
observed in populations in which the incidence of gastric
Springer

1808

cancer is high. Specifically, Hp infection in inner-city patients is associated with an increase in the severity of acute
and chronic inflammation in the gastric mucosa, as well as an
increase in the incidence and severity of intestinal metaplasia. With respect to the genotype of Hp strains infecting this
population, the BabA2 gene was absent from the majority of
Hp-positive samples, while the incidence of antral intestinal
metaplasia appears to be related to CagA expression.
Acknowledgements The authors would like to thank Edward
Binkowski for assisting with the statistical analysis of the data.

References
1. Hocker M, Hohenberger P (2003) Helicobacter pylori virulence
factorsone part of a big picture. Lancet 362(9391):12311233
2. Ilver D, Arnqvist A, Ogren J, Frick IM, Kersulyte D, Incecik ET,
Berg DE, Covacci A, Engstrand L, Boren T (1998) Helicobacter pylori adhesin binding fucosylated histo-blood group antigens
revealed by retagging. Science 279(5349):373377
3. Mahdavi J, Sonden B, Hurtig M, Olfat FO, Forsberg L, Roche
N, Angstrom J, Larsson T, Teneberg S, Karlsson KA, Altraja
S, Wadstrom T, Kersulyte D, Berg DE, Dubois A, Petersson C,
Magnusson KE, Norberg T, Lindh F, Lundskog BB, Arnqvist A,
Hammarstrom L, Boren T (2002) Helicobacter pylori SabA adhesin in persistent infection and chronic inflammation. Science
297(5581):573578
4. Evans DG, Queiroz DM, Mendes EN, Evans DJ Jr (1998) Helicobacter pylori cagA status and s and m alleles of vacA in isolates
from individuals with a variety of H. pylori-associated gastric diseases. J Clin Microbiol 36:34353437
5. van Doorn LJ, Figueiredo C, Sanna R, Plaisier A, Schneeberger
P, de Boer W, Quint W (1998) Clinical relevance of the cagA,
vacA, and iceA status of Helicobacter pylori. Gastroenterol 115(1):
5866
6. Yamaoka Y, El-Zimaity HMT, Gutierrez O, Figura N, Kim JG,
Kodama T, Kashima K, Graham DY, Kim JK (1999) Relationship between the cagA 3 repeat region of Helicobacter pylori,
gastric histology and susceptibility to low pH. Gastroenterol 117:
342349
7. Rudi J, Rudy A, Maiwald M, Kuck D, Sieg A, Stremmel W (1999)
Direct determination of Helicobacter pylori vacA genotypes and
cagA gene in gastric biopsies and relationship to gastrointestinal
diseases. Am J Gastroenterol 94(6):15251531
8. Alm RA, Ling LS, Moir DT, King BL, Brown ED, Doig PC, Smith
DR, Noonan D, Guild BC, de Jonge BL, Carmel G, Tummino
PJ, Caruso A, Uria-Nickelsen M, Mills DM, Ives C, Gibson R,
Merberg D, Mills SD, Jiang Q, Taylor DE, Vovis GF, Trust TJ
(1999) Genomic sequence comparison of two unrelated isolates of
the human gastric pathogen Helicobacter pylori. Nature 397:176
180
9. Odenbreit S, Puls J, Sedlmaier B, Gerland E, Fischer W, Haas
R (2000) Translocation of Helicobacter pylori CagA into gastric
epithelial cells by type IV secretion. Science 287(5457):1497
1500
10. Odenbreit S, Kavermann H, Puls J, Haas R (2002) CagA tyrosine phosphorylation and interleukin-8 induction by Helicobacter
pylori are independent from alpAB, HopZ and bab group outer
membrane proteins. Int J Med Microbiol 292(34):257266
11. Higashi H, Tsutsumi R, Muto S, Sugiyama T, Azuma T, Asaka
M, Hatakeyama M (2002a) SHP-2 tyrosine phosphatase as an in-

Springer

Dig Dis Sci (2006) 51:18011809

12.
13.

14.
15.
16.
17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

tracellular target of Helicobacter pylori CagA protein. Science

295:683686
Hatakiyama M (2004) Oncogenic mechanisms of Helicobacter
pylori cagA protein. Nature Rev Cancer 4:688694
Higashi H, Tsutsumi R, Fujita A, Yamazaki S, Asaka M, Azuma
T, Hatakeyama M (2002) Biological activity of the Helicobacter
pylori virulence factor CagA is determined by variation in the
tyrosine phosphorylation sites. Proc Natl Acad Sci USA 99:14428
14433
Correa P (1996) Helicobacter pylori and gastric cancer: state of
the art. Cancer Epidemiol Biomarkers Prev 5(6):477481
Scheiman JM, Cutler AF (1999) Helicobacter pylori and gastric
cancer. Am J Med 106(2):222226
Goldstone AR, Quirke P, Dixon MF (1996) Helicobacter pylori
infection and gastric cancer. J Pathol 179(2):129137
El Serrag HB, Sonnenberg A (1999) Ethnic variations in the occurrence of gastroesophageal cancers. J Clin Gastroenterol 28(2):135
139
Straus EW, Patel H, Chang J, Gupta RM, Sottile V, Scirica J,
Tarabay G, Iyer S, Samuel S, Raffaniello RD (2002) H. pylori
infection and genotyping in patients undergoing upper endoscopy
at inner-city hospitals. Dig Dis Sci 47(7):15751581
Kidd M, Lastovica AJ, Atherton JC, Louw JA (1999) Heterogeneity
in the Helicobacter pylori vacA and cagA genes: association with
gastroduodenal disease in South Africa? Gut 45:499502
Dixon MF, Genta RM, Yardley JH, Correa P (1996) Classification
and grading of gastritis. The updated Sydney System. International
Workshop on the Histopathology of Gastritis, Houston 1994. Am
J Surg Pathol 20(10):11611181
Zambon CF, Navaglia F, Basso D, Rugge M, Plebani M (2003)
Helicobacter pylori babA2, cagA, and s1 vacA genes work synergistically in causing intestinal metaplasia. J Clin Pathol 56:287
291
Lee I, Lee H, Kim M, Fukumoto M, Sawada S, Jakate S, Gould
VE (2005) Ethnic difference of Helicobacter pylori gastritis:
Korean and Japanese gastritis is characterized by male- and antrumpredominant acute foveolatus in comparison with American gastritis. World J Gastroenterol 11(1):9498
Atherton JC, Cao P, Peek RM Jr, Tummuru MK, Blaser MJ, Cover
TL (1995) Mosaicism in vacuolating cytotoxin alleles of Helicobacter pylori. Association of specific vacA types with cytotoxin
production and peptic ulceration. J Biol Chem 270:1777117777
Hennig EE, Trzeciak L, Regula J, Butruk E, Ostrowsky J (1999)
vacA genotyping directly from gastric biopsy specimens and estimation of mixed Helicobacter pylori infections in patients with
duodenal ulcer and gastritis. Scand J Gastroenterol 34:743749
Nogueira C, Figueiredo C, Carneiro F, Gomes AT, Barreira R,
Figueira P, Salgado C, Belo L, Peixoto A, Bravo JC, Bravo LE,
Realpe JL, Plaisier AP, Quint WG, Ruiz B, Correa P, van Doorn
LJ (2001) Helicobacter pylori genotypes may determine gastric
histopathology. Am J Path 158(2):647654
Prinz C, Schoniger M, Rad R, Becker I, Keiditsch E, Wagenpfeil S,
Classen M, Rosch T, Schepp W, Gerhard M (2001) Key importance
of the Helicobacter pylori adherence factor blood group antigen
binding adhesin during chronic gastric inflammation. Cancer Res
61(5):19031909
Yu J, Leung WK, Go MY, Chan MC, To KF, Ng EK, Chan FK,
Ling TK, Chung SC, Sung JJ (2002) Relationship between Helicobacter pylori babA2 status with gastric epithelial cell turnover
and premalignant gastric lesions. Gut 51(4):480484
Parsonnet J, Friedman GD, Orentreich N, Vogelman H (1997) Risk
for gastric cancer in people with CagA positive or CagA negative
Helicobacter pylori infection. Gut 40:297301
Rugge M, Busatto G, Cassaro M, Shiao YH, Russo V, Leandro
G, Avellini C, Fabiano A, Sidoni A, Covacci A (1999) Patients
younger than 40 years with gastric carcinoma: Helicobacter pylori

Dig Dis Sci (2006) 51:18011809

genotype and associated gastritis phenotype. Cancer 85(12):2506
2511
30. Tsutsumi R, Higashi H, Higuchi M, Okada M, Hatakeyama M
(2003) Attenuation of Helicobacter pylori CagA-SHP-2 signaling
by interaction between CagA and C-terminal Src kinase. J Biol
Chem 278(6):36643670
31. Covaccia A, Censini S, Bugnoli M, Petracca R, Burroni D,
Macchia G, Massone A, Papinit E, Xiang Z, Figurat N, Rappuoli
R (1993) Molecular characterization of the 128-kDa immunodominant antigen of Helicobacter pylori associated with cytotoxicity and duodenal ulcer. Proc Natl Acad Sci USA 90(12):5791
5795

1809
32. Lage AP, Godfroid E, Fauconnier A, Burette A, Butzler JP, Bollen
A, Glupczynski Y (1995) Diagnosis of Helicobacter pylori infection by PCR: comparison with other invasive techniques and detection of cagA gene in gastric biopsy specimens. J Clin Microbiol
33(10):27522756
33. Atherton JC, Cover TL, Twells RJ, Morales MR, Hawkey CJ,
Blaser MJ (1999) Simple and accurate PCR-based system for typing vacuolating cytotoxin alleles of Helicobacter pylori. J Clin
Microbiol 37(9):29792982
34. Gerhard M, Lehn N, Neumayer N, Boren T, Rad R, Schepp W,
Miehlke S, Classen M, Prinz C (1999) Clinical relevance of the
Helicobacter pylori gene for blood-group antigen-binding adhesin.
Proc Natl Acad Sci USA 96:1277812783

Springer

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.