Prevalence of Helicobacter Pylori in Endoscopic Gastric Biopsies of Chronic Gastritis Patients at A Tertiary Care Centre

ABSTRACT Introduction: Presence and severity of Helicobacter pylori (H. pylori) colonization is an important factor to decide the treatment of chronic gastritis. This study aimed to find the prevalence of H. pylori colonization in chronic gastritis patients. Methods: This descriptive,cross-sectional study was carried out at the tertiary care center in the the western region of Nepal among the dyspeptic patients undergoing endoscopic gastric biopsy from October 2018 to March 2020 after approval from the Institutional review committee. Convenience sampling was done to reach the sample size. Two hundred fifty cases were included in the study. Data were recorded in proforma and Data analysis was done in the statistical package for social sciences (SPSS 16.0). The severity of H. pylori colonization and gastritis was graded using the Updated Sydney System. Results: All cases showed chronic gastritis on histopathology. H. pylori were seen in 150 (60%) of cases. Mild, moderate, and severe H. pylori infection was seen in 59, 78, and 13 cases respectively. Out of 59 mild H. pylori cases, 35 (59.32%) had mild chronic inflammation; out of 78 moderate H. pylori cases 51 (65.38%) had moderate chronic inflammation and among 13 severe H. pylori cases, 10 (76.92%) had severe chronic inflammation. Conclusions: Prevalence of H. pylori colonization is high in chronic gastritis and there is a parallel increase in the severity of gastritis with an increase in the severity of H. pylori load.


INTRODUCTION
Helicobacter pylori (H. pylori) is a bacterium, first discovered in 1982 by Robin Warren and Barry Marshall. 1 Since its discovery, it has been associated with a wide spectrum of gastro-duodenal diseases including gastritis, gastro-duodenal ulcers, mucosa associated lymphoid lymphoma and gastric adenocarcinoma. 2 H. pylori is the most common human infection of the stomach and it is also common in Nepal. 3,4 The prevalence and histopathology of H. pylori induced gastritis has been studied globally.
Gastritis is a common health problem among the Nepalese population and endoscopy along with gastric biopsies are frequently performed at our institution. Data regarding the prevalence of H. pylori and JNMA I VOL 58 I ISSUE 228 I August 2020 histomorphology of chronic gastritis in relation to H. pylori infection is sparse in our country.
This study aimed to find the prevalence of H. pylori colonization in chronic gastritis patients.

METHODS
This descriptive cross-sectional study was conducted at the Department of Pathology, Lumbini Medical College, and Teaching Hospital from October 2018 to March 2020 over eighteen months. This study was approved by the Institutional Review Committee (IRC NoIRC-LMC 12-H/018) of LMCTH, Tansen, Palpa,Nepal. Both the verbal and written informed consents were taken from each of the participants (or their guardians). The study population is patients who have undergone upper gastrointestinal (UGI) endoscopic evaluation. Patients with dyspeptic symptoms who underwent UGI endoscopy and gastric biopsy were included in the study. Biopsies of patients who were receiving or had received H. pylori eradication treatment within one month and neoplastic cases were not included in the study. Biopsies of patients of all ages and both sexes were included in the study. Age and sex of the patients, detailed clinical history, and upper gastrointestinal endoscopy findings were obtained from the requisition form.
Histopathological diagnosis was made based on antral biopsy sections findings, as an antral biopsy specimen was received in all the cases and considering the fact that in subjects with intact acid secretion, H. pylori, in particular, colonizes the gastric antrum. Biopsy specimens were fixed in 10 % formalin routinely processed and paraffin blocks were sectioned at 3-4 µm thickness. Two set sections of each specimen were made and both the sections were routinely stained with hematoxylin and eosin(H & E) and Giemsa stain respectively. Both sections from each specimen were evaluated under light microscopy by a single pathologist. The histomorphology of sections was studied on routine H & E stained sections. Giemsa stained sections were studied for the identification of H. pylori.
The presence of the morphological variables (H. pylori density; neutrophilic activity; mononuclear cell (MNC) infiltrations) was determined using the semi-quantitative method of scoring with a Visual Analogue Scale according to the updated Sydney System Classification of chronic gastritis, 5 and scored 0-3 ( 0-none; 1-mild; 2-moderate and 3-marked) to each morphological variable.Intestinal metaplasia, glandular atrophy was not graded and was simply recorded as present or absent.
Selection bias and interpretation bias was minimized as possible.Data were recorded in the proforma form. The data was then coded and entry was done in the statistical package for the social sciences (SPSS) version 16.0. The data was processed and analyzed by using simple descriptive statistics; in terms of percentage and frequency.

RESULTS
A total of 250 gastric biopsy specimens, that met the inclusion criteria were studied. On histological examination, H. pylori were detected in 150 (60%) patients and 100 (40%) of patients were H. pylori negative.
The average age of the total population was 43.43 years (standard deviation (SD) 15.13) with age ranging 12-81years. One hundred sixty (64%) samples were obtained from males and 90(36%) samples were from females, with male to female ratio 1.77:1. The average age of male patients was 44.19 (SD 15.38) years, and the average age of women was 42.08 (SD 14.66) years.The mean age of patients in H. pylori positive group was 44.03 (SD 15.22) years and mean age in H. pylori negative group was 42.52 (SD 15.01) years. Male to female ratio in H. pylori positive and H. pylori negative group was 1.88:1 vs 1.63:1 respectively.

Chronic inflammation (Mononuclear cell infiltrations)
was found in all of the cases of both H. pylori positive and negativecases. The severity ofchronic inflammation was seen high amongH. pylori positive cases. Moderate inflammation predominated in H. pylori positive groupand was found in 75 (50%) cases. In H. pylori negative group, mild inflammation predominated and was found in 51 (51%) cases. In H. pylori positive samples, Neutrophilic activity was not seen in 14 (9.33%) samples, in the remaining 136 (90.66%) specimens, neutrophilic activity was present. In H. pylori negative samples, neutrophilic activity was not seen in 78 (78%) samples, whilet he remaining 22 Free Full Text Articles are Available at www.jnma.com.np (22%) cases showed neutrophilic activity. Distribution of histomorphological features gastritis among H. Pylori positive and negative groups is shown (Table 1).

DISCUSSION
In this study, histopathological reporting was done in all cases on antral biopsies, as antrum was the most common site from which biopsies were received. For the consideration of the patient's comfort and operator's convenience, it was difficult to follow the extensive endoscopy biopsy protocol of five biopsy samples as per the updated Sydney system, from every patient. Eriksson et al have recommended that antrum is the most likely site of histopathological findings in gastritis. 6 Similar to our study, Garg et al, 7 Park et al, 8 and Dhakhwa et al, 9 have alsoconsidered their studies mainly on antral biopsies. This variation in the prevalence of H. pylori may be due variation in biopsy sampling sites for varying intragastric colonization, host immune response, level of acid production, and prior treatment with proton pump inhibitors or anti H. pylori antimicrobial agents. Multiple site sampling may be needed to improve results.
Chronic Gastritis (Mononuclear cell infiltration) was seen in 250 (100%) cases in the present study. Various other studies have shown findings similar to this study. 7,8,15 Majority of inflammation in this study were of moderate grade (48.8%) followed by mild 42% and marked 9.6%, which is similar to the other studies. 8,14,15 In contrary to this, a study by Garg et In H. pylori positive cases, glandular atrophy was seen in 4 (2.6%) and intestinal metaplasia was seen in 7 (4.6 %) cases in the presentstudy. No cases of glandular atrophy or intestinal metaplasia were seen in H. pylori negative cases. In contrary to this finding Dakhwa et al, Pruthi et al, and Maharjan et al found glandular atrophy and intestinal metaplasia in both H. pylori negative and positive cases. 9,12,14 The limitation of this study is that only antral biopsy was considered for this study and the updated Sydney system was not strictly followed regarding sampling of gastric sites. Adherence to updated guidelinesof biopsy sites, considering the topographic distribution of H. Pylori, the diagnostic yield of gastric inflammatory conditions and H. pylori detection would have improved.

CONCLUSIONS
This study concludes that the prevalence of H. pylori infection is high in chronic gastritis. There is a parallel increase in the severity of chronic inflammation (lymphoplasmacytic infiltration) and neutrophilic activity as the severity of H. pylori infection increases. Greater the density of H. pylori, the larger is the degrees of chronic inflammation and neutrophilic