Prevalence, diversity and disease association of Helicobacter pylori in dyspeptic patients from Pakistan.

INTRODUCTION: The etiological association of Helicobacter pylori with gastric ulcer (GU), gastric cancer (GC), and duodenal ulcer (DU) is well-known. Understanding the epidemiology of H. pylori facilitates the estimation of disease burden in a certain population. This study presents the diversity of H. pylori genotypes and their association with different clinical outcomes among dyspeptic patients in Pakistan over a period of four years. METHODOLOGY: Gastric biopsy samples from a total of 450 dyspeptic individualswere subjected to PCR, genotypingand histology. RESULTS: A total of 201 (45%) cases were found positive for H. pylori. The detection rate was high in GU (91%), DU (86%) and GC (83%) cases compared with those cases who had intact gastric mucosa (18%). Histology revealed the presence of infection in 68% of cases of mild/chronic nonspecific gastritis with others belonging to the GU sequel. cagA gene carriage was observed in 104 (51%) cases or mostly from DU, GU and GC groups, of which 97 were Western type strains while 3 were East-Asian type strains that are rarely observed in South Asia. vacA allelic variant s1am1 was most commonly observed, followed by s1am2, and s1bm1, with direct correlation in diseased cases (gastritis, GU, DU and GC). Prevalent genotypic combinations were s1am1/cagA- in gastritis and s1am1/cagA+ in DU, GU, and GC. CONCLUSIONS: Our study indicates the predominant circulation of Western type cagA and vacAs1am1 type H. pylori strains in Pakistan.

Antibiotic resistance and cagA gene correlation: a looming crisis of Helicobacter pylori.

AIM: To determine antibiotic resistance of Helicobacter pylori (H. pylori) in Pakistan and its correlation with host and pathogen associated factors. METHODS: A total of 178 strains of H. pylori were isolated from gastric biopsies of dyspeptic patients. Susceptibility patterns against first and second-line antibiotics were determined and trends of resistance were analyzed in relation to the sampling period, gastric conditions and cagA gene carriage. The effect of cagA gene on the acquisition of resistance was investigated by mutant selection assay. RESULTS: The observations showed that monoresistant strains were prevalent with rates of 89% for metronidazole, 36% for clarithromycin, 37% for amoxicillin, 18.5% for ofloxacin and 12% for tetracycline. Furthermore, clarithromycin resistance was on the rise from 2005 to 2008 (32% vs 38%, P = 0.004) and it is significantly observed in non ulcerative dyspeptic patients compared to gastritis, gastric ulcer and duodenal ulcer cases (53% vs 20%, 18% and 19%, P = 0.000). On the contrary, metronidazole and ofloxacin resistance were more common in gastritis and gastric ulcer cases. Distribution analysis and frequencies of resistant mutants in vitro correlated with the absence of cagA gene with metronidazole and ofloxacin resistance. CONCLUSION: The study confirms the alarming levels of antibiotic resistance associated with the degree of gastric inflammation and cagA gene carriage in H. pylori strains.

Triple hepatitis: frequency and treatment outcome of co/super-infection of hepatitis C and D among patients of hepatitis B.

OBJECTIVE: To determine the frequency of hepatitis C and D in patients of chronic hepatitis B and the treatment response of hepatitis B in such patients. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: Civil Hospital and Lyari General Hospital, Dow University of Health Sciences, from July 2003 to June 2005. PATIENTS AND METHODS: All patients of hepatitis B presenting during the study period were screened for triple infection by carrying out anti-HBc (IgG), anti-HCV and anti-HDV. Patients who were positive to all three were included in the study. Complete Blood Count (CBC); HBsAg; HBeAg; anti-HBc IgM; anti-HDV; anti-HCV; HBV DNA PCR; HCV RNA PCR; serum albumin; SGPT; serum bilirubin and ultrasound abdomen were acquired in all patients. All patients received pegylated interferon-alpha2a 180 mcg sc weekly x 48 weeks. Patients who were also positive for HCV RNA also received ribavirin 1000-1200 mg/d po x 24 weeks for genotype 3 and 48 weeks for genotype 1. Descriptive statistics were used for describing the data. RESULTS: Out of the 246 patients of HBV, 29 (11.8%) patients were also positive for anti-HBc IgG, anti-HDV and anti-HCV. After 48 weeks of therapy, the respective viral undetection by PCR was 4 (13.8%) in patients having only HBV DNA, 3 (10.3%) in patients with only HCV RNA and in patients who had both HBV DNA and HCV RNA positive, simultaneously HCV was cleared in 2 (6.9%) while HBV was not cleared in any case. CONCLUSION: In patients coming with one hepatic infection, other infections should be sought as they share a common mode of spread and may affect the overall response to treatment.

Hemogolbin, ferritin, vitamin B12 and halicobacter pylori infection: a study in patients who underwent upper gi endoscopy at civil hospital karachi.

OBJECTIVE: To compare hemoglobin, ferritin, and vitamin B12 levels in patients undergoing upper GI endoscopy according to their Helicobacter pylori status. STUDY DESIGN: Cross-sectional study. Place and Duration of the Study: Civil Hospital and Lyari General Hospitals, Karachi, from March 2004 to June 2006. PATIENTS AND METHODS: All patients undergoing upper GI Endoscopy were selected, while patients of active peptic ulcers, malignancy, varices, malabsorption and recent blood donation were excluded. Blood samples for CBC, serum ferritin and vitamin B12 were collected and H.pylori status was ascertained by urease test on gastric biopsy. Differences in mean values of age, ferritin, hemoglobin, MCV and vitamin B12 were done by student's 't-test'. Significant confounding factors were identified on multivariate analysis and were further analyzed by univariate analysis. RESULTS: Two hundred and eighty-five subjects were studied, including 171 males and 114 females. H.pylori was positive in 214 (75.1%) patients. Significantly low levels of hemoglobin (p =0.0), ferritin (p = 0.0) and vitamin B12 (p = 0.0) were found in patients with H. pylori infection. Gender, menopause, contraception and history of peptic ulcer disease were identified as significant confounders. CONCLUSIONS: Significantly low levels of hemoglobin, ferritin and vitamin B12 were found in patients with H.pylori infection.

Treatment outcome in patients of hepatitis B with hepatitis D: experience of 4 years at a tertiary care centre in Pakistan.

OBJECTIVE: To determine HBV suppression in patients with dual HBV and HDV infection after 48 weeks with 10.0 MIU of interferon-a 2b. DESIGN: Quasi experimental study. PLACE AND DURATION OF STUDY: Civil Hospital, Karachi and Lyari General Hospital, Karachi, from July 2003 to June 2005. PATIENTS AND METHODS: All HBsAg positive patients were screened for anti-HDV, all positives were included. Baseline investigations, liver chemistries and HBsAg; HBeAg; anti-HBcore IgM; HBV DNA quantitative PCR were done. Patients with hepatocellular carcinoma and decompensated cirrhosis were excluded. Patients were treated with Interferon-alpha 10.0 MIU sc t.i.w. for 48 weeks. HBeAg and quantitative HBV DNA was done at week 0, 24 and 48 while CBC and SGPT were done monthly. HBV suppression was defined as levels < 400 copies/ml. RESULTS: Fifty-two patients were selected for intervention, including 34 males and 18 females. At the end of therapy after 48 weeks, HBV DNA suppression was achieved in 51.9% and HBeAg became undetectable in 53.8% of patients. Twenty-one patients with HBV suppression still had raised SGPT. CONCLUSION: HDV should be screened in all patients eligible for HBV treatment.

Idiopathic gastroparesis.

This case report describes a young female with idiopathic gastroparesis, who presented with persistent vomiting and weight loss. Treatment with erythromycin and tegaserod led to the recovery from symptoms and weight gain.

Correlation between clinical endoscopic and histological findings at esophago-gastric junction in patients of gastroesophageal reflux disease.

OBJECTIVE: To determine the correlation between the clinical, endoscopic and histological findings in patients of GERD. DESIGN: An observational, cross-sectional study. PLACE AND DURATION OF STUDY: Lyari General Hospital, Dow University of Health Sciences from November 2003 to October 2004. PATIENTS AND METHODS: Patients complaining of heartburn and/or acid regurgitation at least twice per week for at least 3 months were inducted in the study. Presence of clinical symptoms of epigastric pain, retrosternal burning, and reflux were recorded. Patients were subjected to esophagogastroduodenoscopy and four biopsies were taken from esophago-gastric junction. Correlation/regression analysis was done on clinical, endoscopic and histological findings. RESULTS: A total of 196 patients were selected and endoscopically examined. Most common grade given by patients to epigastic pain was grade-4 (42.9%), retrosternal burning as grade-4 (41.8%) and reflux grade-5 (36.7%). There was significant correlation between the clinical severity of epigastric pain with endoscopic findings (p = 0.002) and reflux (p = 0.0) but no correlation was observed with histological findings (p = 0.19). Out of 109 (55.6%) patients who had normal mucosa on endoscopy but on histology 70 (35.7%) of them had inflammation. Grading of endoscopic and histological findings showed significant correlation with each other (p = 0.0). CONCLUSION: Endoscopic negative GERD is common; severity of clinical symptoms does not correlate [corrected] with endoscopic findings while histopathological findings correlate with those of endoscopic findings [corrected]