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DOI: 10.1159/000333260
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Table 1. H. pylori density measured in number of CFU and correlation with the grade of gastric inflammation
Reference n H. pylori Clinical manifestation of disease Correlation of H. pylori density with parameters of inflammation
strain
antrum corpus
PNC MNC PNC MNC
Khulusi et al. [3] 1995 110 undetermined gastritis (50%) and DU (50%) rs = 0.53 rs = 0.51 rs = 0.50 rs = 0.53
Atherton et al. [4] 1996 29 undetermined gastritis p < 0.01 p < 0.01 n.s. n.s.
Tummala et al. [5] 2007 19 undetermined gastritis r2 = 0.22 n.s. n.s. n.s.
Yamaoka et al. [7] 1999 100 CagA+ gastritis (50%) rs = 0.83 rs = 0.8 rs < 0.2 (n.s.) rs < 0.2 (n.s.)
DU (50%) rs = 0.67 rs = 0.79 rs < 0.2 (n.s.) rs < 0.2 (n.s.)
Dzierzanowska-Fangrat 41 CagA+ gastritis (76%) and peptic ulcer (24%) r = 0.27 (n.s.) r = 0.22 (n.s.) – –
et al. [8] 2002*
PNC = Polymorphonuclear cell infiltration; MNC = mononuclear cell infiltration; DU = duodenal ulcer; rs = Spearman’s rank correlation coefficient;
r2 = correlation coefficient (regression analysis); r = Pearson’s correlation coefficient. * This study was conducted in patients <18 years of age.
Number of CFU and Grade of Gastric Inflammation gastritis cases, H. pylori density was significantly higher
than in DU cases (5.7 vs. 4.3 ! 105 CFU/mg protein, p !
The first reports on the correlation of high bacteria 0.05), but did not correlate with either PNC or mono-
count with both activity and severity of inflammation ap- nuclear cell infiltration (MNC) in both gastritis and DU.
peared in the 1990s (table 1). Khulusi et al. [3] and Ather- Inadequate cellular inflammatory response in the cor-
ton et al. [4] showed that higher H. pylori density is asso- pus in cases of antral predominant gastritis have been
ciated with an increase of activity and severity of gastritis commonly observed and explained by host factors, espe-
in both the antrum and corpus. In addition, bacterial cially high acid secretion [10]. On the other hand, in both
load in the antrum of duodenal ulcer (DU) patients sig- the antrum and corpus, the relation between the number
nificantly exceeds that in non-DU gastritis, suggesting of CFU and IL-1 and IL-8 expression describes a dose-
that the grade of colonization may influence the clinical response curve [IL-1: PNC and MNC each p ! 0.0001
representation of disease. In a small study of 19 asymp- (antrum) and p ! 0.0005 (corpus); IL-8: PNC and MNC
tomatic H. pylori-infected volunteers, the number of CFU each p ! 0.0001 for antrum and corpus]. All cited authors
correlated significantly with polymorphonuclear cell in- also reported consistent results for H. pylori density
filtration (PNC) infiltration only in the greater curva- when determined by quantitative culture or histological
ture, although bacterial counts were surprisingly similar grading.
at all biopsy sites [5]. This discrepancy can be due to the
small sample size of the study and other variables such as
patient age and duration of infection, which are likely to Histological Determination of Bacterial Density and
modulate the severity of gastritis and bacterial density [6]. Grade of Gastric Inflammation
The number of H. pylori CFU also correlates with the
urease activity (Berthelot reaction) per biopsy, but not per The Sydney Classification established a standardized,
organism. international, and reproducible system for the histologi-
Other studies, which take bacterial virulence factors cal grading of gastritis and H. pylori density using an an-
into account, presented partially different results. CagA+ alogue visual scale [11–13]. PNC and MNC are assessed
H. pylori strains influenced the grade of inflammation separately indicating continuing acute inflammation and
depending on bacterial density in gastritis and DU pa- chronic inflammation, respectively. The density of in-
tients only in the antrum. However, H. pylori density was traepithelial neutrophils represents mucosal damage and
not directly related to the CagA status (CagA+ vs. CagA– is a sensitive predictor of the presence of H. pylori [14].
antrum: 5.1 vs. 5.2 ! 105 CFU/mg protein, p = 0.65; cor- Altogether, significant correlation between bacterial
pus 5.7 vs. 5.0 ! 105 CFU/mg protein, p = 0.22) [7–9]. count and PNC as well as MNC has been repeatedly ob-
Interestingly, they reported that in the corpus of CagA+ served in numerous studies from different continents
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Stolte et al. [17] 1995 Germany 240 2 p < 0.0001 p < 0.0001 p < 0.0001 p < 0.0001
Sepulveda et al. [18] 2002 USA 188 12 p < 0.01 – p < 0.01 –
Misra et al. [23] 2000 India 50 11 p < 0.0001 p < 0.0001 p < 0.0001 p < 0.0001
Yamamura et al. [16] 1999 Japan 81 2 rs = 0.61 rs = 0.57 rs = 0.61 rs = 0.57
Fareed et al. [29] 2000 Pakistan 150 3 rs = 0.54 rs = 0.17 (n.s.) rs = 0.64 rs = 0.245
Alam et al. [19] 1992 USA 903 1 p < 0.001 p < 0.001 – –
[15–22]. Table 2 shows an overview of several selected re- H. pylori Density Assessed by PCR and Grade of
ports. Inflammation
A comprehensive topographic study on H. pylori den-
sity distribution in 11 biopsy sites and associated inflam- After the nucleotide sequences of the H. pylori ge-
mation was conducted on 50 H. pylori-infected individ- nome were determined [61], a number of PCR techniques
uals with chronic gastritis in India [23]. The correlation were proposed for detection and quantification of H. py-
between the occurrence and grading of gastritis at the lori in gastric biopsies and other specimens [16, 30].
site of maximum density (proximal antral lesser curva- Compared to histology, quantitative PCR is generally
ture) was highly significant (r = 0.7096, p ! 0.0001). The equally (or more) sensitive, but has a poorer specificity.
minimum of both H. pylori density and inflammatory Different amplification targets as well as different PCR
changes was observed in the most distal part of the cor- methods (conventional PCR, real-time PCR, nested
pus at the greater curvature [23, 24]. A positive correla- PCR) hinder the analysis and comparability of PCR-
tion between high histological gastritis score and high based studies. Here we focus on some recent reports in-
density of H. pylori was also demonstrated in cases of vestigating the grade of gastritis assessed by histology
nodular gastritis in adults as well as in children, where with H. pylori density measured by quantitative PCR (ta-
this typical endoscopic representation of disease is more ble 3). Kobayashi et al. [31] showed a strong correlation
common [25, 26]. Marked CD4 (Th cell marker) and between histological grade of gastritis and H. pylori ge-
CD19 (B cell marker) positive inflammatory cell infiltra- nomes/pg of human DNA, and a sensitivity and specific-
tion is concomitant in cases with a high histological ity of 100% of a TaqMan PCR amplifying fragments of
grade of gastritis and high density of H. pylori, suggest- 16S ribosomal DNA. Molnar et al. [32] showed increased
ing predominance of a humoral type immune response H. pylori density (urease A target gene) in antral ero-
rather than a cytotoxic response. Significantly increased sions. Interestingly, they found similar bacterial density
IL-8, IL-10, IFN-␥, and MIP-1␣ levels confirm this ob- levels in gastritis and intestinal metaplasia with atrophy,
servation as these chemokines are known to promote whereas numerous histological observations stress the
migration of neutrophils and mononuclear cells, espe- lack of H. pylori colonization in this type of lesion. Such
cially activated CD4 cells, to the inflammatory focus. discrepancies raise the question of the clinical signifi-
Interestingly, the anti-inflammatory cytokine IL-10 is cance of H. pylori detection via PCR. The use of real-time
also found increased in gastric mucosal biopsies from H. PCR targeting the H. pylori SSA gene did not permit the
pylori-positive patients, indicating a dual role for H. py- demonstration of a significant correlation between num-
lori in induction and regulation of inflammatory reac- ber of copies and degree of gastritis [33]. Zsikla et al. [34]
tions [27–29]. also noted a lack of correlation between H. pylori DNA
molecules (urease C gene)/DNA equivalent of 105 cells
and inflammation score in biopsies of chronic gastritis.
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Kobayashi 72 16S ribosomal RNA TaqMan F 5ⴕ-CTCATTGCGAAGGCGACCT-3ⴕ histological grading p < 0.001
et al. [31] R 5ⴕ-TCTAATCCTGTTTGCTCCCCA-3ⴕ
2002 P 5ⴕ-ATTACTGACGCTGATTGC-3ⴕ
Molnar 53 urease A gene LightCycler F 5ⴕ-GCCAATGGTAAATTAGTT-3ⴕ erosive gastritis p < 0.01
et al. [32] R 5ⴕ-CTC CTT AAT TGT TTT TAC-3ⴕ
2008
Ladeira 108 26-kDa SSA gene real-time PCR F 5ⴕ-TGGCGTGTCTATTGACAGCGAGC-3ⴕ histological grading n.s.
et al. [33] R 5ⴕ-CCTGCTGGGCATACTTCACCAG-3ⴕ
2008 P not reported
Zsikla 126 urease C qPCR F 5ⴕ-GGATCTGGGCTTTGCTTTTG-3ⴕ histological grading n.s.
et al. [34] R 5ⴕ-CCCATGCACGATATTCCCTAAA-3ⴕ
2006 P 5ⴕ-Fam-TGGCGATGCGGATAGGCTAGTGGT-Tamra-3ⴕ
Interestingly, they also reported a weak insignificant High H. pylori Density in Complications of Gastritis
correlation of the cumulative grade of inflammation
with histologically assessed density. However, urease C High H. pylori density has been attributed to a clinical
gene PCR scored best in comparison with the other four representation of disease in the form of peptic ulcer [18].
mentioned primer pairs in terms of sensitivity and spec- In a group of 113 patients requiring surgical intervention
ificity, as well as positive predictive value (100%) and due to ulcer disease, bacterial load was found to be close-
negative predictive value (96%) [35]. ly associated with ulcer perforation, rather than with
hemorrhagic or stenotic ulceration [48]. Additionally,
heavy bacterial loads indicate an increased tendency and
13C-Urease Breath Test Result in Relation to H. pylori frequency of bleeding in preformed DUs, but do not pre-
Density and Grade of Inflammation dict the severity of a bleeding episode [49]. Hydrophobic-
ity of gastric mucus is reduced in DU patients as com-
The 13C-urease breath test (13C-UBT) is undoubtedly pared to gastritis cases, and is related to the density of
the most widely used noninvasive test for detection of H. pylori colonization [50]. It is interesting to note that
H. pylori infection in clinical practice and scientific tri- increased epithelial cell proliferation (measured by bro-
als. But the accuracy of 13C-UBT for assessment of bacte- modeoxyuridine and Ki-67 labeling) as well as an in-
rial load in the stomach is a matter of ongoing contro- creased apoptotic count of up to 17% of epithelial cells
versy, originating to a certain extent in the variety of ap- were found to be depending on H. pylori density in in-
plied protocols. A large number of studies have reported fected biopsy specimens [51, 52]. The correlation with
a significant correlation between delta 13CO2 excretion MNC in the examined specimen was stronger than with
and the histologically determined bacterial density [36– that of PNC, suggesting a possible link to gastric carcino-
43]. Additionally, some authors have shown a significant genesis.
correlation of 13C-UBT values with activity of gastritis
[37–40] and pepsinogen I/II ratio [40]. However, other
reports suggest that 13C-UBT is not an appropriate tool Mucosal Agents in the Relationship of H. pylori
for assessment of bacterial load [44–47]. Given the broad Suppression with Gastric Inflammation
variety of protocols and varying sensitivity and specific-
ity of the method, this discrepancy can be explained by Eradication of H. pylori leads to the disappearance of
the lack of comparability standards among the studies gastric mucosal inflammation and complete restoration
(table 4). of normal mucosa unless preneoplastic changes, i.e. atro-
phy and intestinal metaplasia, have already occurred [53].
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13
Reference n C-UBT Reference method Mean delta Correlation of Correlation of
protocol 13CO 13C-UBT value 13C-UBT values
2
with H. pylori with parameters
time cutoff
density of inflammation
Chen et al. [40] 2000 135 20 min 2.5‰ histology, serology 30.0822.44‰ p < 0.01 PNC, p < 0.01
Zagari et al. [37] 2005 192 30 min 5‰ histology, rapid urease test 32.0819.7‰ p < 0.05 PNC, p < 0.05
Chang et al. [38] 2003 100 30 min 4‰ histology 48.6827.5‰ p < 0.001 PNC, p < 0.001
Cho et al. [36] 2008 123 20 min 2‰ histology – rs = 0.674 n.s.
Perri et al. [42] 1998 172 30 min 3.3‰ histology, culture, serology – p < 0.001 erosions, p = 0.03*
Machado et al. [44] 2006 44 60 min 4‰ histology 29.1‰ n.s. n.s.
Logan et al. [45] 1991 50 40 min 4–5‰ histology, culture, serology – n.s. PNC, p < 0.001
MNC, p < 0.07
Auroux et al. [46] 1998 37 20 min – quantitative culture – n.s. –
Table 5. Effect of H. pylori suppression therapies on bacterial load and the grade of gastric inflammation
The influence of H. pylori density reduction on improve- load reduction on sucralfate therapy which was not paral-
ment of gastric mucosal changes was observed with the leled by decreases in gastritis activity scores after 4 weeks
first therapeutic attempts. Substances like bismuth, su- of treatment in 11 DU patients. Berstad et al. [57] even
cralfate, antacids, and proton pump inhibitors were used demonstrated worsening of antral histopathological gas-
in various combinations or as monotherapies, leading in tritis scores and symptoms as compared with placebo,
most of the cases to a reduction of the bacterial load, despite a strong decrease in H. pylori colonization in 10
which resulted in a rapid and significant, but not persis- H. pylori-positive nonulcer dyspepsia patients after treat-
tent, reduction of gastritis activity [54–56]. Nevertheless, ment with antacids. Miyake et al. [55] accurately de-
some authors reported dissociation between H. pylori scribed the close relationship between H. pylori density
density and gastritis scores before and after treatment (ta- reduction and inflammation decrease after 3 months of
ble 5) [57–59]. Using a mucoprotective agent, Barbara et therapy with the mucoprotective drug teprenone. In fact,
al. [58] reported improvement of gastritis score despite teprenone was shown to have a strong effect on corpus
unchanged H. pylori density after therapy with sucral- gastritis with the concomitant reduction of H. pylori den-
fate. In contrast, Banerjee et al. [59] described H. pylori sity and neutrophil infiltration. None of the studies con-
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