Gastrointestinal System

LEARNING OBJECTIVES :
Helicobacter pylori & Campylobacter jejuni

Bacterial Infections - 4
Helicobacter pylori

Helicobacter pylori
&

Campylobacter jejuni

:
Morphology, characteristics, virulence factors

Mode of transmission , Pathogenesis, immunity,

risk factors, clinical manifestations, complications
Laboratory diagnostic methods

Dr. Durgadas
Control and Prevention

Date : 04-03-2016

Helicobacter pylori
(Earlier name Campylobacter pylori)

Helicobacter pylori

Morphology :
Gram negative curved,spiral bacilli , 2-4 u x 0.5 u
Motile with multiple polar sheathed flagella
Microaerophilic, 5-10% CO2, high humidity,
Grow on Skirrow, Butzler media
(Blood agar + antibiotics - vancomycin, trimethoprim, ampotericin)

Catalase +ve,
Oxidase +ve
DNAse +ve
Phosphatase +ve

Urease +ve : produces abundunt urease enzyme

almost 100 times > other bacteria like Proteus

Remind : H.pylori produces abundant Urease

Virulence factors

Cytotoxin
Urease activity
Motility
Protease/mucinase

Cytotoxins : Cag A (cytotoxin associated gene A),

vac A (vacuolating toxin A ) and BabA (Blood group
antigen binding) : deform epithelial cells, leaking of
cell contents
These cytotoxins together with cytokines IL1 beta
upgrade mucosal inflammation.
LPS (endotoxin) also play important role
Flagellum and urease are necessary for its
adhesion & inhabitation

Mode of Transmission :Human gastric mucosa :

only known natural human reservoir
1. H. pylori infection may be acquired
through person-to-person contact
(fecal-oral and Oral-Oral route)
2.By ingestion : From contaminated food and water
Acquired in childhood, probably by faecal oral route.
Poor sanitation, overcrowding facilitates transmission
Repeated infection and cure, finally
establishes chronic infection.
No reservoir other than the human gastric mucosa
has been identified for H pylori.

Escape of natural defense (gastric juice acidity)

Risk factors
Smoking :

Smoking may increase the risk of peptic

ulcers in people who are infected with H. pylori.

Alcohol :

Alcohol can irritate and erode the mucous

lining of stomach, and it increases the amount of
stomach acid that's produced

Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)

aspirin, ibuprofen

Once H. pylori is in the mucus, it is able to

fight the stomach acid that does reach it with
an enzyme - urease.
Urease converts urea, of which there is an
abundant supply in the stomach (from saliva
and gastric juices), into bicarbonate and
ammonia, which are strong bases. This
creates a cloud of acid neutralizing chemicals
around the H. pylori, protecting it from the
acid in the stomach.
The reaction of urea hydrolysis is important for
diagnosis of H.pylori by the breath test.

Immune Response
The immune system responds to an H. pylori infection by white
cells, killer T cells, and other infection fighting agents which
cannot easily get through stomach lining.
Infection fighting agents do not go away either and the immune
response grows and grows. Polymorphnuclear cells die,
and spill their destructive compounds (superoxide radicals)
on stomach lining cells.

H. pylori associated inflammatory reaction is characterized by a

mucosal infiltration of different cells like polymorphonuclear
leukocytes (PMN), T cells, macrophages, and plasma cells
H. pylori adheres to the cells of gastric mucosa and secretes
different molecules that can change gastric epithelial cell function
Chronic active gastritis is associated with an increased CD4/CD8
T-cell ratio within the gastric mucosa and accumulation of CD4+ Thelper lymphocytes in the lamina propia of the gastric mucosa.
H. pylori infection results in a Th1-predominant host immune
response in the gastric mucosa and induction of IFN- (interferon) and IFN- -related genes.
A Th1-predominant immune response is associated with elevated
levels of the pro-inflammatory cytokines IL-12, IL-18 and TNF-
The IL-1, a potent pro-inflammatory cytokine and powerful
inhibitor of gastric acid secretion that had a most important
responsibility in initiating and amplifying the inflammatory
response to H. pylori infection

Pathogenesis :
H.pylori has attachment sites for gastric mucus
epithelial cells (Lewis B , ganglioside GM3)
(H.pylori also synthesizes Lewis X ,
may be reason for molecular mimicry).
After attachment induce the production of IL 8
that attract Neutrophils.
If deep colonization occurs ,
secretion of IL1 inhibits acid secretion.

Ingestion Urease enzyme degardes Urea present

in gastric juice to ammonia, and bicarbonate. Thereby
protecting H.pylori

After several weeks .. achlorhydria probably because of

combined action of cytotoxin, ammonia, cytokines IL1

Signs and symptoms

In general, patients infected with H pylori are asymptomatic,
and no specific clinical signs have been described.
Acute infection : (due to increased acid secretion)
Dyspepsia, Epigastric discomfort, nausea, vomiting
Other signs and/or symptoms may include :
Abdominal pain
Heartburn (A burning pain in the chest )
Diarrhea
Halitosis (bad breath)

Cytotoxins :
cag A (cytotoxin associated gene A),
vac A (vacuolating toxin A )
BabA (Blood group antigen binding) deform
epithelial cells, leaking of cell contents

These cytotoxins together with cytokines IL1 beta

upgrade mucosal inflammation.

Gastric cancer :
H.pylori infection associated with diet contents,
environmental factors, genetic factors
Childhood infection destroys corpus mucosa that leads to
chronic atrophic gastritis with decreased acid secretion.
That allows other organisms to colonize, and convert
nitrates into nitrites and then to nitrosamine(Carcinogen) .
In addition action of ammonia and cytotoxin.

H.pylori secreted Cag A is associated with

duodenal ulcer (high acid state) and
stomach cancer (low acid state).
Those who have duodenal ulcer donot progress to cancer.
That means acid provides protection from carcinogens.
It is possible to develop cancer due to other factors
(consumption of carcinogen, age, environmental factors,
hypochlorohydria)
~ 90% of MALT lymphoma is associated with H.pylori
infection

HP+ caused by H.pylori,

HP- Not caused by H.pylori

Atrophic gastritis is a histopathologic entity characterized by

chronic inflammation of the gastric mucosa with loss of gastric glandular
cells and replacement by intestinal-type epithelium, and fibrous tissue.

H.pylori in Biopsy specimen

Dyspepsia

50%

Active
Chronic
Gastritis

Atrophic
gastritis

Metaplasia Dysplasia

Cancer

1%

0-20%

Point of No Return

Complications :

LABORATORY DIAGNOSIS

Left untreated, peptic ulcers can result in:

Internal bleeding. Bleeding can occur as slow blood loss that
leads to anemia or as severe blood loss that may require
hospitalization or a blood transfusion.
Severe blood loss may cause black or
bloody vomit or black or bloody stools.
Infection. Peptic ulcers perforation of wall of
stomach or small intestine, -at risk of serious
infection of abdominal cavity (peritonitis).
Scar tissue. Peptic ulcers can also produce scar tissue
that can block passage of food through the digestive tract,
causing, to vomit and to lose weight.

H.pylori IgG kit

Endoscopy
A long, thin instrument called an
endoscope is inserted into
stomach and duodenum.
An attached camera sends back
images that are viewed on a
monitor.

H. Pylori IgG is a rapid test for the qualitative detection of IgG antibodies
specific to H. pylori in human serum, plasma & whole blood specimens.

Any abnormal areas can be

inspected, and special tools used
with the endoscope can take a
sample of these areas(Biopsy).

Urea Breath Test (UBT) test principle

1. Patient swallows a
labeled C13/14 urea tablet. Dissolves to release 14C-urea.
2. If present, H. pylori metabolizes 14C-urea to labeled carbon
dioxide (14CO2) and ammonia via the enzyme urease.

H2N(13/14CO)NH2 + H20 urease 2NH3 + 13/14CO2

3.

14CO
2

is transported in the blood to the lungs.

4. Patient exhales. 14CO2 is captured for analysis.

(If H. pylori is absent, the 14C-urea is simply absorbed and subsequently voided)

How Heliprobe System works

Simply swallow, breathe and analyze

1. Swallow HeliCap

2. Wait 10 minutes.
Breathe into
BreathCard

3. Insert BreathCard
into Heliprobe
Analyzer

4. Read the result after

just 5 minutes

H.pylori antigen/ antibodies detection by ELISA

H.pylori antigen detection by Dipstick

ELISA

Other Tests.less frequently used

Upper GI X-ray Examination

with Barium meal
Polymerase Chain Reaction (PCR):
Detects Bacterial DNA
Culture is done from biopsy specimen using
Skirrow, Butzler medium with antibiotics

Treatment
Eradication means complete absence of H.pylori for 4 weeks.
Reinfection is possible.
Acid protects H.pylori from antibiotics.
Therefore strong acid suppression with proton pump inhibitor .
Triple therapy with a proton-pump inhibitor, clarithromycin,
and amoxicillin or metronidazole remains an appropriate
first-line therapy
Recurrence or persistence of symptoms after eradication
therapy for uninvestigated dyspepsia is much less likely to
indicate that treatment has failed than to indicate that the
symptoms are unrelated to H. pylori infection.
Prevention
Personal hygiene is the first step in decreasing human to
human transmission. This is especially important for those
involved in food preparation, either in the home or in public
places.
No vaccine

Helicobacter pylori (summary) :

A Gram negative spiral, curved, motile bacterium that known to
produce exotoxins (cytotoxins) causes stomach inflammation
(gastritis) and ulcers in the stomach and duodenum. Produces
abundant urease
H. pylori infection may be acquired from contaminated food and water or
through person-to-person contact. It is common in people who live in
crowded conditions with poor sanitation. H. pylori infects 50% of the
worlds population

This bacterium is the most common cause of peptic ulcers (gastric +

duodenal )worldwide. This bacterium is also believed to be
associated with stomach cancer (gastric adenocarcinoma) and a rare
type of lymphoid tumor called gastric MALT lymphoma.
Laboratory diagnosis : UBT, Serology (IgG), Fecal ag , endoscopy
Infected persons usually carry H. pylori indefinitely,
often without symptoms, unless treated with antibiotics
to eradicate the bacterium. Triple therapy with a proton-pump
inhibitor, clarithromycin, and amoxicillin or metronidazole remains
an appropriate first-line therapy

Campylobacter jejuni :
(formerly known as Campylobacter fetus subsp. jejuni)

Illness : Campylobacteriasis, campylobacter enteritis or

gastroenteritis
Gram Negative, Slender, curved, comma, s, girdle sahped and Motile
(darting or Corkscrew type)
unusual techniques are used for isolation from fecal specimens.
growth at 42C, selective media are blood-based, antibiotic-containing
media such as Skirrow, Butzler, and Campy-BAP.
- microaerophilic organism, 3 to 5% oxygen and 2 to 10% carbon dioxide
- oxidase positive with C jejuni hydrolysing hippurate
- causes more disease than Salmonella and Shigella combined.
- Habitat : cattle, sheep, goats, pigs, chickens, birds and even flies.
- sometimes present in non-chlorinated water sources like streams &
ponds.
Campylobacter organisms may also be an important cause of traveler's
diarrhea in Southeast Asia.

Stool Microscopy Gram stain

Mode of Transmission :
- Fecal-oral,
- Contaminated food , water, milk
- person-to-person sexual contact,
- unpasteurized raw milk and poultry ingestion,

C. jejuni - 20 to 100% of retail chickens are contaminated.

Many healthy chickens carry these bacteria in their intestinal
tracts.
Bacteria are often carried by healthy cattle, sheep, goats,
pigs, a number of animals, birds.
Raw milk is also a source of infections.

45

Virulence Factors :
- Enterotoxin watery diarrhea
- Cytotoxin Bloody diarrhea
- Invasiveness motility invasion of mucosa and
submucosa layer
- Endotoxin
-

Camylobacter fetus - a surface S-layer protein that functions

like a capsule and disrupts c3b binding to the organisms,
results in resistance to phagocytosis

C. jejuni -mucus layer interacts with intestinal

epithelial cells causing
interleukin (IL)-8
production.
C. jejuni is internalized
by epithelial cells.
IL-8 causes the
recruitment of dendritic
cells (DC), macrophages
and neutrophils, which
interact with C. jejuni.
These interactions result
in a massive proinflammatory response
and increases in the
corresponding cytokines.

The infectious dose is 1000-10,000 bacteria

Immunity in C.jejuni infections :
C jejuni infections also show recurrence in children and adults
with immunoglobulin deficiencies.
Acute C jejuni infection confers short-term immunity. Patients
develop specific immunoglobulin G (IgG), immunoglobulin M
(IgM), and immunoglobulin A (IgA) antibodies in serum;
IgA antibodies also develop in intestinal secretions.
The severity and persistence of C jejuni infections in individuals
with AIDS and hypogammaglobulinemia indicates that both cellmediated and humoral immunity are important in preventing
and terminating infection

Complications are relatively rare :

Reactive arthritis,
Hemolytic uremic Syndrome
Bacteremia, septicemia, infections of any
organ (AIDS)

Incubation period : 2-5 days

C. jejuni infection - diarrhea often with blood (usually
occult) and fecal leukocytes.
Other symptoms often present are fever, abdominal pain, nausea, headache and muscle pain.
Illness generally lasts 7-10 days, but relapses are not
uncommon (about 25% of cases).
Most infections are self-limiting and are not treated with
antibiotics.
Dehydration may be clinically evident in patients who are
moderately to severely ill.

Most reported bacteremias have been due

to Campylobacter fetus infection.

Campylobacter coli and C. lari, produce diarrhea

Rare complications :

Campylobacter upsaliensis may cause diarrhea or

bacteremia,

Meningitis,
Recurrent colitis,
Acute cholecystitis
Guillain-Barre syndrome

Campylobacter hyointestinalis, occasional bacteremia

in immunocompromised individuals.

Laboratory diagnosis :
Stool Microscopy - Darkfield or phase-contrast microscopy of fecal
specimens darting corkscrew type of motility

Stool smear staining by Carbol Fuchsin Curved, Comma, S,

girdle shaped organisms

Methylene blue or Gram stain : Fecal leukocytes and erythrocytes

(75%cases) in enteritis

Culture :
Transport medium Wang, Carry Blair , Alkaline peptone water

Control & Prevention

Pasteurization of milk
Boiling of water
Proper food-handling techniques, including thorough
cooking of chicken/turkey
Hygienic measures in slaughter house
community health education

Selective special medium : Blood agar/Brucella agar base with

antibiotics - Skirrow, Butzler, Campy-BAP medium
Oxidase +ve, Hippurate hydrolysis, H2S production

chlorination of water body destroy Campylobacter

organisms.

Serodiagnosis : recombinant antigens to detect Antibodies by ELISA