GLOBAL JOURNAL OF PURE AND APPLIED SCIENCES VOL. 25, 2019: 145-151
COPYRIGHT© BACHUDO SCIENCE CO. LTD PRINTED IN NIGERIA ISSN 1118-0579
www.globaljournalseries.com, Email: [email protected]
PREVALENCE OF HELICOBACTER PYLORI INFECTION AMONG
DYSPEPSIA PATIENTS IN CALABAR.
KOOFFREH-ADA MBANG, OKONKWO UCHENNA, UGBONG EMMANUEL, ESSIEN
ANIEKAN, CHUKWUDIKE EVARISTUS, EDOGIAWERIE DONALD, NGIM OGBU.
(Received 20 May 2019; Revision Accepted 14 June 2019)
Helicobacter pylori is an ubiquitous organism. It is estimated that more than 50% of the world’s population is
infected with the bacteria. The infection is typically acquired in infancy and has been associated with poor living
conditions and low socio-economic status. Once helicobacter pylori is acquired, it commonly persists lifelong
unless treated. This pathogen has been implicated as a major aetiologic agent in the pathogenesis of peptic ulcer
disease and is an established carcinogen. The aim of this study was to determine the prevalence of helicobacter
pylori infection among our dyspeptic patients. This was a retrospective study conducted from April 2014 to
December 2018. A total of one hundred and fifteen (115) patients who had symptoms of dyspepsia were recruited
within this period of time. The presence of helicobacter pylori was determined using urea breath test. The results
showed that 42.6% of the patients were positive for helicobacter pylori, while 51.3% of patients had a negative
result. A borderline result was seen in 6.1% of patients. The mean age of the studied population was 45.10 years
(SD= 12.55), with most patients aged between 41-60 years. This study showed no sex predilection, with an equal
sex distribution of the study participants. Reports from other parts of the country also found the prevalence of
helicobacter pylori to be highest in individuals between the 4th and 5th decade of life. This study concluded that the
prevalence of helicobacter pylori infection is relatively high among patients with dyspepsia in South South Nigeria.
KEYWORDS: Helicobacter pylori, dyspepsia, urea breath test, South South Nigeria.
Robin Warren and Barry Marshall brought to the
attention of the world the role of Helicobacter pylori
(H.pylori) in the pathogenesis of peptic ulcer disease
(PUD) over a decade ago (Peura et al, 2010). Since
then, several studies have been done worldwide and
even in Nigeria regarding this pathogen, however
there is paucity of data regarding this infection in
Calabar, Southern Nigeria. Helicobacter pylori is a
resilient gram negative, micro-aerophilic bacillus
which resides in the acidic milieu of the human
stomach (Adeniyi et al, 2012).It has a unique spiral
shape and multiple unipolar flagella which enables it
to traverse the course of the mucous layer of the
gastric epithelium, where it remains protected from the
low gastric ph (Peura et al, 2010).Helicobacter pylori
further controls the acidic environment of the stomach
by producing copious amounts of urease, an enzyme
that hydrolyses urea to alkaline ammonia and carbon
Kooffreh-Ada Mbang, Department of Internal Medicine, University of Calabar Teaching Hospital, Nigeria.
Okonkwo Uchenna, Department of Internal Medicine, University of Calabar Teaching Hospital, Nigeria.
Ugbong Emmanuel, Department of Internal Medicine, University of Calabar Teaching Hospital, Nigeria.
Essien Aniekan, Department of Internal Medicine, University of Calabar Teaching Hospital, Nigeria.
Chukwudike Evaristus, Department of Internal Medicine, University of Calabar Teaching Hospital, Nigeria.
Edogiawerie Donald, Department of Internal Medicine, University of Calabar Teaching Hospital, Nigeria.
Ngim Ogbu, Department of Surgery, University of Calabar Teaching Hospital, Nigeria.
© 2019 Bachudo Science Co. Ltd. This Work is Licensed under Creative Commons attribution 4.0 international License.
dioxide (Peura et al 2010, Ferwana et al 2015). The
production of urease is the principle behind the urea
breath test and rapid urea biopsy tests for the
detection of H.pylori infection (Peura et al 2010,
Ferwana et al 2015). Helicobacter pylori infection is
prevalent worldwide involving more than half of the
world populace (Peura et al 2010, Hunt et al
2010).The prevalence rate is influenced by age,
geographic, ethnic, and socioeconomic factors (Hunt
et al 2010).). Recent trends suggest a decrease in the
incidence of H.pylori in the Western world, but an
increasing prevalence in developing countries
(Jemikalajah et al 2014). Worldwide prevalence
figures reveals varied reports, in the United States for
instance, the prevalence rate is 30 to 40%, while
higher figures (70 to 90%) have been reported in
South American and African studies (Adeniyi et al,
2012, Hunt et al 2010). In West Iran, Sheikhan et al
found the overall prevalence rate of H.pylori infection
to be 43%, this was lower than figures seen in other
developing countries (Sheikan et al, 2011). The earlier
concept of an ‘African enigma’ regarding the low
prevalence of H. pylori infection and its complications
(peptic ulcer and gastric cancer) in Africa has been
debunked with current reports revealing a prevalence
that is comparable with data in developing countries
(Agha et al, 2005). One reason given for this trend, is
the improved diagnosis of the infection (whilst
investigating PUD) through histologic specimens
obtained from upper gastrointestinal endoscopy (Agha
et al, 2005).
A report in Ghana, found that 74.8% of patients with
dyspeptic symptoms had H.pylori infection
(Archampong et al, 2015).Similarly, Ndububa et al in
South West Nigeria, reported a prevalence of 73%
among dyspeptic patients (Ndububa et al, 2001). Both
studies used campylobacter-like organism (CLO)-
urease test on gastric specimens at upper
gastrointestinal endoscopy (Archampong et al
2015,Ndububa et al, 2001).Whereas, in Keffi, North
Central Nigeria, Ishaleku et al reported a relatively
lower sero-prevalence rate of 54.0% among University
undergraduates (Ishaleku et al 2010). While reports in
South-east Nigeria and South – south Nigeria revealed
lower sero-prevalence rates of 25% and 12.7%
respectively ( Ahaneku et al 2010, Jemikalajah et al
2014). These Nigerian studies showed a steady
decline in H. pylori prevalence over the past decade.
Socioeconomic differences among the populations
studied may be contributory to the variations in
H.pylori prevalence. Poor sanitary methods, lack of
potable water as well as overcrowding and poor
dietary habits have been linked to the transmission of
H.pylori usually through the oral–oral or faeco–oral
routes (Peura et al, 2010). Childhood infections are
reported to be common globally especially in
developing countries (Peura et al 2010, Jemikalajah et
al2014). Helicobacter pylori infection is a major public
health concern and has been implicated in the
pathogenesis of gastric and duodenal ulcer as well as
gastric mucosa–associated lymphoid tissue (MALT)
lymphoma, and adenocarcinoma (Peura et al, 2010).
Host genetics, bacterial traits and environmental
features have been proven to influence the clinical
outcome of the infection(Peura et al, 2010).The
infection has a high morbidity but low mortality rate
and a ‘cure’ can be achieved with an appropriate
antibiotic regimen (Malaty et al 2007). Currently the
diagnosis of H.pylori can be through invasive and noninvasive
techniques, including endoscopy with biopsy,
serology for immunoglobulin titres, stool antigen test
and UBT (Ferwana et al).The sensitivity of serology is
quite high (90% to 100%) but its specificity is variable
(76% to 96%), especially in areas where the
prevalence of H. pylori is low. Therefore, in places
where infection is less common (most areas of the
United States), the negative predictive value of
serology is high (Peura et al, 2010). Conversely, the
positive predictive value is poor, suggesting most
often positive results are actually falsely positive
especially in areas were the infection is prevalent
(Peura et al, 2010).Hence, the diagnosis is best
confirmed with another method such as a stool
antigen or UBT before commencing treatment (Peura
et al, 2010).Stool antigen test or UBT is the preferred
non -invasive test for the preliminary diagnosis of
active H. Pylori infection (Hunt et al, 2010). Both
investigations have a comparable sensitivity (88% to
95%) and specificity rate (95%)(Hunt et al,
2010).Endoscopic biopsy of gastric tissue is preferred
in patients undergoing a diagnostic endoscopy who
are found to have a pathology such as an ulcer or for
those requiring endoscopy to follow-up a gastric ulcer
or suspected MALT lymphoma. The reported
sensitivity of rapid urease tests is 90% to 95% (Hunt
et al, 2010).
MATERIALS AND METHOD
The University of Calabar Teaching Hospital (UCTH)
is a tertiary health institution located at Calabar the
state capital of Cross River State. It is a main
reference centre in the state and also neighbouring
states like Akwa Ibom, Abia and Benue.
Study design and data collection This study was a
retrospective study involving patients with dyspeptic
symptoms who presented to the Medical Outpatient
Department of the University of Calabar Teaching
Hospital for UBT screening. Data was retrieved from
patient’s records from April 2014 to December 2018.
KOOFFREH-ADA MBANG, OKONKWO UCHENNA, UGBONG EMMANUEL, ESSIEN ANIEKAN,
146 CHUKWUDIKE EVARISTUS, EDOGIAWERIE DONALD, NGIM OGBU.
A total of one hundred and fifteen (115) patients were
investigated within this period of time. Demographic
information such as age, sex, occupation, educational
status, state of origin were obtained. In addition,
history of smoking of cigarettes and number of
siblings was also gathered.
The Heliprobe analyser with serial number 1919
(manufacturer: KIBION AB, SE-751 05 Uppsala
Sweden) was used for the detection of gastro
duodenal H.pylori infection. The results are obtained
on-site with a diagnosis being made within 20
Patients were instructed to come fasting for the test,
they were to swallow the Helicap capsule with 50mls
of water. The Helicap capsule contains 14C- labelled
urea, which disintegrates rapidly in the stomach and
14C-urea is dissolved. In the presence of H.pylori, the
14C-urea is metabolized to carbon dioxide and
ammonia by the enzyme urease produced by H.pylori.
The available 14C isotopes, now in the form of 14C02,
diffuses into the blood to be transported to the lungs ,
where it is exhaled in the breath to be captured during
sampling using the breath card. In the absence of
H.pylori, the administered urea is absorbed in the
gastrointestinal tract and subsequently voided.
Results were expressed as; Heliprobe 0= patient not
infected, Heliprobe 2= patient infected and Heliprobe
1 = borderline. The sensitivity and specificity of the
Heliprobe analyser are 95% and 100% respectively.
Analysis of data was done using the Statistical
Package for Social Sciences version 18 (PASW
statistics 18). Quantitative data was expressed as
mean and standard deviation (SD). Categorical
variables were compared using the Chi-square tests
to establish association with H.pylori. A p-value of
0.05 or less was considered statistically significant.
Results A total of 115 individuals were tested for
H.pylori infection, comprising patients with dyspeptic
symptoms (belching, bloating, epigastric pain,
retrosternal burn and flatulence). A comparable
number of males (58, 50.4%) and females (57, 49.6%)
were investigated, with the mean age of patients
being 45.10 years (SD=12.55) and the age ranging
between 18 to 77 years. Most patients had an
average of three to four siblings (53, 46.1%). The
mean number of siblings was 4.37 (SD=2.28), with the
range being 0 to 13.Forty nine (42.6%) patients tested
positive for H.pylori (heliprobe 2), while 59 (51.3%)
and 7 (6.1%) had negative (heliprobe 0) and
borderline (heliprobe 1) results respectively (see
figure 1). Most patients (23, 42.6%) who tested
positive for H.pylori infection were aged between 41 to
60 years, however this finding was not statistically
significant (p> 0.005). It was also observed that most
patients (35, 38.9%) that came from Southern Nigeria
(Cross River State, Akwa Ibom State, Rivers State,
etc) had H.pylori infection, however this was not
statistically significant (p>0.005). Majority of patients
(34, 41.0%) with H.pylori had tertiary level of
education, though this finding was not statistically
significant (p> 0.005), see table 1.
PREVALENCE OF HELICOBACTER PYLORI INFECTION AMONG DYSPEPSIA PATIENTS IN CALABAR. 147
Heliprobe 0 N=
18-40 25 (51.0) 21 (42.9) 3 (6.1) 0.630* 1.000
41-60 28 (51.9) 23 (42.6) 3 (5.6)
>60 6 ( 50.0) 5 (41.7) 1 (8.3)
Male 30 (51.7) 24 (41.4) 4 (6.9) 0.238* 1.000
Female 29 (50.9) 25 ( 43.9) 3 (5.3)
Civil servant 22 (51.2) 17 (39.5) 4 (9.3) 9.002* 0.502*
Public servant 11 (35.5) 18 (58.1) 2 (6.5)
Trading/Business 17 (58.6) 11 (37.9) 1 (3.4)
Unemployed 2 (66.7) 1 (33.3) 0 (0)
Student 3 (60.0) 2 (40.0) 0 (0)
Healthcare worker 4 (100.0) 0 (0) 0 (0)
Married 51 (51.5) 41 (41.4) 7 (7.1) 2.971* 0.722
Single 8 (53.3) 7 (46.7) 0 (0)
Widowed 0 (0) 1 (100.0) 0 (0)
Primary 6 (75.0) 2 (25.0) 0 (0) 3.988* 0.651
Secondary 9 (45.0) 11 (55.0) 0 (0)
Tertiary 42 (50.6) 34 (41.0) 7 (8.4)
Informal 2 (50.0) 2 (50.0) 0 (0)
Place of Origin
Southern Nigeria 50 ( 55.6) 35 (38.9) 5 (5.6) 9.008* 0.121
Eastern Nigeria 6 (40.0) 9 (60.0) 0 (0)
Western Nigeria 2 (33.3) 2 (33.3) 2 (33.3)
Northern Nigeria 1 (25.0) 3 (75.0) 0 (0)
No. of Siblings
0 1 (50.0) 1 (50.0) 0 (0) 4.046* 0.707
1-2 9 (56.3) 5 (31.5) 2 (12.5)
3-4 29 (54.7) 21(39.6) 3 (5.7)
>4 20 (45.5) 22 (50.0) 2 (4.5)
No 59 (51.8) 48 (42.1) 7 (6.1) 2.367* 0.487
Yes 0 (0) 1 (100.0) 0
*Fisher’s exact test was used where counts are less than 5 in any cell.
KOOFFREH-ADA MBANG, OKONKWO UCHENNA, UGBONG EMMANUEL, ESSIEN ANIEKAN,
148 CHUKWUDIKE EVARISTUS, EDOGIAWERIE DONALD, NGIM OGBU.
A total of one hundred and fifteen (115) individuals
with dyspeptic symptoms were investigated in this
retrospective study. Forty nine (42.6%) of these
patients tested positive for H.pylori infection, while 59
(51.3%) were negative. The prevalence rate shown in
our study is lower than the average global prevalence
rate (50%) and most African reviews (Adeniy
2012, Archampong et al, 2015, Ndububa et al,
2001).Reports from Western (Ibadan), North central
(Keffi) and Eastern (Enugu) Nigeria had prevalence
rates way above the average global prevalence rate
(Adeniyi et al 2012, Ishaleku et al 2010, Ezugwu e
2014).However, the prevalence rate found in our
study was higher than reports found in the Southern
part of the country (Ahaneku et al 2010, Jemikalajah
et al 2014). The relatively lower prevalence of H.pylori
infection reported in our study and in other parts of
Southern Nigeria, when compared to other regions of
the country may suggest a decline in the disease
trend in the region. The disparity in prevalence rates
in the various parts of the country may largely be
linked to the socioeconomic status of dyspeptic
patients in the region. This could be associated with
improved hygiene standards and wide spread use of
antibiotics (Jemikalajah et al 2014). Furthermore,
gradual urbanization with better access to healthcare
facilities and potable water could be another reason
PREVALENCE OF HELICOBACTER PYLORI
Adeniyi et al
her he f . for this observation, as may be deduced from our
study. A low socioeconomic status has been reported
to promote the transmission of H.pylori
and it has been speculated that the spread of the
infection may be associated with dom
overcrowding, high housing density as well as sharing
of beds especially in developing countries (Oling et al
2015, Whitaker et al 1993, Ozbey et al 2017 and Den
Hoed et al 2011). Bello and his colleagues, in their
review showed that the lower social
significant association with H.pylori (Bello et al, 2018).
They proposed that Individuals from the lower
socioeconomic class were more likely to be linked
with poor education, including poor health education
and a more likelihood of living in an environment that
predisposes to faecal contamination of food and water
(Bello et al, 2018). On the contrary our study found
the prevalence of H.pylori to be higher in patients with
tertiary level of education, these category of
individuals tend to fall under the high or middle social
class demographic (civil and public servant), however
no statistical significant association was seen. It could
be assumed that these well-educated group of
individuals had a better health seeking attitude
regarding their dyspeptic symptoms than those in the
lower socioeconomic class (who could probably be
more at risk). The mean age of patients in this study
was 45.10 years (SD=12.55), with most patients who
INFECTION AMONG DYSPEPSIA PATIENTS IN CALABAR.
ello class had a
tested positive for H.pylori aged between 41-60 years.
This was comparable with reports from other parts of
the country which found the prevalence of H.pylori to
be highest between the 4thand 5th decade of life
(Ezugwu et al 2014, Jemilohum et al 2011).The
prevalence of H. pylori has been reported to increase
with age, with the prevalence climbing up to 50% in
those 60 years or older (Adeniyi et al, 2012).This
increased prevalence of infection with age was initially
thought to be due toon-going acquisition throughout
adult life(Peura et al, 2010). However, in developing
countries new adult infection and reinfection are
infrequent (Peura et al, 2010). Rather this observation
reflects possible childhood infection among this age
group (Jemikalajah et al, 2014).A comparable number
of males (58, 50.4%) and females (57, 49.6%) were
studied in this report, with no sex predilection
observed. This finding was also seen in a Kano report,
where there was no significant differences in
prevalence among both genders (Kumurya et al
2015).This was contrary to other reports in the country
which found a higher prevalence of H.pylori infection
in their female patients (Jemikalajah et al, 2014,
Omosor et al 2015, Olokoba et al 2013, Samson et al
2018). Whereas, Bello et al found a male
preponderance for H.pylori infection among their
patient’s (Bello et al, 2018).The lack of sex
predilection for H.pylori infection in both sexes in our
study could be as a result of a common risk of
acquiring the infection in both genders. Helicobacter
pylori infection was also found to be more prevalent in
our patients who had either 3 to 4 siblings or more
than 4 siblings, however there was no significant
association. The number of siblings has been linked
with an increased risk of acquiring H.pylori (Peura et
al, 2010, Ozbey et al, 2017). This finding suggests
that our patients who had a higher number of siblings
may have acquired H.pylori in childhood. The number
of siblings may essentially be measuring crowded
living conditions, sharing of beds as well as house
density during the childhood of our patients. This may
give a glimpse of the socioeconomic status of our
patients during their childhood. This report showed a
relatively lower overall prevalence of H.pylori when
compared with local and global studies. The higher
trend of H.pylori infection in the 4th and 5th decade of
life in this study, is in keeping with most reports and is
reflective of the ‘birth cohort effect’ of H,pylori, which
describes the increasing prevalence of the infection
with age (Lim et al 2013, Mhaskar et al 2013). Though
a low socioeconomic status has been linked with an
increased prevalence of H.pylori especially in
developing countries (Mhaskar et al 2013). The
finding of our patients being from a higher
socioeconomic status does not preclude possible
childhood acquisition of the disease from crowded
living conditions or sharing beds as a result of having
a higher number of siblings. Other factors such as
cigarette smoking has been reported to exacerbate
the outcome of H.pylori infection (Zhu et al, 2014).
However, this review, showed no association with
cigarette smoking probably due to the fact that only
one person in our study acknowledged this habit.
This study was limited by the relatively small study
population (this could account for the lack of statistical
association with established risk factors for the
acquisition of H,pylori). A community based study may
address this concern.
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