Does a high prevalence of Helicobacter pylori in patients with Peptic ulcer disease at Charlotte Maxeke Johannesburg Academic Hospital justify empiric H. pylori eradication?

A Dissertation submitted to the Faculty of Health Sciences, University of the Witwatersrand, in fulfilment of the requirements for the degree of Master of Medicine in Surgery, Johannesburg 2018Introduction: Peptic ulcers (PUs) are defects in the mucosa of the gastro-intestinal tract (GIT) which extend through the muscularis mucosa. They develop when the protective mucosal barriers such as the mucous and bicarbonate get overwhelmed by the toxic effects of gastric acid and pepsin. The major risk factor in the development of Peptic ulcer disease (PUD) is Helicobacter pylori (H.pylori) infection. It is found in approximately 50% of the world’s population, with most of those infected (70-90%) residing in developing countries. H.pylori infection is associated with a number of GIT diseases, including chronic gastritis, which can be atrophic or nonatrophic, PUD, H.pylori associated dyspepsia, gastric cancer and gastric mucosa associated lymphoid tissue lymphoma (MALToma). The treatment for it is eradication therapy. It can be administered empirically (i.e. without confirming the presence of H.pylori infection) or after confirming the presence of infection through diagnostic tests. Empiric eradication therapy for H.pylori infection is justified in high prevalent areas and if duodenal ulcers (DUs) are invariably associated with it. In Africa, the prevalence of H.pylori infection ranges between 88 and 93%, with 70% of gastric ulcers (GUs) and 90% of DUs associated with H.pylori infection. In South Africa (SA), previous studies have found H.pylori infection prevalence to be 66%; with 88% of GUs and 98% of the DUs associated with H.pylori infection. Aim: To determine if empiric eradication therapy for H.pylori is justified in patients with PUD at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). Methods: The study was a retrospective record review of the Oesophagogastroduodenoscopy (OGD) reports of patients who presented with upper gastro-intestinal tract (UGIT) symptoms at CMJAH, Parktown Johannesburg, between the 1st of October and 31st December 2012. We excluded patients who had interventional endoscopy, previous gastric surgery, confirmed or v suspected malignancy and incomplete endoscopy. Data collected included patients’ demographics, endoscopic findings, H.pylori status and histological findings. Helicobacter pylori testing was done through histological assessment (i.e. using histochemical stains) of the endoscopically derived gastric mucosal biopsies. The permission to conduct the study was granted by the University of the Witwatersrand Human Research Ethics Committee (HREC) (M130668). Results: We obtained 311 records of which 91.6% were diagnostic OGD reports. 196 records met the study’s inclusion criteria. The mean age in years of the patients which were included in the study was 52.5 +/- 16SD. The commonest endoscopic diagnosis was gastritis (35.2%). PUD was diagnosed in 29.6% of the patients and the commonest site of peptic ulcers was found to be the stomach. Helicobacter pylori testing was performed in 69.9% of all the study participants. This cost the laboratory approximately R1 833. The overall prevalence of H.pylori infection was found to be 33.6%; 40-43.5% in PUD and 50.0% in DUs. Discussion: The overall prevalence of H.pylori infection of 33.6%; 40-43.5% and 50.0% in PUD and duodenal ulcers respectively is much lower compared to what the previous studies done in SA have shown. O’Keefe et al (2000) (32) reported an overall H.pylori infection prevalence of 80% and 81% found in PUs. Louw et al (1993) (27) showed an overall incidence of H.pylori infection to be 80% in GUs and 95% in DUs. Whilst, Tanih et al (2010) (12) found an overall H.pylori infection prevalence of 66.1%, 70.8% in GUs and 65% in DUs. We’ve noticed a decreasing trend of H.pylori infection in SA. This has also been observed in other parts of Africa e.g. Ethiopia. The prevalence of PUD of 29.6% was comparable to similar studies. Conclusion: In view of the fact that less than half of the population that present with UGIT symptoms at CMJAH is H.pylori infected and up to 50.0% of PUs are associated with H.pylori infection. In addition, testing for H.pylori is cost-effective. We conclude that empiric H.pylori eradication in patients with PUD at CMJAH is not justified.XL201