Helicobacter pylori seroprevalence in cirrhotic patients with hepatitis B virus infection

Abstract

Liver cirrhosis is a significant cause of death in Italy and one of the most frequent causes of hospitalization. The burden of cirrhotic patients on the National Health System is extremely high due to the frequent need for medical care. Acute peptic ulcer and upper gastrointestinal bleeding reportedly occur in over one-third of cirrhotic patients. Since Helicobacter pylori (H. pylori) infection strongly correlates with peptic ulcer, we wished to ascertain the prevalence of H. pylori infection in cirrhotic patients. In a case-control study we looked for this infection in 45 consecutive male patients suffering from hepatitis B virus (HBV)-related cirrhosis and 310 sex and age matched blood donors resident in the same area. Antibodies against H. pylori were present in 40/45 (89%) patients and 183/310 (59%) blood donors (P<0.001). This very high prevalence of H. pylori may explain the frequent occurrence of gastroduodenal ulcer in cirrhotic patients. (See Editorial p. 203)

Introduction

Cirrhosis of the liver is a diffuse process characterized by fibrosis and nodule formation. It may follow hepatocellular necrosis [1]. One cause of necrosis is chronic hepatitis. Hepatitis B virus (HBV) infection is quite prevalent in Italy: 3.5% of italian navy recruits were reported to carry the virus in 1981 [2] and it is likely that at least 3% of the adult male population is infected and at risk of developing the long-term sequelae. Cirrhosis of the liver eventually develops in 5 to 25% of patients with chronic HBV infection [3] though it is not clear why only a proportion of the infected patients progress to end-stage disease, and by which mechanisms HBV-related cirrhosis may ultimately lead to hepatocellular carcinoma, which reportedly occurs 5 to 40-fold more frequently in HBV patients [4].

The medical history of cirrhotic patients is punctuated by frequent hospitalizations due to the high rate of complications. Peptic ulcer and upper GI haemorrhage are life-threatening complications and they impose a heavy burden on the National Health Service, requiring emergency care and long hospital stays [5], [6].

Kirk et al. demonstrated a frequency of ulcer of 33% in patients with chronic liver disease and associated HBV [7]. In an Italian multicenter study frequency of gastric or duodenal ulcer was 12–20% in cirrhotic patients with the higher prevalence for gastric ulcers [8].

Gastric ulcer is rather infrequent in Torino and the incidence of duodenal ulcer was reported to occur in 3 to 5% of patients operated on for abdominal hernia. Duodenal and gastric ulcer appear to be related to infection by the Gram-negative bacterium Helicobacter pylori (H. pylori). Its natural habitat is the antral gastric mucosa where it induces chronic gastritis and may lead to peptic ulcer, gastric cancer and MALT Lymphoma [9]. H. pylori infection is particularly frequent in cirrhosis patients [10].

Chen et al. found a significantly increased prevalence of H. pylori infection in HBsAg positive cirrhotic patients: they report that the prevalence of peptic ulcer was 28.7% higher than in the general population in Taiwan [11]. Curiously one-half of the patients with an ulcer were not found H. pylori-positive. By contrast, in a multivariate analysis study of cirrhotics with different aetiologies, Calvet et al. found that male sex and H. pylori seropositivity (OR 1.7, 95% CI 1.02–2.81) were variables independently related to peptic ulcer [12]. Fan et al. found a higher seroprevalence of H. pylori in Chinese patients with HBV-related chronic hepatitis than in controls matched for age and socioeconomic status [13].

Peptic ulcer in cirrhotic patients is multifactorial in origin. The identification of preventable risk factors in different populations appears to be an important step to reduce morbility, mortality and social cost due to peptic ulcer.

This paper reports the prevalence of H. pylori antibodies in cases of HBV-related cirrhosis and controls (a group of blood donors).