Helicobacter Pylori Associated Antral Gastritis in Peptic Ulcer Disease Patients and Normal Healthy Population of Kashmir, India

Aim: To study the association of Helicobacter pylori infection with chronic antral gastritis in peptic ulcer disease patients and healthy population of Kashmir. Methods: 50 peptic ulcer patients (duodenal ulcer = 46, gastric ulcer = 2 and combined duodenal and gastric ulcer = 2) and 30 asymptomatic healthy volunteers were included in this study. Peptic ulcer was diagnosed on endoscopic examination. 4–6 punch biopsies were taken from gastric antrum in all the individuals and in case of gastric ulcer an additional biopsy was taken from the edge of the ulcer to exclude its malignant nature. Helicobacter pylori (H. pylori) organism was diagnosed using three different test methods, viz. Histology (using Giemsa Stain), Microbiology (Gram Stain) and Biochemistry (using one minute Endoscopy Room Test). Histological diagnosis of H. pylori was taken as the “gold standard” for the presence of H. pylori organism. Histological diagnosis of gastritis was made using Hematoxylin and Eosin Stain and the gastritis was classified as active chronic gastritis and superficial chronic gastritis. Results: Out of 30 peptic ulcer disease patients with associated antral gastritis, 27 (90%) were positive for H. pylori on histological examination (13 superficial chronic gastritis and 14 active chronic gastritis) whereas out of 8 healthy volunteers with histological evidence of chronic antral gastritis, H. pylori was observed in 7 individuals (87.50%) (4 active chronic gastritis and 3 superficial chronic gastritis). Conclusion: A highly significant association between H. pylori infection with chronic antral gastritis both in peptic ulcer disease patients and healthy volunteers of Kashmir was found in this study. Association between H. pylori infection and chronic gastritis was 90% in peptic ulcer group and 87.50% in healthy population (P<0.005).


INTRODUCTION
Peptic ulcer disease (PUD) and chronic gastritis are most common disorders throughout the whole world. Chronic antral gastritis is a common finding in PUD especially in duodenal ulcer (DU)., (in whom pre-ingestion antral biopsies were normal) following ingestion of H. pylori [8,9].

MATERIAL AND METHODS
Chronic antral gastritis also occurs in gastric This study consisted of 50 PUD patients ulcers. One study has reported association (DU-46, GU-2 and combined DU and between chronic gastritis and active duodenal GU-2) whose disease was diagnosed on endoulcer as 100% compared to 50% in non-ulcer scopic examination and 30 asymptomatic healthy controls [1]. Since [2,3]. Helicobacter pylori infection Srinagar, Kashmir. 4-6 antral biopsies were has been strongly found to be associated with taken from each participant using sterilized type B (chronic non-autoimmune) gastritis [2][3][4].
biopsy forceps. One biopsy was used for one min-This type of chronic gastritis is associated with ute endoscopy room test, (Urease test) one for inflammation and patchy gastric atrophy. How-microbiological study (Gram's Stain) and another ever, a preliminary study of dyspeptic patients two for histological examination (For H. pylori from Bombay (India) found a non-significant and status of gastritis). An additional biopsy was association of 30% between antral Helicobacter taken from the edge of gastric ulcers to exclude pylori infection and chronic gastritis. Type A its malignant nature.
chronic gastritis thought to be of autoimmune etiology is rarely associated with H. pylori infec-Histopathology tion. Also a strong association has been found between the number of antral H. pylori organisms and severity of chronic gastritis [4][5][6][7].
A definite pathological association between H. pylori infection and gastritis is supported by (i) a positive correlation between chronic gastritis and H. pylori infection, (ii) a significant correlation between the number of H. pylori organism and the degree of polymorphonuclear (PMN) leukocyte infiltration in gastric mucosa, (iii) absent or For histopathological study, paraffin sections of 3-5 tm thickness were taken of the biopsy material and these were stained with Hematoxylin and Eosin Stain (to study the histology of gastric antrum) and Giemsa Stain (For identification of H. pylori organism) separately. The Hematoxylin and Eosin stained tissue were broadly classified as: (i) normal (when no inflammatory cells were seen), decreased number of PMN infiltration in por-(ii) active chronic gastritis (when PMN cell infiltions of gastric mucosa not associated with H. tration was observed in mucosal glands, pits pylori infection, (iv) an improvement of chronic or scattered throughout the epithelium or gastritis following eradication of H. pylori and lamina propria and with intact mucosal sur-(v) development of gastritis in healthy volunteers face) and H. PYLORI ASSOCIATED ANTRAL GASTRITIS 137 (iii) chronic superficial gastritis when inflammatory changes were confined to the lamina propria of the superficial mucosa and glands being preserved).
Detection of H. pylori on Giemsa Stain was taken as "Gold Standard" for the presence of H. pylori infection.
One Minute Endoscopy Room Test (Urease Test) A freshly prepared 10% W/V urea solution in deionized water at a PH of 6.8 was taken in two 5ml capacity glass test tubes. Two drops of freshly prepared one percent phenol was added to each tube. One test tube served as a reagent and other as a control. One of the antral biopsy material was put into the reagent test tube and change of color from yellow to pink within 5 min was considered as positive thereby meaning the presence of H. pylori.

Microbiology
One of the biopsy material was rubbed over a clean and dry glass slide and was heat fixed. The tissue was stained with Gram's Stain and observed under light microscope for the presence of gram negative, spiral shaped H. pylori organisms.

Statistical Analysis
Chi-square test was used to analyze the results and a P value of less than 0.05 was taken to be significant.

Ethics
Both the patients and volunteers were fully explained this study and informed consent was obtained from every participant for performing endoscopy and for obtaining biopsy tissue. Human experimentation guidelines laid by "Declaration of Helisinki" were followed. This study was approved by principal/Dean, Government Medical College, Srinagar, after consideration and approval by members of board of studies.

RESULTS
Of the 50 peptic ulcer disease patients (DU 46, GU 2 and combined DU and GU 2), 42 were males and 8 females, whereas out of 30 healthy volunteers 25 were males and five females in the mean age group of 30.88+/-12.80 and 29.80+/-11.22 respectively ( Table I).
In PUD group, 30 (60%) were having antral gastritis on Hematoxylin and Eosin staining (14 with active chronic gastritis and 16 with superficial     (Table IV). A highly significant (P < 0.002 to P < 0.00005) was found between H. pylori positivity on histology and chronic active gastritis (Table V).

DISCUSSION
Helicobacter pylori organisms has been found to play an important pathogenic role in peptic ulcer disease (especially in duodenal ulcer), gastritis H. PYLORI ASSOCIATED ANTRAL GASTRITIS 139 and recently in gastric cancer [2,4,6,7]. The antral colonization with H. pylori organism has been reported from every corner of the globe especially from developing and underdeveloped countries [2,4,6]. This study was carried out in a highly endemic peptic ulcer disease area of India [10] to find out any association between chronic gastritis and Helicobacter pylori positivity among peptic ulcer patients and asymptomatic healthy volunteers. In this study the association of Helicobacter pylori with peptic ulcer disease (duodenal ulcer) was found to be 76% and prevalence of H. pylori in healthy asymptomatic volunteers was found to be 33.33%. The association with peptic ulcer disease was statistically significant (P < 0.005). The association between H. pylori positivity and chronic antral gastritis was also very significant in both peptic ulcer disease and healthy volunteers (P < 0.002 to P < 0.00005). Despite absence of symptoms or risk features 26.67% of healthy volunteers were found to have histologic antral gastritis and 87.50% of these were positive for H. pylori organism. Thereby showing direct relation between chronic gastritis and H. pylori positivity.
This study confirms the data published from different parts of the world [2][3][4][5][6][7][8] but contradicts the earlier study published from India [11], in which study on 95 dyspeptic patients found a non-significant association of 30% between antral Helicobacter pylori infection and chronic gastritis.
In conclusion, this study found a highly significant association between Helicobacter pylori infection and peptic ulcer disease (duodenal ulcer). Also a very significant association between H. pylori infection and chronic antral gastritis was found in both peptic ulcer group and asymptomatic healthy volunteers.