Helicobacter pylori associated gastritis

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Helicobacter pylori associated gastritis among Bahraini children presenting
with abdominal pain
Article · April 2010
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Hasan M Isa
Arabian Gulf University
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52 Vol. 22, No: 2 April – June 2010
JBMS Journal of the Bahrain Medical Society
Helicobacter Pylori Associated Gastritis among
Bahraini Children Presenting with Abdominal Pain
Hasan Ali Zainaldeen, MBChB1
Hasan Mohamed Ali Isa Al-Faraj, MBBCh1
Objectives: This cross-sectional retrospective study was done to determine the prevalence of H.pylori
gastritis among Bahraini children presented with recurrent abdominal pain (RAP) as primary objective.
The secondary objectives were to study the significant associated symptoms with abdominal pain among
patients proven to have H. pylori associated gastritis and to determine their response of to treatment.
Methods: Hundred patients, aged 3-17 years, from Jan1999 – Jan2004 were studied. All patients were
evaluated by UGI endoscopes and biopsies. Patients with H.pylori gastritis were treated for two weeks with
triple therapy and followed up for six months.
Results: H.pylori gastritis was found in 57 (57%) patients. Abdominal pain was central in 54% and nocturnal
in 65%. Vomiting (53%) and nausea (51%) were the most frequent associated symptoms. 49 % of infected
patients showed improvement of these symptoms, after triple therapy, upon six months follow-up.
Conclusion: This study showed high prevalence of H pylori associated gastritis among Bahraini children
presenting with recurrent abdominal pain. Further prospective studies are needed to determine the longterm
outcome of H.pylori associated gastritis among our pediatric population.
Keywords: Helicobacter pylori, gastritis, recurrent abdominal pain, upper gastrointestinal endoscopy,
gastroesophageal reflux disease.
ص? الملخ
شريحة من الأطفال البحرينيين ? صاحب لجرثومة الهليكوبكتر بايلوري بين ? شار ا إ للتهاب المعدي الم ? نت � سة : هو تحديد مدى إ ? هدف الدرا
صاحبة ل آلام البطن وكذلك مدى ? ضالم ? هم الأعرا � سة أ ? أما الأهداف الثانوية فهي درا � . ولي � آلام البطن المتكررة كهدف أ � الذين يعانون من
ستجابة الإلتهابات المعدية للعلاج . ?�إ
ضى ? سنة في الفترة ما بين يناير 1999 – يناير 2004 ،كما تم تقييم كل المر ? 17 – أعمارهم بين 3 � سة 100 طفل تتراوح ? الطريقة : تم درا
سبوعين والمتابعة ?أ� صابين بالعلاج الثلاثي لمدة ? أخذ عينات معدية ، ومن ثم علاج الم � ضمي العلوي مع ? جراء منظار للجهاز اله � عن طريق إ
شهر . ?� ستة أ ? لمدة
ؤ � أن التقي � صاحبة ل إ للتهابات المعدية المزمنة و ? صابين بجرثومة الهليكوبكتر الم ? ؤلاء كانوا م � أن % 57 من ه � سة ? ضح من الدرا ? إت� : النتائج
ستجابوا للعلاج . ?إ� ؤلاء ا أ لطفال � أن % 49 من ه � صاحبة ل آلام البطن المتكررة كما تبين ? ضالم ? هم الأعرا � و الغثيان كانا أ
شريحة الأطفال ? صاحب لجرثومة الهليكوبكتر بايلوري بين ? شار عالية من ا إ للتهاب المعدي الم ? نت � سبة إ ? سة تبين وجود ن ? الخاتمة:هذه الدرا
ستقبلية لتحديد ا آ لثاربعيدة المدى للإلتهاب ? سات الم ? آلام البطن المتكررة و المطلوب هو المزيد من الدرا � البحرينيين الذين يعانون من
صاحب لجرثومة الهليكوبكتر بايلوري على ا أ لطفال. ? المعدي الم
ضمي العلوي ، ا إ لرتداد المعدي المريئ. ? آلام البطن المتكررة ، منظار الجهاز اله � ، الكلمات الدالة : هليكوبكتر بايلوري ، الإلتهاب المعدي
1 Pediatric department, Salmaniya medical complex, Manama , Kingdom of Bahrain
Received 17th January 2009
Accepted 25th February 2010
Helicobacter pylori is a gram negative curved bacillus that colonizes
gastric mucosa in humans1. It has been recognized as a pathogen
that causes gastritis, peptic ulcer disease and some forms of gastric
cancer. Although most of the severe clinical manifestations of this
infection appear in adults, the epidemiological studies showed
that an acquisition of infection usually occurred in childhood.
Our understanding of the pathogenesis of H. Pylori suggested
that gastric mucosal damage is progressive2. Studies from the
developed countries showed that there are marked differences in
the prevalence and age specific frequency of H.pylori infection in
the different population and the different socioeconomic groups3, 4.
A study done in Bahrain demonstrated high prevalence of H. pylori
infection in dyspeptic adults. The prevalence reached up to 75%
and had positive association with duration of dyspepsia5. There is
no exact figure reported for the prevalence of H.pylori infection
among Bahraini children. The primary objective of this study was
to determine the prevalence of H pylori infection among Bahraini
children presented with recurrent abdominal pain. The secondary
objectives were to study the significant symptoms associated with
abdominal pain among patients proven to have H. pylori associated
gastritis and to determine their response of to treatment.
Vol. 22, No: 2 April – June 2010 53
JBMS Helicobacter Pylori Associated Gastritis among Bahraini Children Presenting with Abdominal Pain Journal of the Bahrain Medical Society
Patients and Methods
In a cross sectional retrospective study, one hundred patients
were admitted to Salmaniya Medical Centre(Bahrain), over four
years period, from January 1999 to January 2004. All patients
were referred to pediatric gastroenterology clinic with a history of
recurrent abdominal pain.
One hundred patients’ medical records were reviewed for
demographic data, abdominal pain characteristics, H. pylori
serology, endoscopic findings, histopathology, tissue culture and
response to treatment. The diagnosis of gastritis was based on
histological evaluation of tissue biopsy stained by hematoxylin and
eosin. H pylori organisms were identified on histology, by modified
gram stain and by gastric biopsy tissue culture. H. pylori antibodies
(IgG) were determined by enzyme immune assays (EIA) for most of
the patients as a screening test. Further assays were done on follow
up to a lesser number of patients. Patients with H.pylori associated
gastritis was treated with fourteen days of triple therapy which
includes a protein pump inhibitor (PPI) omeperazole 1mg/ kg/
day up to 20 mg daily, amoxycillin 45mg/ kg / day up to one gram
twice daily and clarithromycin 15 mg/ kg/ day up to 500mg twice
daily. The response to treatment was monitored by improvement of
clinical symptoms and disappearance of H.pylori antibodies.
Statistical analysis: The mean value was calculated for continuous
variable and the frequency for all categorical variables was also
Among hundred patients with recurrent abdominal pain included
in this study, fifty seven patients (28 boys and 29 girls) were found
to have H.pylori associated gastritis. The clinical characteristics of
patients with H. pylori gastritis were shown in (table 1). H.pylori
gastritis was associated with nocturnal pain in 37 patients (65%)
and hematemesis in 3 patients (5%). The chronic active gastritis
was confirmed by at least one of the following tests being positive;
histology, biopsy gram stain, biopsy tissue culture or H. pylori serology
(Table 2). Most patients had three or four positive tests. Out of those
57 patients, two patients only had normal upper gastrointestinal
endoscopies while 55 patients had endoscopes which showed
Table 1. Demographic data of patient with
chronic gastritis = 57 pt
Characteristics & symptoms No. of patients %
Sex (M/F) 28/29 49/51
Age Range 3-17 years
Mean 11 years
Abdominal pain duration
3-96 months
Epigastric 20 35
Central 31 54
Generalized 6 11
Nocturnal pain 37 65
Diarrhea 7 12
Nausea 29 51
Vomiting 30 53
Regurgitation 4 7
Hematemesis 3 5
Table 2. Diagnostic tests used to confirm
H.pylori gastritis
Positive % Negative % Not done %
Histology 45 79 12 21 – –
Gram stain 44 77 13 23 – –
Culture 42 74 15 26 – –
33 58 15 26 9 16
Table 3. Endoscopic findings of patient with
chronic gastritis
Endoscopic No. of Histopathology
appearance patients % features
Normal 2 4 Chronic active
44 77 gastritis
(Gastritis &
Chronic active
Esophagitis) 11 19 Chronic active
Micro nodular 33 58 –
Duodenal ulcer 9 16 –
Stomach ulcer 1 2 –
Hiatus hernia 9 16 –
Table 4. Clinical response to treatment
among H.pylori associated gastritis patients
No. %
Improved 28 49
Not improved 19 33
Lost follow up 10 18
Total 57 100
macroscopic changes in the form of hyperemic gastric antrum
(Table 3). The histological changes were positive in all patients with
Hpylori associated gastritis and recurrent abdominal pain. Chronic
esophagitis consistent with gastro esophageal reflux disease was
found in 11 patients (19.2 %) but no PH studies were done. Nine
patients(15.7%) had duodenal ulcers and only one patient had
stomach ulcer(1.7%). Micro nodular gastric antral mucosa was
seen in 33 patients (57.8%) and hiatus hernia of various degrees
in 9 patients (15.7%). The diagnosis was confirmed by two to four
positive diagnostic tests in 45 patients (79%) and one positive
test in 12 patients (21%) as shown in table 2. Positive histology for
spiral shaped organisms was found in 45 patients (79%), positive
gram stain in 44 patients (77%) and positive culture in 42 patients
54 Vol. 22, No: 2 April – June 2010
JBMS Journal of the Bahrain Medical Society
explained by the presence of associated gastroesophageal reflux
disease in some patients or by the patients who lost follow up
(18%). Recently, a proposed 10 days sequential treatment achieves
higher eradication rate than standard triple therapy11. This study
had its limitation as a retrospective study. It was not possible to
compare between the group of patients involved in this study and
the patients who had idiopathic recurrent abdominal pain and had
been endoscoped. Other problem was the lack of scoring system
to assess the recurrent abdominal pain before and after treatment.
Lastly, the clinical improvement was not confirmed by endoscopic
biopsies or urea breath test.
This study showed high prevalence of H.pylori associated gastritis
among Bahraini children presenting with recurrent abdominal
pain. Vomiting and nausea were the most frequent associated
symptoms. 49 % of infected patients showed improvement of
these symptoms, after triple therapy, upon six months follow-up.
Further prospective studies are needed to determine the longterm
outcome of H.pylori associated gastritis among our pediatric
1. Colin Macarthur, Norman Saunders, F William Feldman. Helicobacter
Pylori gastro duodenal disease and recurrent abdominal pain in children.
JAMA march 1995, 273:729-34.
2. Peter B. Erust, Benjamin D, Gold. Helicobacter Pylori in childhood: New
insight into immunopathogenesis of gastric disease and implication
for managing in children. Journal of Pediatric Gastroenterology and
Nutrition may 1999, 28: 462- 473.
3. Frederick SC, Malaty HM, Evans DL, etal.Factors influencing the
epidemiology of Helicobacter pylori infection in children. Pediatrics 1991;
88: 578- 82.
4. Graham DY, Klein PD, Opekun AR. Epidemiology of campylobacter pylori
infection: ethnic consideration. Scand JGastroenterology 1988; 23(suppl
5. Ramadas Kamath, Jehad Alqumish, Aziz Yousif & A.RahmanFakro.
Prevalence of helicobacter pylori among dyspeptic patients in Bahrain.
Bahrain Medical Bulletin, June 1995, 17:50-52.
6. Drumm B. Helicobacter pylori. Arch Dis Child 1999; 65:1278-82.
7. Sipponen P, Varis K, Fraki O, Korri UM, Sappala K, Siurala M.Cumulative
10- year risk of symptomatic duodenal & gastric ulcers in patients with
or without chronic gastritis: a clinical follow up study of 454 outpatients.
Scand J Gastroenterol 1990; 25: 966-73.
8. Merja Ashorn, Markku Maki, Tarja Ruuska, Riitta Karikoski-Leoetal. Upper
gastrointestinal Endoscopy in Recurrent Abdominal Pain of Childhood. J
Pediatr Gastroenterol Nutr.1993; Apr;16:273-277.
9. S. Radha Krishnan, B. AlNakib, M. Kalaoui & J. Patric. Helicobacter Pylori
associated gastritis in Kuwait; Endoscopy –Based study in symptomatic &
asymptomatic children. J Pediatr Gastroenterol Nutr1993; 16: 126-129.
10. Aliya Uc and Sonny K. F. Chong. Treatments of Helicobacter Pylori gastritis
improve dyspeptic symptoms in children pediatric.gastroentrol nutr.
March 2002; 34: 281-285.
11. Ruggiero Francavilla, Elena Lionetti, Stefonia Paola Castellaneta,etal.
Improved efficacy of 10-day sequential treatment for Helicobacter pylori
eradication in children: A randomized trial. Gastroenerology. Nov 2005;
(72%). H pylori antibodies were positive in 33 patients (60%),
negative in 15 patients (26%) and not done in 9 patients (16%).The
clinical response to treatment of H. pylori gastritis (disappearance
of abdominal pain and its associated symptoms) after a period of
six months follow up was shown in (table 4). Clinical improvement
was seen in 28 patients (49%), 19 patients (13%) did not improve
and 10 patients (18%) lost follow up. Unfortunately, anti H pylori
antibodies were not done regularly on follow up. It was done only
for few patients and mostly those who had persistent abdominal
symptoms. So, we could not draw a conclusion but we can assume
that the test was not done because of clinical improvement. Two
patients were re- endoscoped and both had Hpylori gastritis and
have been treated again.
This study shows high prevalence of H.pylori gastritis (57 %) among
Bahraini children, aged 3-17 years, presenting with recurrent
abdominal pain. The frequency of H.pylori gastritis increases with
age. The prevalence of H.pylori gastritis among adults in Bahrain
was found to be 80%5. In western societies, H. pylori infection
studies are well established, and it showed a prevalence of 10-30%
among symptomatic children6. This obvious difference between
developed and developing countries could be explained by the
differences in the standard of living between them. Most of the
patients involved in this study were from low socioeconomic class.
However, no detailed socioeconomic survey was done. Chronic
gastritis precedes the formation of peptic ulcer7. This study showed
that all children with H.pylori infection had gastritis or duodenal
ulcer disease. 15.7% of the children had duodenal ulcer disease
and 1.7% of them had gastric ulcers. These findings are five times
more than what was found in a Finish study8. The difference
between the prevalence in the two countries could be due to
delayed presentation of the patients and their poor socioeconomic
status. In a Kuwaiti study, micro nodular gastritis was found only in
22% of the patients9, while it is 57% in Bahraini children. Chronic
esophagitis which was consistent with gastroesophageal reflux
disease was found in 19.2%, but no PH studies were done. The
patients involved in this study presented with chronic recurrent
abdominal pain similar to RAP syndrome but with association of
red flag symptoms and signs. Of particular, nocturnal abdominal
pain presented in 37 patients (65%), and hematemesis in 3 patients
(5%). These findings are similar to the other european studies10.
ELIZA IgG is a good screening method in determining which child
should be investigated further by oesophagogastroduodenoscopy.
In this study, the sensitivity of a serology test ELIZA IgG was
60%, which is less than other studies8. In general, the diagnosis
of H.pylori infection could be based on finding of chronic active
gastritis of gastric antrum biopsies. Histopathology can clarify the
diagnosis even if the mucosa appears macroscopically normal.
In this study, 80% of patients had more than two positive tests
(histology, gram staining, culture and serology) that confirmed
the diagnosis. In children a triple therapy with clarithromycin,
amoxicillin and proton pump inhibitor for two weeks can improve
H. pylori gastritis dyspeptic symptoms10. The improvement of
symptoms in the patients in this study was only 49%. This could be
Hasan Ali Zainaldeen, Hasan Mohamed Ali Isa Al-Faraj
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