Pa ge 1 Pa ge 47 American Journal of Medical Science and Innovation (AJMSI) Prevalence of Helicobacter Pylori (H. Pylori) Infection among Patients Undergoing Upper Gastrointestinal Endoscopy: An Institution Based Study Prabhat Pradhan1, Gyan Prasad Bajgai2* Volume 2 Issue 1, Year 2023 ISSN: 2836-8509 (Online) DOI: https://doi.org/10.54536/ajmsi.v2i1.1320 https://journals.e-palli.com/home/index.php/ajmsi Article Information ABSTRACT Received: February 19, 2023 Accepted: March 20, 2023 Published: March 30, 2023 Several studies have established region-based prevalence rate of H. pylori infection and its association with clinical outcomes in Bhutan. However, this study attempts to determine hospital-based prevalence rate of H. pylori and its association with clinical outcomes. A total of 347 volunteers (159 females and 188 males; mean age of 49.8 ± 15.5 years) were enrolled from Central Regional Referral Hospital (CRRH) in Gelephu. Upper gastro-intestinal endoscopy (UGIE) was performed among the dyspeptics and H. pylori infection was determined by Histology examination. The histological prevalence of H. pylori among 347 patients who went upper gastro-intestinal endoscopy was 55.6%. The prevalence of H. pylori infection increased with age but it was statistically insignificant (P > 0.05). Gastritis was the most common endoscopic finding, present in 309 (89%) patients followed by normal upper endoscopy results in 24 (6.9%) patients. The prevalence of H. pylori among patients with gastritis and a duodenal ulcer was significantly higher than in patients with gastric cancer (P < 0.05). The high incidence of gastritis in the hospital may be attributed to the high prevalence of H. pylori infection among the individuals with dyspepsia. Keywords Endoscopy, Gelephu, Helicobacter Pylori, Prevalence 1 Department of Surgery, Jigme Dorji Wangchuck National Referral Hospital, Thimphu Bhutan 2 Department of Dentistry, Jigme Dorji Wangchuck National Referral Hospital, Thimphu Bhutan * Corresponding author’s e-mail: gpbajgai@jdwnrh.gov.bt INTRODUCTION Helicobacter pylori infection is well known to be the most common human infection affecting more than 50% of the world’s population (Salih, B.A. (2009). There is a variation in the prevalence of infection between different countries and, among different societies and ethnic groups within the same country (Van D. et al. 2009; Kaur et al.2003; Malaty et al. 1996). Chronic infection with H. pylori is typically acquired early in life, especially among those in poor socio-economic status and over-crowded conditions (Bardhan PK, 1997; McColl KE 2010). Bhutan is a small country with an estimated population of 8, 00,000. The incidence of gastric cancer in Bhutan is reported to be quite high (with 24.2 cases per 100,000 populations per years) as compared to other neighboring countries like Thailand, India and Bangladesh (Shiota et al, 2013; Dendup et al. 2015). The previous studies have showed association of high incidence of gastric cancer with high prevalence of H. pylori among Bhutanese population (Dorji et al. 2014; Vilaichone et al. 2013). However, there has not been a study conducted as to determine the hospital-based prevalence rate of H. pylori infection and its association with clinical outcomes among the patients regularly visiting the concerned hospital. Helicobacter pylori infection is quite rampant in Bhutan at 66.2%. Punakha district disclosed the highest prevalence of H. pylori infection (85.6%), followed by Wangduephodrang district (75.4%), while Haa had the lowest prevalence (57.7%) (18). The reason why Haa and other districts had lower prevalence could be due to low residing population and seasonal migration during summer and winter months (Ratha-korn et al. 2020). Therefore, we conducted a retrospective hospital-based study over two years (August 2014 to December 2016) to determine the prevalence of H. pylori infection among the dyspeptic patients visiting CRRH and to assess association among clinical outcomes, gender and age with H. pylori infection. METHODS Gelephu is one of the sub-districts located in the Southern part of Bhutan. The region shares border with India. The Central Regional Referral Hospital (CRRH), located in Gelephu, provides healthcare services to the local people residing in Sarpang district, as well as to those patients referred from four other districts which include Trongsa, Tsirang, Dagana and Zhemgang within the Central Region. Patients are referred to CRRH to avail endoscopy service from all five districts as the district hospitals lack such facility. This was a cross-sectional study was carried out among Bhutanese population who attended CRRH between August 2014 and December 2016. The study population included individuals who had undergone UGIE for Figure 1: Central Regional Referral Hospital, Bhutan https://doi.org/10.54536/ajmsi.v2i1.1320 https://journals.e-palli.com/home/index.php/ajmsi Pa ge 48 https://journals.e-palli.com/home/index.php/ajmsi Am. J. Med. Sci. Innov. 2(1) 47-50, 2023 evaluation of dyspeptic symptoms. The information on age, gender, biopsy report and presence or absence of H. pylori infection was reviewed from the medical record maintained in the outpatient registry. Subjects with age below 14 years were excluded from the study. This study was approved by Research Ethics Board of Health (REBH), Ministry of Health. Procedure for Endoscopy and Histology Endoscopy was performed after an overnight fasting of the patients. Scope was inserted through the mouth after lignocaine spray in the throat to make the pharynx numb. Detailed examination of esophagus, stomach and upper part of duodenum was performed. Gastric biopsies were taken randomly from at least two sites. All biopsies were fixed in formalin prior to shipment to Pathology laboratory in Thimphu for Hematoxylin and Eosin (H & E) staining. Statistical Analysis Frequency and percentage were used to describe the characteristics of the study population. The prevalence of H. pylori infection was presented in terms of percentage (%) and Z-test was used to assess whether this prevalence was significantly different from the prevalence of previous studies. The association between age and gender with H. pylori infection was analyzed using Pearson Chi- Square. P value less than 0.05 was considered statistically significant in this study. RESULTS Endoscopic Findings and Prevalence of H. Pylori infection A total of 347 subjects were enrolled for the study of which, 159 (45.82%) were females and 188 (54.18%) were males. The mean age of the study population was 49.8±15.5 years (range: 15 – 83 years). The most common endoscopic finding among the patients with dyspepsia was gastritis (309, 89.05%), followed by normal endoscopy results (24, 6.9%). Gastric cancer, duodenal ulcer and gastric ulcer were less common, present only in eight patients (2.31%), five (1.44%) and, one (0.29%) respectively. A study subject was considered H. pylori positive when the biopsy specimen showed positive in H & E staining. The overall prevalence of H. pylori among the study subjects was 55.6% (95% CI: 50.367 – 60.873). We also tested whether the prevalence in this study was significantly different from previous studies using Z-test (Ha: p < 86% and Ha: p < 73.4%). The prevalence of H. pylori infection among the study population in CRRH was significantly lower as compared to previous prevalence of H. pylori infection found in other Regions (p<0.001). Association of H. Pylori Infection with Age and Gender 109 (57.98%) of the males were H. pylori positive as compared to 84 (52.83%) of the females. In our study, older patients were more likely to be H. pylori positive than the younger ones. The positivity of H. pylori was Table 1: Association of H. pylori infection with age and gender. Characteristics Total number (n) H. pylori P-value Positive (%) Negative (%) Gender Male 188 109(57.98) 79 (42.02) 0.336# Female 159 84 (52.83) 75 (47.17) Age 15 - 29 38 19 (9.87) 19 (12.34) 0.124# 30 - 39 62 38 (19.69) 24 (15.58) 40 - 49 63 42 (21.76) 21 (13.64) 50 - 59 71 40 (20.73) 31 (21.13) > 60 113 54 (27.98) 59 (38.31) observed highest among subjects with age higher than 60 years (27.98%) followed by 40-49 years (21.76%) and 50-59 years (20.73%). 15-29 years subjects had the least H. pylori infection with 9.87%. However, there was no statistically significant association of H. pylori infection with both gender and age (p>0.05) (Table 1). Association between H. pylori infection and clinical outcomes The clinical presentations of the subjects were considered for assessing the association with H. pylori infection (Table 2). Patients with gastritis are more likely to have H. pylori infection (61.8%) than those without it (38.2%; p < Table 2: Association between H. pylori infection and clinical findings. Clinical Findings Total number (%) H. pylori P-value Positive (%) Negative (%) Gastritis 309 (89.0) 191 (61.8) 118 (38.2) < 0.001# Gastric ulcer 5 (1.4) 1 (20.0) 4 (80.0) < 0.001* https://journals.e-palli.com/home/index.php/ajmsi Pa ge 49 https://journals.e-palli.com/home/index.php/ajmsi Am. J. Med. Sci. Innov. 2(1) 47-50, 2023 Duodenal ulcer 1 (0.3) 0 (0.0) 1 (100.0) 0.444* Gastric cancer 8 (2.3) 1 (12.5) 7 (87.5) 0.030* Normal 24 (6.9) 0 (0.0) 24 (100.0) < 0.001# 0.001). In contrary, cases with gastric ulcer, gastric cancer and normal endoscopic findings are less likely to have H. pylori infection (p < 0.05). DISCUSSION This study was endoscopy-based and histological examination was performed to detect H. pylori among patients with dyspepsia. The study revealed high prevalence rate of H. pylori 55.6% among Bhutanese population with dyspepsia. This is in contrast to the previous studies conducted by Vilaichone et al 2014; Dorji et al. 2013) in Bhutan where the prevalence rates ranging from 73.4% to as high as 96% were found among Bhutanese population residing in different districts and regions with dyspepsia. The lower prevalence rate of H. pylori, as revealed by our study compared to the previous studies, possibly could have been due to the sensitivity of histological detection, which was the only method of detection used in this study. The sensitivity of this method depends not only on density of H. pylori biopsy sites but also on expertise of pathologists (el-Zimaity HM, 2000). Many studies have showed several factors such as age of patient, socio-cultural practices, living conditions, environment and geographic location play important roles in H. pylori infection in different population. Therefore, one of the factors contributing to the lower prevalence of H. pylori, as compared to the previous studies, could also be due to the location of the hospital, Southern part of Bhutan where socio-cultural practices are different from the mainstream Bhutanese tradition and cultural practices. The same study conducted by Dorji and his colleagues has revealed the similar trend in the prevalence of H. pylori in Southern Bhutan compared to Western and Central regions. However, it is difficult to compare the H. pylori detection rate since different studies have used different methods. Dorji et al has used serology to determine IgG antibody against H. pylori which does not differentiate past and present infection, therefore, this could have also contributed in higher prevalence rate than this study. Although there is no significant difference in prevalence of H. pylori among the age groups, there is an increasing trend in prevalence with increase in age groups, which is in contrast to the previous studies. The similar trend has also been seen in other studies conducted by (Rodrigo et al 1997; Koch et al 2005)in Spain and Greenland respectively. The most common cause of dyspepsia was found to be gastritis through histological examination which was in concurrence with endoscopic results. Furthermore, this study showed that 61.8% of patients with gastritis had H. pylori infection and this is in consistent with other studies conducted in Nigeria (Jemilohun et al. 2010; Ndububa et al. 2001). Unlike other studies, this study showed gastric and duodenal ulcers have lesser association with H. pylori compared to gastritis which was comparable with the study conducted by Olubuyide and his colleagues in Nigeria (Olubuyide et al. 1989). One of the key limitations of this study is that it was hospital-based setting and may not be a true representation of the prevalence of H. pylori among dyspeptics in the general population of the Central region of Bhutan. Further, the study was carried out only in one centre, therefore, this study calls for a community-based which would be more representative. Also since this study was also a retrospective cohort study, data collection was limited to the information available in hospital records. The records did not include information on risk factors for H pylori infection such as social, economic and other determinants. Conflict of Interest There is no conflict of interest among authors Acknowledgement We would like to acknowledge and thank Mr Tsheten, Mr Binay Thapa, the staff of CRRH rendering full support during the whole study period and staff of JDWNRH involved in the study in any way. CONCLUSION In conclusion, this study found high prevalence of H. pylori infection in concurrence and comparable with other developing countries. Also, there is a strong association between gastritis and H. Pylori infection which suggests treatment of H. pylori infection may be a priority choice while managing gastritis in the hospital set up. Limitation of The Study Some of the limitations were: only ambulant population who visited the hospital for UGIE were performed endoscopy. Other patients from other districts who were not referred to the Gelephu Regional Referral hospital were missed. Moreover, patients refusing or not consenting for UGIE were also missed for the procedures. REFERENCES Salih, B.A. (2009). Helicobacter pylori infection in developing countries: the burden for how long? Saudi journal of gastroenterology. Official Journal of the Saudi Gastroenterology Association,15(3), 201-7. Van Duynhoven, Y. T., & de Jonge, R. (2001). 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