Clinicopathological features of Helicobacter pylori-negative early gastric cancer / 北京大学学报(医学版)

OBJECTIVE@#To investigate the clinicopathological features of Helicobacter pylori (Hp)-negative early gastric cancer.@*METHODS@#The clinicopathological data of 30 cases of Hp-negative early gastric cancer were collected retrospectively at Pingdingshan Medical District, 989 Hospital of PLA Joint Logistics Support Force, and Beijing Chaoyang Hospital, Capital Medical University, from 2009 to 2021, and the histomorphological characteristics and immunophenotype were observed, and combined with the literature to explore.@*RESULTS@#The median age of 30 patients was 58.5 years (range: 21-80 years), including 13 males and 17 females. The upper part of the stomach was 13 cases, the middle part of the sto-mach was 9 cases, and the lower part of the stomach was 8 cases. The median diameter of the tumor was 11 mm (range: 1-30 mm). According to the Paris classification, 9 cases were 0-Ⅱa, 7 cases were 0-Ⅱb, and 14 cases were 0-Ⅱc. Endoscopic examination showed that 18 cases of lesions were red, 12 cases of lesions were faded or white, and microvascular structures and microsurface structures were abnormal. In all the cases, collecting venules were regularly arranged in the gastric body and corner mucosa. There were 18 cases of well differentiated adenocarcinoma in the mucosa. The tumor presented glandular tubular-like and papillary structure, with dense glands and disordered arrangement; the cells were cuboidal or columnar, with increased nuclear chromatin and loss of nuclear polarity, and most of them expressed gastric mucin. Signet-ring cell carcinoma was found in 7 cases, all the cancer tissues were composed of signet-ring cells, and the cancer cells were mainly distributed in the middle layer to the surface layer of mucosa. Gastric oxyntic gland adenoma (gastric adenocarcinoma of the fundic gland type confined to mucosa) in 2 cases, gastric adenocarcinoma of the fundic gland type in 2 cases, and gastric adenocarcinoma of fundic gland mucosa type in 1 case. The tumor tissue was composed of branching tubular glands, except 1 case of mucosal surface epithelium was partially neoplastic, the other 4 cases of mucosal surface epi-thelium were all non-neoplastic; the cells were arranged in a single layer, and the nucleus was close to the basal side, and the nucleus was only slightly atypical. Pepsinogen I and H+/K+ ATPase were positive in 5 cases of gastric fundus gland type tumors, and 1 case of foveolar-type tumor cells at the surface and depth of mucosa showed MUC5AC positive. The gastric mucosa adjacent to cancer was generally normal in all cases, without atrophy, intestinal metaplasia and Hp.@*CONCLUSION@#Hp-negative early gastric cancer is a heterogeneous disease group with various histological types, and tubular adenocarcinoma and signet-ring cell carcinoma are common. Tubular adenocarcinoma mostly occurs in the elderly and the upper to middle part of the stomach, while signet-ring cell carcinoma mostly occurs in young and middle-aged people and the lower part of the stomach. Gastric neoplasm of the fundic gland type is relatively rare.

Helicobacter pylori infection and UBT-13C values are associated with changes in body mass index in children and adults / La infección por Helicobacter pylori y los valores de UBT-13C se asocian con el índice de masa corporal en niños y adultos

BACKGROUND: The urea breath test (UBT-13C) is a non-invasive technique that allows the diagnosis and confirmation of eradication of Helicobacter pylori infection. Aim: To evaluate H. pylori positivity and values of UBT-13C among infected Chilean children and adults, and to analyze its variation in relation to sex, nutritional status, and age of the patients. Material and Methods: Retrospective study of 1141 patients aged 6 to 94 years, with an indication for a UBT-13C either for diagnosis or for confirmation of eradication of H. pylori infection. 13C enrichment was measured using an infrared spectrometer calculating the delta 13C values before and after the ingestion of 13C marked urea. The clinical data of the patients were obtained at the time of the examination. Results: We included 241 children and 900 adults. Infected children obtained lower UBT-13C delta values than infected adults (16.1 ± 8.7 and 37 ± 52.9, respectively). The rates of infection were higher in males who were recruited for diagnosis. Significant differences were obtained between positivity for H. pylori in overweight and obese children but not adults. UBT-13C titers were significantly associated with the body mass index (BMI) only in adults. Conclusions: H. pylori infection rates are similar between sexes and are higher in children probably because of selection bias. In children, H. pylori positivity is associated with higher BMI and excess malnutrition although with similar UBT-13C values. In adults, H. pylori infection is not related with BMI, but a higher BMI impacts UBT-13C titers.

ANTECEDENTES: La prueba de aliento con urea (UBT-13C) es una técnica no invasiva que permite el diagnóstico y confirmación de erradicación de la infección por Helicobacter pylori. Objetivo: Evaluar los valores de UBT- 13C en niños y adultos chilenos infectados y analizar su variación en relación al sexo, diagnóstico nutricional y edad de los pacientes. Material y Métodos: Estudio retrospectivo de 1.141 pacientes de 6 a 94 años. El enriquecimiento de13C se midió usando un espectrómetro de infrarrojos, calculando el delta 13C antes y después de la ingesta de urea marcada con 13C. Los datos clínicos de los pacientes se obtuvieron al momento del examen. Resultados: Incluimos 241 niños y 900 adultos con valores delta de UBT-13C de 16,1 ± 8,7 frente a 37 ± 52,9, respectivamente. Las tasas de infección fueron mayores en los hombres reclutados para el diagnóstico. Se obtuvieron diferencias significativas entre la positividad para H. pylori en niños con sobrepeso y obesidad, pero no en adultos. Los títulos de UBT-13C se asociaron significativamente con el índice de masa corporal (IMC) solo en adultos. Conclusiones: Las tasas de infección por H. pylori son similares entre los sexos y aumentan en los niños probablemente debido al sesgo de selección. En niños, la positividad para H. pylori se asocia con un IMC más alto y malnutrición por exceso, aunque con valores similares de UBT-13C. En los adultos, la infección por H. pylori no se relaciona con el IMC ni con la obesidad, pero el aumento del IMC afecta los títulos de UBT-13C.

Upper gastrointestinal ulcer in children: a clinical analysis of 173 cases / 中国当代儿科杂志

OBJECTIVES@#To study the clinical manifestations and gastroscopic characteristics of upper gastrointestinal ulcer in children.@*METHODS@#A retrospective analysis was performed for the children who underwent gastroscopy and were found to have upper gastrointestinal ulcer for the first time at the Endoscopy Center of Shengjing Hospital, China Medical University, from January 2011 to May 2021. According to the cause of the disease, they were divided into primary ulcer group (primary group; n=148) and secondary ulcer group (secondary group; n=25). The clinical data were compared between the two groups.@*RESULTS@#A total of 173 children with upper gastrointestinal ulcer were enrolled, with a male/female ratio of 3.9:1. Compared with girls, boys had significantly higher proportions of duodenal ulcer and primary ulcer (P<0.05). Compared with the children aged below 6 years, the children aged 6-14 years had higher proportions of duodenal ulcer and primary ulcer and lower proportions of giant ulcer and multiple ulcers. Of the 148 children in the primary group, 95 (64.2%) had Helicobacter pylori infection. Abdominal pain was the most common clinical symptom and was observed in 101 children (68.2%). Duodenal ulcer was common and was observed in 115 children (77.7%), followed by gastric ulcer in 25 children (16.9%) and esophageal ulcer in 7 children (4.7%). Multiple ulcers were observed in 32 children (21.6%). Seventy children (47.3%) experienced complications, among which bleeding was the most common complication and was observed in 63 children (43.6%). Of the 25 children in the secondary group, abdominal pain was the most common clinical symptom and was observed in 9 children (36.0%), with a significantly lower incidence rate than the primary group (P<0.05); foreign body in the digestive tract was the most common cause of ulcer and was observed in 17 children (68%), followed by abdominal Henoch-Schönlein purpura in 5 children (20.0%) and Crohn's disease in 3 children (12.0%). The secondary group had a significantly higher proportion of multiple ulcer or giant ulcer than the primary group (P<0.05).@*CONCLUSIONS@#Upper gastrointestinal ulcer is more common in boys than girls, and duodenal ulcer and primary ulcer are more common in boys. Children aged 6-14 years often have duodenal ulcer and primary ulcer, and giant ulcer and multiple ulcers are relatively uncommon. Primary ulcer in children has a variety of clinical manifestations, mainly abdominal pain, and duodenal ulcer is relatively common, with bleeding as the main complication. The clinical symptoms and endoscopic manifestations of secondary ulcer are closely associated with the primary causes, and it is more likely to induce huge ulcers and multiple ulcers.

Acurácia diagnóstica entre teste rápido da urease e estudo histopatológico para detecção de Helicobacter pylori / Diagnostic accuracy of urease quick test compared to histopathological study for Helicobacter pylori detection

Objetivo: Analisar a acurácia do teste rápido da urease para detecção de Helicobacter pylori comparado com o exame histopatológico. Métodos: Estudo prospectivo e descritivo realizado de abril de 2018 a maio de 2019 em um Serviço de Endoscopia e Biliopancreática e em um laboratório de patologia. A amostra foi composta de 64 pacientes, de ambos os sexos, com idade de 35 a 81 anos, que apresentavam queixas dispépticas. Foram realizados exame histopatológico e teste rápido da urease. Os dados foram analisados pelo R Core team 2019 e submetidos a análises descritivas (variáveis categóricas) e inferenciais (teste de associação de qui-quadrado de Pearson e teste de Mann-Whitney). O nível de significância adotado foi de 5%. Resultados: O teste rápido da urease demonstrou que dez pacientes foram verdadeiros-positivos, 39 verdadeiros-negativos, três falsos-positivos, 12 falsos-negativos, com sensibilidade de 45,4% (25,1% a 67,3%), especificidade de 92,9% (79,4% a 98,1%), valor preditivo positivo de 76,9% (45,9% a 93,8%), valor preditivo negativo de 76,5% (62,2% a 86,7%), acurácia de 76,6% (64,0% a 85,9%), razão de chance diagnóstica 10,8 (2,56 a 45,9), índice de Youden 0,38 (0,16 a 0,60) e taxa de erro de 23,4% (14,1% a 36,0%). Conclusão: O teste rápido da urease apresentou baixa capacidade de detectar pacientes infectados, menor acurácia em relação ao estudo anatomopatológico e alta especificidade. O teste pode ser útil no momento da realização da endoscopia, por fornecer resultado rápido e barato para detectar H. pylori. O diagnóstico da bactéria apresenta maior confiabilidade com a realização dos dois métodos para pesquisa de H. pylori.

Objective: To analyze the accuracy of the rapid urease test for Helicobacter pylori detection when compared with the histopathological examination. Methods: This is a prospective and descriptive study conducted from April 2018 to May 2019, at an Endoscopy and Biliopancreatic Service and in a pathology laboratory. The sample consisted of 64 male and female patients aged 35 to 81 years old with dyspeptic complaints. Histopathological examination and rapid urease test were performed. Data were analyzed by R Corel team 2019 and underwent descriptive (categorical variables) and inferential (Pearson's Chi-squared association test and Mann-Whitney test) analyzes. The significance level adopted was 5%. Results: The rapid urease test showed that ten patients were true positive, 39 true negative, three false-positive, and 12 false-negative, and sensitivity was of 45.4% (25.1% to 67.3%), specificity 92.9% (79.4% to 98.1), positive predictive value of 76.9% (45.9-93.8%), negative predictive value of 76.5% (62.2% to 86.7%), accuracy of 76.6% (64.0% to 85.9%), diagnostic odds ratio of 10.8 (2.56% to 45.9), Youden index 0.38 (0.38% to 0.60), and error rate 23.4 (14.1% to 36.0%). Conclusion: The rapid urease test showed low ability to detect infected patients, lower accuracy compared to the pathological study, and high specificity. The test may be useful at the time of endoscopy, as it provides a quick and inexpensive result to detect H. pylori. The diagnosis of the bacterium is more reliable when both methods for H. pylori investigation are performed

Adaptación a la realidad de Latinoamérica de la Guía Clínica NASPGHAN/ESPGHAN 2016 sobre Diagnóstico, Prevención y Tratamiento de Infección por Helicobacter pylori en Pediatría / Adaptation to the reality of Latin America of the NASPGHAN/ESPGHAN 2016 Guidelines on the Diagnosis, Prevention and Treatment of Helicobacter pylori Infection in Pediatrics

Resumen: Introducción: Las últimas guías clínicas conjuntas de NASPGHAN y ESPGHAN en relación a la infección por H. pylori publicadas el año 2016, contienen 20 afirmaciones que han sido cuestionadas en la práctica respecto a su aplicabilidad en Latinoamérica (LA); en particular en relación a la preven ción del cáncer gástrico. Métodos: Se realizó un análisis crítico de la literatura, con especial énfasis en datos de LA y se estableció el nivel de evidencia y nivel de recomendación de las afirmaciones mas controversiales de las Guías Conjuntas. Se realizaron 2 rondas de votación de acuerdo a la técnica Delfi de consenso y se utilizó escala de Likert (de 0 a 4) para establecer el "grado de acuerdo" entre un grupo de expertos de SLAGHNP. Resultados: Existen pocos estudios en relación a diagnóstico, efectividad de tratamiento y susceptibilidad a antibióticos de H. pylori en pacientes pediátricos de LA. En base a estos estudios, extrapolaciones de estudios de adultos y la experiencia clínica del panel de expertos participantes, se realizan las siguientes recomendaciones. Recomendamos la toma de biopsias para test rápido de ureasa e histología (y muestras para cultivo o técnicas moleculares, cuando estén disponibles) durante la endoscopia digestiva alta sólo si en caso de confirmar la infección por H. pylori, se indicará tratamiento de erradicación. Recomendamos que centros regionales seleccio nados realicen estudios de sensibilidad/resistencia antimicrobiana para H. pylori y así actúen como centros de referencia para toda LA. En caso de falla de erradicación de H. pylori con tratamiento de primera línea, recomendamos tratamiento empírico con terapia cuádruple con inhibidor de bomba de protones, amoxicilina, metronidazol y bismuto por 14 días. En caso de falla de erradicación con el esquema de segunda línea, se recomienda indicar un tratamiento individualizado considerando la edad del paciente, el esquema indicado previamente y la sensibilidad antibiótica de la cepa, lo que implica realizar una nueva endoscopía con extracción de muestra para cultivo y antibiograma o es tudio molecular de resistencia. En niños sintomáticos referidos a endoscopía que tengan antecedente de familiar de primer o segundo grado con cáncer gástrico, se recomienda considerar la búsqueda de H. pylori mediante técnica directa durante la endoscopia (y erradicarlo cuando es detectado). Con clusiones: La evidencia apoya mayoritariamente los conceptos generales de las Guías NASPGHAN/ ESPGHAN 2016, pero es necesario adaptarlas a la realidad de LA, con énfasis en el desarrollo de centros regionales para el estudio de sensibilidad a antibióticos y mejorar la correcta selección del tratamiento de erradicación. En niños sintomáticos con antecedente familiar de primer o segundo grado de cáncer gástrico, se debe considerar la búsqueda y erradicación de H. pylori.

Abstract: Introduction: The latest joint H. pylori NASPGHAN and ESPGHAN clinical guidelines published in 2016, contain 20 statements that have been questioned in practice regarding their applicability in Latin America (LA); in particular in relation to gastric cancer prevention. Methods: We conduc ted a critical analysis of the literature, with special emphasis on LA data and established the level of evidence and level of recommendation of the most controversial claims in the Joint Guidelines. Two rounds of voting were conducted according to the Delphi consensus technique and a Likert scale (from 0 to 4) was used to establish the "degree of agreement" among a panel of SLAGHNP ex perts. Results: There are few studies regarding diagnosis, treatment effectiveness and susceptibility to antibiotics of H. pylori in pediatric patients of LA. Based on these studies, extrapolations from adult studies, and the clinical experience of the participating expert panel, the following recom mendations are made. We recommend taking biopsies for rapid urease and histology testing (and samples for culture or molecular techniques, when available) during upper endoscopy only if in case of confirmed H. pylori infection, eradication treatment will be indicated. We recommend that selected regional centers conduct antimicrobial sensitivity/resistance studies for H. pylori and thus act as reference centers for all LA. In case of failure to eradicate H. pylori with first-line treatment, we recommend empirical treatment with quadruple therapy with proton pump inhibitor, amoxi cillin, metronidazole, and bismuth for 14 days. In case of eradication failure with the second line scheme, it is recommended to indicate an individualized treatment considering the age of the pa tient, the previously indicated scheme and the antibiotic sensitivity of the strain, which implies performing a new endoscopy with sample extraction for culture and antibiogram or molecular resistance study. In symptomatic children referred to endoscopy who have a history of first or se cond degree family members with gastric cancer, it is recommended to consider the search for H. pylori by direct technique during endoscopy (and eradicate it when detected). Conclusions: The evidence supports most of the general concepts of the NASPGHAN/ESPGHAN 2016 Guidelines, but it is necessary to adapt them to the reality of LA, with emphasis on the development of regional centers for the study of antibiotic sensitivity and to improve the correct selection of the eradication treatment. In symptomatic children with a family history of first or second degree gastric cancer, the search for and eradication of H. pylori should be considered.

Respuesta inmune Th1/Th2 en pacientes co-infectados con Helicobacter pylori y helmintos / Immune response Th1/Th2 to Helicobacter pylori and Helminths in co-infected patients

Resumen: Introducción: La inflamación asociada con la infección por Helicobacter pylori (H. pylori) se relaciona con la pro gresión de las lesiones precancerosas gástricas. Las infecciones por helmintos podrían modular la respuesta proinflamatoria a la infección por H. pylori desde un perfil tipo LTCD4+ Th1 hacia una respuesta menos perjudicial tipo LTCD4+ Th2. Objetivo: Caracterizar la polarización de la respuesta inmune tipo LTCD4+ Th1/Th2 de pacientes coinfectados por H. pylori y helmintiasis procedentes de áreas de bajo riego para el desarrollo de cáncer gástrico. Pacientes y Método: Se analizaron 63 pacientes, 40 adultos y 23 niños infectados con H. pylori. La determinación de los perfiles séricos de las interleucinas asociadas con la polarización de la respuesta inmune tipo LTCD4+ Th1 (IL-1Β, INF-γ y TNF-α) y tipo LTCD4+ Th2 (IL-4, IL-10 e IL-13) se realizó con Análisis Multiplex (xMAP). La relación entre el estado de coinfección por helmintos en pacientes infectados con H. pylori y la polarización de la respuesta inmune mediada por LTCD4+ Th1 y LTCD4+ Th2, se estudió con un modelo de regresión logístico de efectos mixtos. Resultados: La frecuencia de helmintos fue similar en adultos (15%) y niños (17%). La polarización de la respuesta inmune fue más prevalente hacia el tipo LTCD4+ Th1. Los valores séricos de las interleucinas asociadas con la polarización de la respuesta inmune tipo LTCD4+ Th1 (IL-1 Β, INF-γ y TNF-α) y tipo LTCD4+ Th2 (IL-4, IL-10 e IL-13) fueron independientes del estado de infestación por helmintos. Conclusión: La prevalencia de infección por parasitismo intestinal fue alta y la polarización de la respuesta inmune fue predominantemente hacia un perfil tipo LTCD4 + Th1.

Abstract: Introduction: Inflammation associated with Helicobacter pylori (H. pylori) infection is linked to the development of a gastric precancerous lesion. Helminth infections could influence the pro-inflam matory response to such infection from LTCD4+ Th1 to a less harmful LTCD4+ Th2 response. Ob jective: To characterize the polarization of the LTCD4+ Th2 immune response in co-infected pa tients with H. pylori and helminths from low-risk areas for developing gastric cancer. Patients and Method: We analyzed 63 patients infected by H. pylori (40 adults and 23 children). Through the Multiplex Analysis technology (xMAP), we determined the serum profiles of the interleukins asso ciated with the polarization of the immune response of LTCD4+ Th1 (IL-1Β, INF-γ, TNF-α) as well as the LTCD4+ Th2 (IL-4, IL-10, and IL-13). The ratio between helminths co-infection status in H. pylori-infected patients and the polarization of the immune response mediated by LTCD4+ Th1 and LTCD4+ Th2 was assessed using a Mixed Effects Logistic Regression Model. Results: The frequency of helminths was similar between adults (15%) and children (17%). The polarization of the immu ne response was more prevalent in LTCD4+ Th1. Serum values of interleukins associated with the immune response polarization of LTCD4+ Th1 (IL-1Β, INF-γ, and TNF-α) and LTCD4+ Th2 (IL-4, IL-10, and IL-13) were independent of helminths infection status. Conclusion: The prevalence of in testinal parasitic infection was high and the immune response polarization was mainly LTCD4 + Th1.

Is there any association between Helicobacter pylori and otitis media with effusion? / Há associação entre Helicobacter pylori e otite média com efusão?

Abstract Introduction: It is proposed that Helicobacter pylori can be responsible for the development of otitis media with effusion. Objective: The aim of this study is to investigate the prevalence of H. pylori in the adenoid tissue and fluid of the middle ear in patients who suffer from adenoid hyperplasia and otitis media with effusion in comparison with those who suffer from adenoid hyperplasia without otitis media with effusion. Methods: This is a case-control study that was carried out in 50 children of age 2-7 years old who were admitted with adenoid hyperplasia. Patients were divided into case and control groups. The study group included 25 patients with adenoid hyperplasia and otitis media with effusion and the control group included 25 patients with adenoid hyperplasia without otitis media with effusion. The patients in both groups underwent surgical adenoidectomy. For the case group we carried out myringotomy and placement of tympanostomy tube, and fluid samples were collected under sterile conditions. The samples were sent to the laboratory for polymerase chain reactions. Results: In the case group H. pylori was found to be positive in 18 samples of the middle ear fluid (70%) and in 1 polymerase chain reaction adenoid tissue sample (4%). In the control group H. pylori was positive in 3 samples of adenoid tissues (12%). There was no gender difference. Conclusion: H. pylori is one of the important bacteria that plays a role in the pathogenesis of otitis media with effusion. Whether adenoid tissue may be a reservoir for H. Pylori is unclear.

Resumo Introdução: Propõe-se que o Helicobacter pylori possa ser responsável pelo desenvolvimento de otite média com efusão. Objetivo: Investigar a prevalência de H. pylori no tecido adenoideano e no fluido da orelha média em pacientes com hiperplasia de adenoide e otite média com efusão em comparação àqueles com hiperplasia de adenoide sem otite média com efusão. Método: Este é um estudo de caso-controle feito em 50 crianças de 2 a 7 anos, com sinais e sintomas de hiperplasia de adenoide. Os pacientes foram divididos em grupo de estudo e grupo controle. O grupo de estudo incluiu 25 pacientes com hiperplasia de adenoide e otite média com efusão e o grupo controle incluiu 25 pacientes com hiperplasia de adenoide sem otite média com efusão. Os pacientes dos dois grupos foram submetidos a adenoidectomia e, no grupo de estudo, realizou-se também miringotomia com colocação de tubo de ventilação e amostras de fluidos foram coletadas sob condições estéreis. As amostras foram enviadas para o laboratório, para investigação por reação de polimerase em cadeia. Resultados: No grupo de estudo, houve positividade para H. pylori em 18 amostras do fluido de orelha média (70%) e uma amostra de tecido adenoideano foi positiva na reação de polimerase em cadeia (4%). No grupo controle, houve positividade para H. pylori em 3 amostras de tecido adenoideano (12%). Não houve diferença entre os gêneros. Conclusão: H. pylori é uma das bactérias importantes que desempenham um papel na patogênese da otite médica com efusão. Se o tecido adenoideano pode ou não representar um reservatório para H. pylori ainda necessita ser esclarecido.

Chronic use of proton pump inhibitors and the quantity of g, d, and ecl cells in the stomach / Uso crônico de inibidores de bomba de prótons e a quantidade de células g, d e ecl no estômago

ABSTRACT Background: Acid inhibition from chronic proton pump inhibitor use and a possible increase in gastrin can lead to changes in the regulation of hydrochloric acid production. However, it has not known whether such chronic use changes the presence of gastrin, delta, and enterochromaffin-like cells in the stomach or the relationship between gastrin and delta cells. Aim: To analyze the number of gastrin-producing gastrin cells, somatostatin-producing cells, and histamine-producing cells in patients who were chronic users of proton pump inhibitor, with or without related Helicobacter pylori infection. Methods: Biopsies from 105 patients, including 81 chronic proton pump inhibitor users (experimental group) and 24 controls, were processed immunohistochemically and subjected to counting of gastrin, delta, and enterochromaffin-like cells in high-magnification microscopic fields and in 10 glands. Results: Gastrin cell, delta cell, and enterochromaffin-like cells counts were similar across the groups and appeared to be unaffected by Helicobacter pylori infection. The ratio between gastrin cells and delta cells was higher in the chronic users of proton pump inhibitor group than in controls. Conclusion: Chronic users of proton pump inhibitor does not affect gastrin cell, delta cell, and enterochromaffin-like cell counts significantly, but may alter the ratio between gastrin cells and delta cells.

RESUMO Racional: A inibição ácida pelo uso crônico de inibidores de bomba de prótons e o possível aumento da gastrina podem ser seguidos de alterações na regulação da produção do ácido clorídrico. Ainda não está definido se o uso crônico altera a quantidade de células G, D e ECL no estômago ou a razão células G/D. Objetivo: Avaliar o número de células G - produtoras de gastrina -, células D - produtoras de somatostatina - e células ECL - produtoras de histamina -, em pacientes com uso crônico de inibidores de bomba de prótons, com ou sem infecção pelo Helicobacter pylori. Método: Trata-se de estudo retrospectivo avaliando 105 pacientes, 81 usadores crônicos de inibidores de bomba de prótons e 24 controles, através de biópsias com contagem das células G, D e ECL por estudo imunoistoquímico, de forma quantitativa onde havia maior número de células positivas por campo microscópico de grande aumento e em 10 glândulas. Resultados: Não houve diferença estatística comparando-se o número de células G, D e ECL. A razão entre as células G e D foi maior nos pacientes usadores crônicos de inibidores de bomba de prótons. Conclusão: O uso crônico de inibidores de prótons parece não interferir na contagem das células G, D e ECL, porém, interfere na razão entre as células G e D.

Métodos de diagnóstico para la detección de la infección por Helicobacter pylori / Diagnostic methods for detection of Helicobacter pylori infection

Helicobacter pylori (H. pylori) is a Gram-negative bacterium that survives in gastric acidity. Approximately 50% of the world population is a carrier of this infection and the prevalence is higher in African and Latin American populations. The clinical manifestations associated with this infection are gastritis, peptic ulcers, MALT lymphoma, gastric cancer (GC), and other extra-digestive pathologies. Chronic H. pylori infection is the most important risk factor for GC development. There are several diagnostic methods to detect H. pylori infection. The most widely used invasive methods are the rapid urease test and Giemsa staining in gastric biopsies. Culture and molecular techniques are very useful for the study of H. pylori presence and antibiotic resistance, but they are not easily available in health centers. The most widely used non-invasive methods are the urea breath test and bacterial antigens in stools. Serological studies are used for population studies. The use and indication of the diagnostic method for detecting H. pylori infection will depend on the clinical manifestations, risk factors for GC, and the age of the patient.

Helicobacter pylori (H. pylori) es una bacteria Gram negativa que sobrevive a la acidez gástrica. Se estima que aproximadamente el 50% de la población mundial es portadora de esta infección, siendo mayor la prevalencia en poblaciones africanas y latinoamericanas. Entre las manifestaciones clínicas asociadas a esta infección se encuentra gastritis, úlceras pépticas, linfoma MALT, cáncer gástrico y otras patologías extradigestivas. La infección crónica por H. pylori es el factor de riesgo más importante para el desarrollo de CG. Existen diversos métodos diagnósticos para detectar la infección por H. pylori, los métodos invasivos más utilizados son la prueba rápida de ureasa y tinción de Giemsa en biopsias gástricas. El cultivo y las técnicas moleculares son de gran utilidad para el estudio de presencia de H. pylori y estudios de resistencia antibiótica, pero suelen estar poco disponibles en los centros de atención en salud. Los métodos no invasivos más utilizados son la prueba de aire espirado con urea marcada y antígeno bacteriano en deposiciones. Los estudios serológicos son utilizados para estudios poblacionales. El uso e indicación de cada uno de los métodos de diagnóstico para la detección de infección por H. pylori, dependerá de las manifestaciones clínicas, los factores de riesgo de CG y la edad del paciente.

Erradicación de Helicobacter pylori en pacientes con dispepsia funcional / Helicobacter pylori eradication in patients with functional dyspepsia

La dispepsia constituye un motivo de consulta frecuente en atención primaria. A propósito de un paciente con diagnóstico de dispepsia funcional, la autora se plantea si el tratamiento de erradicación del Helicobacter pylori podría mejorar los síntomas. Luego de una búsqueda rápida se encontró evidencia que señala que el tratamiento de la infección por este germen podría ser beneficiosa para aliviar los síntomas de la dispepsia funcional a largo plazo, aunque con mayor riesgo de efectos adversos, por lo que otros tratamientos alternativos continúan siendo ser una opción válida en el manejo de los pacientes con este problema de salud. (AU)

La derivación protocolizada a endoscopía asociada a la detección de Helicobacter pylori mediante antígeno en deposiciones disminuye lista de espera para endoscopía y optimiza la detección de lesiones pre-malignas y cáncer gástrico incipiente / Protocolized referral to endoscopy and Helicobacter pylori detected in stools aimed to decrease endoscopy waiting lists

Background Chile has one of the highest mortality rates by gastric cancer (GC) worldwide. Primary prevention of GC and detection of pre-neoplastic and early neoplastic lesions should be a national priority. Aim To assess the impact of the protocolization of endoscopy referral and the use of H. pylori stool antigen test (HPSA) in the management of dyspepsia to decrease the waiting list for endoscopy and increase the detection of gastric pre-neoplastic and early neoplastic lesions. Material and Methods We included all patients referred to the Endoscopy Unit of a regional hospital, from January 2015 to December 2017. We also included patients with known pre-neoplastic lesions and all those with first degree relatives with GC. We implemented protocols for referral of patients with dyspepsia considering the use of HPSA test, prioritizing to endoscopy those with a higher risk of GC. Results A total of 4,641 endoscopies and 2,631 HPSA tests were carried out. After the adoption of these protocols, we observed a 52% decrease in the waiting time for endoscopy. The GC detection rate in this period was 1.8 to 3.1 cases per 100 endoscopies. After the adoption of the protocols, we observed a significant increase in early GC detection rate (from none in 2015 to 13% in 2017, p = 0.03). Conclusions The protocolization of the referral for endoscopy associated with widespread use of HPSA test in the management of patients with dyspepsia, are successful strategies to decrease waiting lists for endoscopy and optimize the detection rate of pre-neoplastic lesions and early GC.

Bacteriemia por Helicobacter cinaedi: presentación de los primeros casos descritos en Argentina / Helicobacter cinaedi bacteremia: Presentation of the first cases reported in Argentina

Se presentan 2 casos de bacteriemia por Helicobacter cinaedi. El primero se diagnosticó en un varón de 76 años y resultó secundario a la colocación de un acceso vascular; el segundo correspondió a un lactante febril de 37 días de vida, asociado a un cuadro de gastroen-terocolitis aguda. H. cinaedi es un microorganismo que presenta dificultad para desarrollarse en diferentes medios de cultivo y lograr su identificación a nivel de especie. En ambos casos fue fundamental la observación microscópica en fresco de las botellas de hemocultivo, la utilización de la espectrometría de masas y la posterior secuenciación del gen hsp60 para llegar a esa instancia. En los últimos anos se han informado infecciones por H. cinaedi con frecuencia creciente en otras partes del mundo. En este trabajo presentamos los primeros casos de bacteriemia por H. cinaedi documentados en Argentina.

Two cases of bacteremia caused by Helicobacter cinaedi are presented. The first case was diagnosed in a 76-year-old male patient, and was secondary to a vascular access device placement; the second case corresponded to a febrile infant of 37 days of life, and was associated with acute gastroenteritis. H. cinaedi is a microorganism difficult to grow in different culture media and also to identify to species level. In both cases, the microscopic observation of blood culture bottles, the use of mass spectrometry and the subsequent sequencing of the hsp60 gene were essential. In the recent literature, H. cinaedi infections are being reported more frequently. In this report we present the first documented cases of bacteremia caused by H. cinaedi in Argentina.

Estudo prospectivo para validação de protocolo único para o teste respiratório com ureia marcada com carbono-13 empregando dois dispositivos diferentes, no diagnóstico da infecção por H. pylori / Prospective study for validation of a single protocol for the 13c-urea breath test using two different devices in the diagnosis of h. pylori infection

ABSTRACT BACKGROUND: 13C-urea breath test (UBT) is the gold-standard, noninvasive method for H. pylori diagnosis. However, there is no uniform standardization of the test. This situation can be unpractical for laboratories running with two or more devices. OBJECTIVE: To perform a prospective comparison validation study of UBT employing one validated protocol for two different devices: BreathID Hp Lab System® (Exalenz Bioscience Ltd, Israel), here called device A and IRIS-Doc2® (Wagner Analysen-Technik, Germany, now Mayoly Spindler Group, France), here called device B, in the diagnosis of H. pylori infection. METHODS: A total of 518 consecutive patients (365 females, 153 males, mean age 53 years) referred for UBT were included. All patients received device A protocol as follow: after at least one hour fasting, patients filled two bags prior to the test, then ingested an aqueous solution containing 75 mg of 13C-urea with a 4.0 g citric acid powder and filled another two bags 15 min after ingesting the test solution. One pair of breath sample bags (before and after ingestion) was analyzed by the two different devices. A delta over baseline (DOB) ≥5‰ indicated H. pylori infection. Statistics: Wilcoxon test, kappa coefficient with 95% CI, Wilson's method. RESULTS: Considering the device A protocol as the gold standard, its comparison with device B showed a sensitivity of 99.3% (95% CI: 96.3-99.9) and a specificity of 98.9% (95% CI: 97.3-99.6). Kappa coefficient was 0.976 (95% IC: 0.956-0.997). CONCLUSION: Correlation between the two devices was excellent and supports a uniform standardization of UBT.

RESUMO CONTEXTO: O teste respiratório com ureia-marcada com carbono-13 (TR-13C) é o método padrão-ouro para o diagnóstico não invasivo da infecção por H. pylori. Apesar disto, não existe uma uniformização de protocolos para a sua realização, trazendo dificuldades operacionais para laboratórios ou clínicas que operam com equipamentos de fabricantes diferentes. OBJETIVO: Estudo prospectivo e comparativo para validação do TR-13C para o diagnóstico de infecção por H. pylori, com emprego de protocolo único para dois equipamentos diferentes, a saber: BreathID Hp Lab System® (Exalenz Bioscience Ltd, Israel), aqui denominado equipamento A e IRIS-Doc2® (Wagner Analysen-Technik, Alemanha, agora Mayoly Spindler Group, França), aqui denominado equipamento B. MÉTODOS: Um total de 518 pacientes (365 mulheres e 153 homens, idade média de 53 anos) consecutivamente encaminhados para a realização do TR-13C foram incluídos no estudo. Todos os participantes realizaram TR-13C, que foi processado e analisado simultaneamente pelos dois equipamentos. Embora os dois equipamentos possuam protocolos independentes previamente validados, foi optado, por sua maior praticidade, pela utilização de um único protocolo, conforme recomendado pelo fabricante do equipamento A, e assim resumido: após jejum mínimo de 1h, foram amostras de ar expirado coletadas em dois pequenos sacos coletores (120 mL), correspondendo ao tempo-zero (amostra-1, controle). Em seguida, os pacientes ingeriram, em até 2 min, uma solução aquosa (200 mL) contendo 75 mg de 13C-ureia e 4,0 gramas de ácido cítrico em pó, adicionado com edulcorante. Uma segunda coleta de ar expirado era realizada 15 min após a ingestão do substrato em dois novos pequenos sacos coletores, correspondendo à amostra-2. Foram considerados positivos para a presença da infecção por H. pylori quando apresentavam um delta over baseline (DOB) igual ou maior que 5‰. Análise estatística foi realizada com o teste de Wilcoxon, coeficiente kappa com IC 95% e método de Wilson. RESULTADOS: Considerando o protocolo do equipamento A como o padrão-ouro, sua comparação com o equipamento B mostrou sensibilidade de 99,3% (IC 95%: 96,3-99,9) e especificidade de 98,9% (IC 95%: 97,3-99,6). O coeficiente kappa observado foi de 0,976 (IC 95%: 0,956-0,997). CONCLUSÃO: A correlação entre os dois equipamentos foi excelente e contribui para uma uniformização de protocolos para TR-13C.

Helicobacter pylori: qué debemos saber en el año 2018. Revisión de la evidencia y nuevas recomendaciones de tratamiento / Helicobacter pylori: what should we know in the year 2018. Review of the evidence and new treatment recommendations

Helicobacter pylori (HP) is the most widely chronic human infection around the world, and the main risk factor for the development of gastric cancer. Our country has high rates of this neoplasia and a high prevalence of HP infection. Even both have fallen in the last year, is a major concern to diagnose the population infected with HP in early stages, before the development of premalignant lesions and properly eradicate this infection. In this review, we discussed the different methods for the diagnosis of HP and factors that change positivity as the use of proton pump inhibitors. Also, we discussed the factors to be considered in the choice of the treatment, like local resistance to antibiotics, specially clarithromycin. In the last years has been documented in Chile a significant increase in resistance to clarithromycin, from 20 to 46%, which predicts inadequate effectiveness for the classic triple therapy. As the result of the previous analysis we discussed new possible therapies, including bismuth quadruple therapy and concomitant therapy. (AU)

Erradicación de Helicobacter pylori, consideraciones clínicas según la edad / Helicobacter pylori eradication, clinical considerations related to age

Helicobacter pylori (H. pylori) is a gram negative bacteria that survives in the gastric acid environment. The infection is acquired mainly during childhood. Fifty to 70% of adult population has the infection. However, in the last 10 year, a decrease in the prevalence of this infection has been observed in all age groups, in particular in pediatric population and elderly patients over 60 years old. The evolution of the infection depends on bacterial factors (virulence and toxins) and host immune response. People infected mainly develop gastrointestinal diseases such as gastritis, peptic ulcer and MALT lymphoma. H. pylori infection is the main risk factor of gastric cancer and for that reason, the eradication is recommended if H. pylori has been detected through invasive or non-invasive tests. Among children, eradication is not recommended unless there is a clinical manifestation that merits. H. pylori eradication is recommended in symptomatic adults and there is a controversy about massive eradication in asymptomatic population due to the risk of development of antibiotic resistance. Treatment is based on the use of proton pump inhibitors (PPI) associated to antibiotics, that should be chosen taking into account the increasing antibiotic resistance, and local availability. Clarithromycin (CLA) and levofloxacin resistance is increasingly high, and CLA-free quadruple therapy schemes are currently recommended for first-line therapy. H. pylori eradication must be confirmed with invasive or non-invasive tests. Second-line therapy based on antibiotics not previously used, PPI high doses and bismuth is recommended.

Helicobacter pylori (H. pylori) es una bacteria gramnegativa que sobrevive en el medio ácido gástrico. La infección se adquiere principalmente en la niñez. Un 50 a 70% de la población adulta es portadora, pero en los últimos 10 años, se ha observado una disminución en la prevalencia de infección en todos los grupos etarios, en particular en población pediátrica y mayores de 60 años. La evolución de la infección depende de factores propios de la bacteria (virulencia, toxinas) y de la respuesta inmune del huésped. Los individuos infectados desarrollan principalmente patologías gastrointestinales como gastritis, úlcera péptica y linfoma MALT. La infección por H. pylori es el principal factor de riesgo del cáncer gástrico por lo que se recomienda su erradicación en caso de haberse detectado mediante test invasivo o no invasivo. En niños, no es recomendable la erradicación a menos que exista una manifestación clínica que lo amerite. Se recomienda su erradicación en adultos sintomáticos y existe controversia respecto a la erradicación masiva en población asintomática debido al riesgo de desarrollar resistencia antibiótica. El tratamiento se basa en el uso de inhibidores de la bomba de protones asociado a antibióticos, los cuales deben ser escogidos teniendo en cuenta la tasa de resistencia antimicrobiana y disponibilidad local. La resistencia a claritromicina (CLA) y levofloxacino es creciente, por lo que se recomienda el uso de esquemas de cuadriterapia libre de CLA en esquemas de primera línea. Se recomienda confirmar su erradicación con test no invasivos y retratar con esquema de segunda línea con antibióticos no utilizados previamente, asociado a dosis altas de inhibidores de bomba de protones y sales de bismuto.

Usefulness of rapid urease test samples for molecular analysis of clarithromycin resistance in Helicobacter pylori / Utilidad de las muestras de test rápido de ureasa para el análisis molecular de resistencia a claritromicina en Helicobacter pylori

Helicobacter pylori is a gastric pathogen that is widely recognized as a causative agent of gastric disease. Its eradication is variable, mainly due to increased resistance to clarithromycin. Our objective was: to evaluate (i) if the biopsy specimen used for the rapid urease test is a useful sample to detect resistance to clarithromycin by PCR-RFLP and (ii) the distribution of A2142G and A2143G point mutations in the 23S rRNA gene, in relation to virulence factors in our region. Gastric specimens were collected from adult dyspeptic patients (n = 141) and H. pylori was investigated by the rapid urease test, histopathological analysis and PCR for the hsp60 gene. Clarithromycin resistance was detected by PCR-RFLP in 62 H. pylori (+) paired biopsy specimens submitted to molecular analysis and the rapid urease test. H. pylori virulence factors were analyzed by multiplex PCR using specific primers for the cagA, vacA and babA2 genes. Thirteen out of 62 strains (20.9%) were resistant to clarithromycin: 6/13 (46.2%) harbored the A2143G mutation whereas 7/13 (53.8%) carried the A2142G point mutation. vacA m1s1 was the most frequent genotype among the resistant strains. In conclusion, the biopsy specimens used for the rapid urease test were suitable samples for clarithromycin resistance detection in patients infected with H. pylori, which became especially useful in cases where the number or size of the biopsies is limited. In addition, this is the first report of a molecular analysis for clarithromycin resistance performed directly from gastric biopsies in our region.

Helicobacter pylori es un patógeno ampliamente reconocido como causante de enfermedad gástrica. Su erradicación es variable, principalmente debido al incremento de la resistencia a claritromicina. Nuestros objetivos fueron evaluar la utilidad de la biopsia usada para realizar el test rápido de ureasa en la detección de resistencia a claritromicina por PCR-RFLP y conocer la distribución de las mutaciones puntuales A2142G y A2143G en el gen ARNr 23S, en relación con los factores de virulencia en nuestra región. Se recolectaron muestras gástricas (n=141) provenientes de pacientes adultos dispépticos y se investigó la presencia de H. pylori mediante el test rápido de ureasa, análisis histopatológico y PCR para el gen hsp60. La resistencia a claritromicina se analizó por PCR-RFLP en 62 muestras pareadas de biopsias gástricas H. pylori+ destinadas al análisis molecular y al test rápido de ureasa. Los factores de virulencia de H. pylori fueron analizados mediante PCR multiplex usando oligonucleótidos específicos para los genes cagA, vacA y babA2. Trece de 62 cepas (20,9%) fueron resistentes a claritromicina, 6/13 (46,2%) llevaron la mutación A2143G, mientras que 7/13 (53,8%) presentaron la mutación A2142G. El genotipo vacA s1m1 fue el más frecuente entre las cepas resistentes a claritromicina. En conclusión, las biopsias destinadas al test rápido de ureasa fueron muestras apropiadas para la detección de la resistencia a claritromicina en pacientes infectados con H. pylori. Esto es especialmente útil en aquellos casos en los que el número o el tamaño de las muestras son limitados. Además, este es el primer reporte de estudio de resistencia a claritromicina (mediante técnicas moleculares), directamente de biopsias gástricas en nuestra región.

Development and validation of a whole-cell ELISA for serologically diagnosing Helicobacter pylori infection in Brazilian children and adults: a diagnostic accuracy study

ABSTRACT BACKGROUND: Serological tests are practical, with low cost, but no noninvasive tests are available for diagnosing Helicobacter pylori (H. pylori) infection in Brazil. The aim here was to develop and validate enzyme-linked immunosorbent assay (ELISA) serological tests to detect anti-H. pylori immunoglobulin G antibodies, based on cultured strains from Brazilian patients. DESIGN AND SETTING: Cross-sectional, diagnostic accuracy study comparing a locally developed and validated ELISA and invasive tests among dyspeptic patients at two public hospitals in São Paulo, Brazil. METHODS: An ELISA test was prepared using whole-cell antigen from 56 strains. After genotypic characterization, it was standardized and optical density (OD) cutoffs were determined based on the serum antibody response of 100 H. pylori-negative samples, compared with 82 H. pylori-positive samples. Validation was performed on 174 symptomatic patients. RESULTS: The optimal OD cutoffs established (for monoclonal and polyclonal tests, respectively) were 0.167 and 0.164; overall ELISA sensitivity: 84.3%, 78.9%; specificity: 88.6%, 90.6%; positive predictive value (PPV): 75.4%, 80%; negative predictive value (NPV): 93.1%, 81.8%; accuracy: 87.3%, 86.2%; child and adolescent ELISA sensitivity: 74.2%, 81.8%; specificity: 90.8%, 86.7%; PPV: 66.6%, 84.3%; NPV: 95.8%, 84.8%; accuracy: 88.5%, 84.6; adult ELISA sensitivity: 84.4%, 75%; specificity: 86.9%, 93%; PPV: 81.8%, 78.3%; NPV: 88.9%, 91.8%; accuracy: 85.9%, 88.5%. CONCLUSION: The polyclonal serological test developed using local strains presented better diagnostic performance among children and adolescents, while the monoclonal test was better among adults. The results from both tests suggest that these in-house serological tests could be used to detect anti-H. pylori antibodies in our population, for screening purposes.

Duodenal pathologies in children: a single-center experience / Patologias duodenais em crianças: experiência de único centro

Abstract Objective Several studies have been performed concerning pathologies of the stomach and esophagus in the pediatric age group. However, there have been very few studies of duodenal pathologies in children. The authors aimed to examine the clinical, endoscopic, and histopathological characteristics, as well as the etiology of duodenal pathologies in children. Method Patients aged between 1 and 17 years undergoing esophagogastroduodenoscopy during two years at this unit, were investigated retrospectively. Demographic, clinical, endoscopic data, and the presence of duodenal pathologies, gastritis, and esophagitis were recorded in all of the children. Results Out of 747 children who underwent endoscopy, duodenal pathology was observed in 226 (30.3%) patients. Pathology was also present in the esophagus in 31.6% of patients and in the stomach in 58.4%. The level of chronic diarrhea was higher in patients with duodenal pathology when compared with those without duodenal pathology (p = 0.002, OR: 3.91, 95% CI: 1.59-9.57). Helicobacter pylori infection was more common in patients with pathology in the duodenum (59.3%). Conclusion Duodenal pathology was detected in 30.3% of the present patients. A significantly higher level of chronic diarrhea was observed in subjects with duodenal pathologies compared to those with no such pathology. The rate of Helicobacter pylori infection was considerably higher than that in previous studies. In addition, there is a weak correlation between endoscopic appearance and histology of duodenitis.

Resumo Objetivo Foram feitos vários estudos com relação a patologias do estômago e esôfago na faixa etária pediátrica. Contudo, poucos estudos das patologias duodenais em crianças. Visamos a examinar as características clínicas, endoscópicas e histopatológicas, juntamente com a etiologia, das patologias duodenais em crianças. Método Foram investigados retrospectivamente pacientes entre 1 e 17 anos submetidos a esofagogastroduodenoscopia durante dois anos em nossa unidade. Os dados demográficos, clínicos e endoscópicos e a presença de patologias duodenais, gastrite e esofagite foram registrados com relação a todas as crianças. Resultados Das 747 crianças submetidas a endoscopia, 226 (30,3%) apresentaram patologia duodenal. A patologia também esteve presente no esôfago de 31,6% dos pacientes e no estômago de 58,4%. O nível de diarreia crônica foi maior nos pacientes com patologia duodenal, em comparação com os pacientes sem patologia duodenal (p = 0,002, RC: 3,91, IC de 95%: 1,59-9,57). Infecção por Helicobacter pylori foi mais comum em pacientes com patologia no duodeno (59,3%). Conclusão Foi detectada patologia duodenal em 30,3% de nossos pacientes. Um nível significativamente maior de diarreia crônica foi observado em indivíduos com patologias duodenais, em comparação aos sem patologia. A infecção por Helicobacter pylori esteve presente consideravelmente maior do que em estudos anteriores. Além disso, há uma fraca correlação entre a imagem endoscópica e a histologia de duodenite.

Helicobacter pylori infection in family members of patients with gastroduodenal symptoms. A cross-sectional analytical study

ABSTRACT BACKGROUND: Primary Helicobacter pylori (H. pylori) infection is acquired predominantly in childhood in the family setting. We aimed to investigate the presence of intrafamilial concurrent H. pylori infection. DESIGN AND SETTING: Cross-sectional analytical study with a control group, conducted in a tertiary care hospital. METHODS: Fifty adult patients with gastroduodenal symptoms who underwent gastroscopy (index parents), their spouses and their children were enrolled in the study. Blood samples were collected from all of the study subjects to test for immunoglobulin G (IgG) antibody response. H. pylori antigen was investigated in the stool specimens of children only. RESULTS: The participants were divided into two groups: Group 1 consisted of the 40 patients in whom H. pylori infection was demonstrated via endoscopy, their spouses and their children. Group 2 included the remaining 10 patients who underwent endoscopy revealing negative results for H. pylori, their spouses and their children. IgG antibodies were present in all of the index parents, 95% of their spouses and 93% of their children in group 1; 13 of the children (9%) were also positive for H. pylori stool antigen (HpSA). However, IgG antibodies were present in only 2 of the 10 index parents in group 2. One of their spouses and one of their children had a positive antibody response. All of their children had negative stool antigen test results. CONCLUSION: H. pylori infections exhibit intrafamilial clustering. Parental infection, age ≥ years and having three or more siblings are the major risk factors for H. pylori infection in children.